Category Archive : Health

Coronavirus: How the UK is sleeping under lockdown

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A survey suggests more than half the UK population has struggled with sleep during the lockdown.

Sleep problems were more common in people facing financial hardship, while two in five reported having more vivid dreams than usual.

And some people, particularly the young, slept for longer than usual, but without feeling rested.

The study was carried out by market research company Ipsos MORI, and King’s College London.

The findings are based on online interviews in late May with 2,254 UK residents in the 16-75 age bracket.

The researchers said lack of sleep may itself have had knock-on effects on people’s capacity to be resilient during the pandemic, and there are signs of a disproportionate impact on particular groups: women, younger people and those facing financial difficulties.

“As with so much about Covid-19, the crisis is affecting people very differently depending on their circumstances, and that includes the most fundamental aspects of life, such as sleep,” said Prof Bobby Duffy of King’s College London.

He said nearly two-thirds of the public reported some negative impact on their sleep, showing just how unsettling the pandemic and lockdown measures have been.

Disturbed sleep is often caused by stress, and can itself increase stress levels, creating a cycle that is difficult to break, added Dr Ivana Rosenzweig, of Kings College.

However, a quarter of participants reported they were sleeping more and feeling better for it, she said, highlighting that, “as a society, we simply do not get the chance to sleep as much as we need, and that this pandemic is allowing some of us to rediscover the importance of sleep”.

Previous research has shown that for many people lockdown has led to disturbed sleep, insomnia and vivid dreams.

Experts have suggested keeping to a routine, not taking naps and trying to get some exercise outside.

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Stalled vaccine programmes ‘put children’s lives at risk’

Rafatou holds her son while waiting for him to be vaccinated, at Gamkalé health centre, NigerImage copyright
Juan Haro

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Services have been hit in Niger

Millions of children could die from preventable disease because of severe disruptions to vaccination programmes caused by coronavirus, experts warn.

At least 68 countries have been affected – with some stopping vaccination campaigns completely.

The World Health Organization advised many countries to suspend vaccinations to help slow the spread of coronavirus.

But now it is one of several groups expressing concern about the long-term impact.

United Nations Children’s Fund (Unicef), the Sabin Vaccine Institute and Gavi, the Vaccine Alliance are also worried thousands of children every day could die needlessly.

In a usually packed clinic in Niger’s capital, Naimey, the waiting room is quiet.

There have been almost 1,000 Covid-19 cases reported in the country.

But polio, which can cause paralysis or even death, is also making a comeback – four new cases have been reported since February.

Zeinabou Tahirou sits in a pink headscarf and a blue face mask, cradling her baby girl, Fadila.

“I was so scared to come here, because of the coronavirus,” she says.

“But health workers have told me how important these immunisations are, and also what I need to do to stay safe – like washing my hands all the time.”

There are a number of reasons vaccination services have been so badly disrupted, including:

  • parents’ fear of catching Covid-19 if they leave the house
  • health workers being diverted to deal with the pandemic
  • problems getting vaccine supplies to clinics

“Measles is on the rise, diphtheria, cholera,” United Nations Children’s Fund (Unicef) executive director Henrietta Fore says.

“So this is going to be a real problem.

“As a world, we had conquered many of these preventable diseases for children.”

Now, there are grave concerns these gains could be “wiped away”.

At least 80 million under the age of one are at risk

Estimated number of babies missing routine vaccinations because of the coronavirus pandemic:

  • South East Asia – 34.8 million
  • Africa – 22.9 million

Current outbreaks of preventable deadly diseases:

  • Nepal and Cambodia – measles
  • Ethiopia – measles, cholera and yellow fever

Source: The World Health Organization, Unicef, Sabin Vaccine Institute and Gavi, the Vaccine Alliance

Recent modelling by Johns Hopkins Bloomberg School of Public Health suggests disruption to these kinds of crucial health services for women and children, could result in as many as 6,000 additional children dying every day.

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M Sherpa

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Queues for immunisation at a clinic in Nepal

“What we fully expect is these diseases will come roaring back,” WHO immunisation and vaccines department head Kate O’Brien says.

“And what that means… is that we’re going to see deaths of children in numbers that are unprecedented in recent times.”

But this potentially devastating situation can still be prevented, “if governments act now”.

The warnings come as global leaders meet virtually for the Global Vaccine Summit, on Thursday, hosted this year by the UK.

Countries and donor organisations will asked to pledge $7.4bn (£5.8bn) to ensure Gavi, the Vaccine Alliance can continue delivering lifesaving vaccines to some of the poorest communities in the world, both during the pandemic and beyond.

Its leader, Dr Seth Berkley, says ensuring routine vaccination systems are up and running again as soon as possible, is crucial.

“When you have a big effect on vaccine [services] like this, it takes some time to rebuild some of the systems around it,” he says.

“As we rapidly move towards having Covid-19 vaccines available, these are the same systems we will use to deliver those vaccines as well.”

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‘I feel like I don’t count,’ says man with MND

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Phil Rossall

Phil Rossall, a 67-year-old retired teacher and charity worker from Kent, was first diagnosed with motor neurone disease (MND) in 2016.

At the time, doctors told him he had just “one or two” years left to live.

Four years have passed since his diagnosis, and he is now unable to move his limbs or breathe without a ventilator.

But he has refused to let the disease break his spirit, and last year managed to smash two Guinness World Records for running marathons in his wheelchair.

Phil says that it has become difficult to keep track of how far his disease has progressed: “I don’t notice day-to-day changes, but then looking back to the start of this year is a scary experience for me,” he told the BBC.

MND is a degenerative and often fast-progressing disease. Due to its nature, those with the condition have a heightened risk of complications if they catch a respiratory infection like Covid-19.

Phil and his partner, Brenda, have been self-isolating for the last month.

“The enforced isolation has meant that my blog and book have been the main respite from a world of hoists, wheelchairs and face masks,” he said.

“My speech is now completely incomprehensible, so writing is now my only form of communication with the outside world. I miss my St Christopher’s carers and the MND Association visitors, but my heart goes out to people who are desperately ill and who feel deserted by their own government.”

‘Mixed messages’

Despite relying on a ventilator to breathe, Phil was not initially included in the government’s list of who should be shielding. He says that the government’s advice since the coronavirus outbreak began has felt like a succession of “mixed messages” that left him and his partner unsure of his situation.

“I have two postgraduate degrees and have worked as a research manager, and yet I have been very confused,” he said. “Seeing that I have a debilitating condition and that I am reliant on ventilation 24/7, I was expecting to be included, but instead I was not in the 1.5 million most vulnerable in the country. All I can say is that there must be an awful lot of very sick people out there.”

While the disease is on the NHS England list of underlying health conditions, it has yet to be explicitly named on the list of those who should be “shielding”.

The advice on whether MND patients should be on the shielding list has said it depends on the stage of their illness.

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Phil Rossall

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Phil doesn’t know why MND isn’t included on the “most vulnerable” list

The MND Association, a charity dedicated to the care and protection of those living with the disease, told the BBC it had been inundated with concerned and upset patients and families.

“Many are terrified of catching coronavirus, knowing the implications for them could be catastrophic,” said head of policy and campaigns, Susie Rabin.

She said more than 3,500 of the charity’s supporters had emailed their MPs urging them to ask Health Secretary Matt Hancock to add MND to the “extremely vulnerable” list.

“Not being automatically added to the extremely clinically vulnerable shielding and protecting list, means that people are struggling to get food and essential medicines delivered, particularly if they live alone.

“People with MND have died of Covid 19 already. We’d like all people with MND shielded and protected from this disease.

“We believe that inclusion on the ‘extremely vulnerable’ list is the safest and most appropriate option for people with MND.

“There needs to be more support for social care workers and much more adequate provision of PPE for carers both in care homes and in domestic settings to enable them to support and care for disabled people.”

‘Vital service’

As his primary carer, Phil’s partner is unable to leave him alone in the house. Because of this, the couple have come to rely on a delivery service from their local supermarket over the last three years.

However, due to not being classed as “extremely vulnerable” by the government, the couple were told that they were not eligible for a delivery slot.

“The fact remains that I was receiving a vital service until the ‘extremely vulnerable’ rules came in. Whether the omission of MND from the official shielding list was a result of incompetence, ignorance or prejudice, doesn’t matter to me.

“I will not go hungry. But for the first time in my life, I feel I am a victim of discrimination. I never get angry. I may be wrong, but I feel like I don’t count, that I belong to a group that’s not worth bothering about because we’ll be dead soon anyway.”

He felt forced to take matters into his own hands, and only after he had asked his consultant to send a supporting letter to his GP, did he finally receive the phone call to tell him he had been placed on the list.

Case-by-case basis

A spokesman for the Department of Health and Social Care told the BBC that patients with MND are being assessed on an individual basis.

“Expert doctors have identified specific medical conditions that put someone at greatest risk of severe illness from Covid-19, meaning they’re clinically extremely vulnerable and need to shield.

“The list will continue to be reviewed, and doctors are identifying additional people who need to shield depending on their individual circumstances.”

Those who are not classified as “extremely vulnerable”, but have underlying health conditions, are still advised to adhere to stay-at-home guidelines, he added.

Despite his victory, Phil says he’s concerned that others like him may not be so lucky.

“I am still concerned that other people with this terrible disease do not have the support I have.”

He added: “I am still angry that the government advisers forgot some of the most vulnerable people in the country and ignored our pleas for so long. Surely it shouldn’t be so hard.”

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Coronavirus: The struggle of living in lockdown with autism


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Simon is one of many autistic people left isolated by coronavirus

For most people the Covid-19 crisis is an unsettling, confusing time. But for hundreds of thousands of adults with autism in the UK the problems are acute.

Families and charities say this vulnerable group has been forgotten in the pandemic and they are often not receiving the care they need. Here some of them describe what things have been like since the lockdown began.

‘Sick with worry’

In a few weeks Simon will be 53. He was diagnosed with autism when he was three and has been in residential care his whole life.

He has very limited communication but can say when he wants a cup of tea. In normal times, he would go riding and swimming once a week.

“He’s a very active young man,” says his mother Andrea. “And to me he’s still a young man.”

But two weeks ago Simon fell ill, with a high temperature and severe cough.

“I just felt sick with worry,” Andrea says. “I mean what’s going to happen to him if he is so ill he has to go into hospital?”

Despite having typical symptoms, like thousands of others, Simon has not been tested for coronavirus and Andrea is not allowed to see him.

She has nothing but praise for the care home staff but says: “No doctors will come and that is the whole problem. We don’t know what we are dealing with.

“It’s been terrible – probably the most stressful week in my life.”

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Simon’s mum says he would struggle to cope if he had to be taken to hospital

Simon has no way of communicating how he’s feeling, whether he’s getting better or worse, and no way of processing what is happening to him.

“I can’t imagine what he’s thinking,” Andrea says.

“Even his favourite cup of tea has disappeared because they are giving him cold drinks to keep his temperature down. He can’t even say to someone, I’d really love to have a cup of tea.”

Under NHS guidelines if someone with autism or a learning disability does need hospital treatment for Covid-19 then a single family member or carer can visit.

But Andrea still thinks Simon would struggle to cope.

“He would be absolutely terrified,” she says. “Most hospitals have very, very limited staff who can deal with autism and learning disabilities. I just don’t know what would happen.”

She says Simon’s condition has started to improve and he is now eating small amounts and sitting in the garden with a drink.

‘What protection do I have?’

David* was diagnosed with autism and multiple learning disabilities as a child. Now in his 50s, he’s spent the last 30 years living in three different residential care homes.

He is worried about what will happen if the virus spreads in the home and says people like him have been forgotten.

“Testing should be done daily on residents and care workers,” he says.

“If my care workers get it or other residents get it, I’m stuck. What protection do I have? I am concerned about the lack of PPE for all care providers not just my own.”

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Christopher’s two long-term carers have resigned, leaving him without the care he ‘desperately needs’

Like many people with autism, Christopher finds it hard to handle the unpredictable.

“He gets very confused, very frustrated, with any form of change to his timetable or his daily routines,” says his mother Jane. “So when situations like this arise you get a lot of anxiety from him.”

Christopher lives on his own, in his own house. He has two long-term carers who help with meals, cleaning, personal care and other everyday tasks he can’t do alone, but last month they both had to resign – one for health reasons, the other to look after their own children – leaving him with no support.

And because Jane lives with another vulnerable person, lockdown means she isn’t able to help her son face-to-face.

“Everything has to be done within his drive, keeping the two metre distance,” she says. “But that means we can’t provide the personal care he desperately, desperately needs.”

If – as seems likely – the lockdown continues for weeks, perhaps months, Jane fears it could be “catastrophic” for her son.

“The longer this goes on, the more anxious he’s becoming, the more unconfident he’s becoming, the more he’s losing what we’ve built up with him over the years.

“He’s a 40-year-old young man who has lots to give. He’s an absolute treasure, but I’m so worried about this time for him.”

‘I’m afraid he’ll lose his social skills’

Living in supported accommodation, James* has been used to receiving regular visits from his care workers.

But since the coronavirus outbreak his contact has been limited to brief phone calls or a knock at the door.

He has Asperger Syndrome and has recently been discharged from hospital where he was a patient for over 10 years.

“Gradually he’s staying in more, not seeing or speaking to anyone, staying up all night and in bed for a huge part of the day,” says his mother Kathy.

“I’m afraid that he’s going to lose all his social skills again and get very depressed, ending up back in hospital.”

Because of her age, Kathy is having to self-isolate so can only contact her son by email or video call.

“He keeps saying ‘what’s the point of living if we’re in lockdown’.

“He’s relying more and more on me for mental support rather than turning to his team. So I’m on the receiving end of the brunt of his frustrations. I’ll be very glad when the lockdown is over and he can get the full support he needs.”

Jane Harris, Director of External Affairs at the National Autistic Society, says “Autistic people often have communication difficulties. That means that it’s harder to understand what is going on in the first place.

“But also autistic people don’t often have the best support networks to start with so it’s really, really hard for them to get support in a crisis, things like shopping or even just a phone call just to check that somebody is okay.

“There will be thousands of people across the country who are deeply isolated during this crisis and who need support more than ever.”

The charity has published guidance for autistic people and their families to help during the pandemic. For more information on organisations that can help visit BBC Action Line.

(*names have been changed)

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Coronavirus immunity: Can you catch it twice?

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Can you catch coronavirus again? Why are some people sicker than others? Will it come back every winter? Will a vaccine work? Could immunity passports get some of us back to work? How do we manage the virus in the long-term?

The immune system is at the heart of some of the most important questions about the coronavirus.

The problem is we know very little.

How do you become immune to coronavirus?

Our immune system is the body’s defence against infection and it comes in two parts.

The first is always ready to go and leaps into action as soon as any foreign invader is detected in the body. It is known as the innate immune response and includes the release of chemicals that cause inflammation and white blood cells that can destroy infected cells.

But this system is not specific to coronavirus. It will not learn and it will not give you immunity to the coronavirus.

Instead you need the adaptive immune response. This includes cells that produce targeted antibodies that can stick to the virus in order to stop it and T cells that can attack just the cells infected with the virus, called the cellular response.

This takes time – studies suggest it takes around 10 days to start making antibodies that can target the coronavirus and the sickest patients develop the strongest immune response.

If the adaptive immune response is powerful enough, then it could leave a lasting memory of the infection that will give protection in the future.

It is not known if people who have only mild symptoms, or none at all, will develop a sufficient adaptive immune response.

How long does immunity last?

The immune system’s memory is rather like our own – it remembers some infections clearly, but has a habit of forgetting others.

Measles is highly memorable – one bout should give life-long immunity (as the weakened version in the MMR vaccine does). However, there are many others that are pretty forgettable. Children can get RSV (respiratory syncytial virus) multiple times in the same winter.

The new coronavirus, called Sars-CoV-2, has not been around long enough to know how long immunity lasts, but there are six other human coronaviruses that can give a clue.

Four produce the symptoms of the common cold and immunity is short-lived. Studies showed some patients could be re-infected within a year.

But the common cold is generally mild. There are two more troublesome coronaviruses – the ones that cause Severe Acute Respiratory Syndrome (Sars) and Middle East Respiratory Syndrome (Mers) – in which antibodies have been detected a few years later.

“The question is not whether you become immune, it’s how long for,” said Paul Hunter, a professor in medicine at the University of East Anglia.

He added: “It almost certainly will not last for life.

“Based on antibody studies in Sars it is possible that immunity will only last about one to two years, though this is not yet known for certain.”

However, even if you are not completely immune it is possible a second infection would not be as severe.

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Immunity could affect vaccine research

Have people caught it twice?

There have been reports of people appearing to have multiple coronavirus infections in a short space of time.

Some have argued people are genuinely being infected twice. Another school of thought is the virus goes into stealth mode in the body before being reactivated.

However, the scientific consensus is that testing is the issue with patients being incorrectly told they were free of the virus.

Nobody has been deliberately reinfected with the virus to test immunity, but a pair of rhesus macaque monkeys have.

They were infected twice, once to build up an immune response and then a second time three weeks later. Those very limited experiments showed they did not develop symptoms again after such a quick reinfection.

If I have antibodies am I immune?

This is not guaranteed and that is why the World Health Organization is nervous about countries using immunity passports as a way out of lockdown.

The idea is if you pass the antibody test then you are safe to go back to work. This would be particularly valuable for staff in care homes or hospitals who come into contact with those at risk of developing severe symptoms.

But while you will find some antibodies in nearly every patient, not all are equal. Neutralising antibodies are the ones that stick to the coronavirus and are able to stop it infecting other cells. A study of 175 recovered patients in China showed 30% had very low levels of these neutralising antibodies.

That is why the World Health Organization says “that cellular immunity [the other part of the adaptive response] may also be critical for recovery”.

Another issue is that just because you might be protected by your antibodies, it doesn’t mean you cannot still harbour the virus and pass it onto others.

Why does immunity matter?

It matters for obvious personal health reasons and whether you will get Covid-19 multiple times and how often.

Immunity will also affect how deadly the virus is. If people retain some, even imperfect, protection then it will make the disease less dangerous.

Understanding immunity could help ease lockdown if it is clear who is not at risk of catching or spreading the virus.

If it is very difficult to produce long-term immunity, then it could make a vaccine harder to develop. Or it may change how the vaccine needs to be used – will it be a once a lifetime or once a year like the flu shot.

And the duration of immunity, whether by infection or immunisation, will tell us how likely we are to be able to stop the virus spreading.

These are all big questions we still lack answers to.

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Coronavirus doctor’s diary: ‘We aren’t diagnosing many cancers now’

Sonia Lockwood and Frankie MosleyImage copyright
John Wright

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Planned surgery has been cancelled at hospitals across the UK, leaving much work to be done once the Covid-19 emergency is over. But two colorectal surgeons at Bradford Royal Infirmary also believe that the surgical world will be permanently changed – as Dr John Wright discovers in his regular diary.

27 April 2020

Like a runner who has discovered halfway through her race that it has changed from a sprint to a marathon, the hospital is coming to terms with a new pace and is recalibrating its stamina.

Numbers of cases have started to fall, but there’s no finishing line in sight.

And as we continue running, we have to look ahead to the future – we have to work out how we can resume normal business, looking after patients with cancer and heart disease, asthma and arthritis.

At present, half the hospital is empty, while the other half has become a Covid-19 Red Zone; in time it will contain two parallel universes, Covid and non-Covid.

Surgeons, who have concentrated on emergency operations since the start of the epidemic, will resume planned operations in the non-Covid universe. But until a reliable test is developed that can be used to confirm that a patient is Covid-negative, the assumption will have to be that they are Covid-positive, and this has some important consequences.

I spoke to two consultant colorectal surgeons, Sonia Lockwood and Frankie Mosley, about what has changed for them so far, and what they think will change in future.

They confirmed that all work except for emergency surgery and some cancer surgery has been put on hold. They also said that keyhole surgery has come to a halt, as evidence from China and some European countries suggests that open surgery is safer for operating theatre staff.

Front line diary

Prof John Wright, a medical doctor and epidemiologist, is head of the Bradford Institute for Health Research, and a veteran of cholera, HIV and Ebola epidemics in sub-Saharan Africa. He is writing this diary for BBC News and recording from the hospital wards for BBC Radio 4’s The NHS Front Line

It may now resume, in some cases, with the increased risk to medical staff being weighed against the risks to the patient of a longer stay in hospital, which is one of the consequences of open surgery.

But increased efforts will also be made to explore non-surgical options. Appendicitis provides a good example of this, Sonia says.

“We are looking to treat people conservatively, with antibiotics wherever we can. We’re doing more complex scanning on patients to try and determine who will be suitable for that. So we’re really avoiding operating on patients wherever possible.”

And appendicitis also illustrates another point – people who really need treatment are not always coming to hospital.

“Where we would normally do appendectomies maybe once a day, maybe two or three a day, at first, after the lockdown, we didn’t see any. But then, after a week or so, the patients that are coming in with appendicitis have come in with terrible appendicitis,” Sonia says.

“They’ve waited at home until it’s perforated, so what would have been a relatively straightforward illness and operation then becomes a much more significant illness and operation.”

Normally, there would be a minimum of about 30 admissions coming through the hospital’s surgical assessment unit every day but that went down to two or three, Sonia says.

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John Wright

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Wearing full PPE is tiring, and tight-fitting masks can cause headaches

The surgeons are also dealing with fewer cancer patients.

In some cases this is because a calculation has been made that the risk of bringing them in is higher than the risking of waiting. But there is another factor too, Frankie says.

“We certainly, at the moment, aren’t diagnosing many cancers at all. Our main modality for diagnosing them is endoscopy – colon endoscopy [a camera inserted into the body on the end of a tube] – and we’ve more or less ceased that activity,” she says.

“We are investigating people – we’re scanning them, so we’ll pick up the most advanced cancers – but we’re not diagnosing anywhere near the normal numbers. So we are just putting this work off for later.”

But operations carried out in full personal protective equipment (PPE), as they must be until there is a test for Covid-19, are time-consuming.

“What we may have been able to do six months ago, in a given day, we can only do half of that – and that’s if we get all the theatres back, and all the ventilators back,” Frankie says.

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Each patient at Bradford Royal Infirmary who leaves hospital after recovering from Covid-19 is commemorated with a heart

The same applies to diagnostic tests – X-rays, camera tests, endoscopy – everything will take longer because of safety procedures that have been put in place in for both patients and staff.

And this, combined with the fact that there will be a backlog of operations, will lead inevitably to more prioritisation, Sonia and Frankie believe.

At present, cancer surgery is a top priority, and for everyone else it’s been first come first served, as Frankie puts it. In future they envisage pushing lower-priority operations down the queue.

What does that mean in the case of colorectal surgery?

“For us it will be some of people’s haemorrhoid operations. They might have to put up with bleeding – it is inconvenient and unpleasant, but they might have to put up with it for a bit longer than they traditionally have had to,” Frankie says.

Sonia adds that when it comes to general surgery, some hernia patients could be de-prioritised.

“While they’ve got lumps and bumps that are maybe uncomfortable and they’ve got some symptoms, most people have very mild symptoms,” she says.

The remarkable drop off we’ve seen in hospital referrals, has been matched when it comes to A&E attendances. While we’re worried about the patients who may not be coming to hospital when they need to, this also suggests that people who are using A&E have not always experienced an accident or an emergency.

“There are lots of people who use the NHS inappropriately, acknowledging that it’s quicker to come to A&E and wait for hours than maybe wait for a GP appointment two weeks from now,” Sonia says. “And I think the Covid crisis has actually highlighted that – that people are trying to bypass the system.”

In an NHS which is struggling to meet ever increasing demand, we have an opportunity to reduce unnecessary hospital appointments – to do things differently. Patients have discovered the joys of seeing their consultant without leaving the comfort of their own homes, and remote or virtual consultations look like one of the big changes that are here to stay.

The success of our response to Covid-19 in hospitals across the UK has been down to a grassroots movement of doctors and nurses on the front line. They have been the ones who have taken control of the NHS, put their lives on the line and tamed the Covid dragon.

This has broken down a barrier between clinical and managerial staff in hospitals, Sonia says, and she looks forward to a continuation of open dialogue as we plan for the future.

In management theory, there’s a classical model about change that describes how to unfreeze the existing system and then refreeze it in a new way of working. It’s a neat concept but in reality this never happens. Until now. Covid-19 has defrosted the whole of the NHS, and we have to now work out what we want to keep and what we want to do differently.

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Coronavirus: Can superspreading be stopped?

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Zumba classes can spread the disease

As the world races to find treatments and vaccines for coronavirus, scientists have another target in their sites – the superspreading event, when one person infects many others.

Why is superspreading important for coronavirus?

During the pandemic, there has been a focus on the reproduction (R) number, which reveals how the virus spreads through a population.

If coronavirus is left unchecked, the R number is about three.

One infected person will pass the virus on to three other people, who will each infect three more, and so on.

But that is the average picture.

And in reality, the spread is far more uneven.

Coronavirus superspreaders: Why are they important?

The mystery of asymptomatic ‘silent spreaders’

“Typically, what happens is a lot of people don’t give the infection to anyone,” Dr Adam Kucharski, of the London School of Hygiene and Tropical Medicine (LSHTM), says.

“And then there’s a handful of events where you see large amounts of transmission happening with five, 10, 20 people potentially infected.

“And we saw that even quite early on with Covid.”

He says 10-15% of people are responsible for about 80% of infections.

This variability in spread – the dispersion factor – is measured by the K number.

The smaller K number is, the fewer people there are driving the bulk of disease transmission.

Why does superspreading happen?

Covid-19 is passed on through people shedding virus particles from their bodies.

How infectious someone is depends on many factors that differ dramatically from person to person, including:

  • the dose of virus they were initially infected with
  • how long they have been infected for
  • the severity of their symptoms

But it is what they do when they are shedding the most virus that is really driving superspreading events.

“If someone, when they’re most transmissible, happens to go to an all-day meeting with a large number of people and then go out for dinner afterwards, you may well see a superspreading event,” Dr Kucharski says.

“If that person happened to have an evening at home, it might not have generated any transmission.”

Where is superspreading happening?

Scientists have been keeping track of clusters of Covid-19 since the pandemic began.

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Choir practice could help spread the virus

Dr Gwen Knight, from LSHTM, says: “We found that many of the settings are what we expected.

“So care settings – hospitals and care homes – unfortunately, are coming up.

“And also cruise ships, which is something we know from other infectious diseases.”

But she also found clusters repeatedly appearing in other places – meat-processing plants, choirs, bars and gyms.

The strange case of the choir that coughed in January

All of these involve being indoors, in close contact with others, for prolonged periods of time.

But Dr Knight says there is another common thread.

“These settings are likely to be loud settings,” she says.

“And obviously, that has an impact on the kind of breathing you do.

“There is the hypothesis that because it’s loud, and you’re expelling more or faster air, it could be this that makes the setting more and more risky.

“There were several clusters linked to fitness classes in South Korea, and more were linked to Zumba classes than to Pilates classes.

“So it might be that you’re engaged in an exercise that requires you to breathe more heavily and deeper, as opposed to a more gentle breathing, for example.”

Can superspreading happen outside?

Dr Muge Cevik, of the University of St Andrews, says: “Not all activities, not all environments have the same risk of infection.

“So, for example, the risk of infection would be higher indoors compared to outdoors.

“But outdoors, generally people worry about cyclists or runners passing by – but that would be lower risk.

“We could say the transmission risk is negligible.

“Whereas if you spend a whole day together, in a big group in a park, and if you exchange lots of food and you have really close contact, less than 2m [6ft], the risk is lower than being indoors – but there is still risk.”

Hand-washing, social distancing and not sharing utensils is essential, she says.

How can understanding superspreading help?

Strict lockdowns were a blunt tool for halting the spread of coronavirus.

But as infections decrease, and the world opens up, scientists say a more targeted approach is needed,

Dr Cevik says: “We need to understand the transmission dynamics so we can concentrate our contact-tracing focus.

“But if we can avoid these superspreading events, and the environments and activities associated with them, you can decrease almost 80% of infections.

“And that’s huge.”

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Coronavirus: When your child’s in intensive care with Covid-19

Children make up a small percentage of those so far diagnosed with coronavirus and often have milder reactions than adults when they become infected.

But there are cases around the world where they have been left needing intensive care treatment.

The mothers of four-year-old Lincoln, and baby Peyton – who contracted the virus at just three weeks old – told the BBC about their experiences.

Video by Callum Tulley

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Coronavirus: ‘Many said goodbye to loved ones in an ambulance’

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St George’s Hospital

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Dr Nigel Kennea trained as a doctor for newborn babies and is now focused on helping the bereaved

When Dr Nigel Kennea talks of the “unexpectedness and awfulness” of deaths in his hospital in the past six weeks, he tempers it with a positive focus on helping bereaved families left behind.

As a medical examiner at St George’s Hospital, in south London, his job is to advise clinical teams on completing death certificates, then support relatives through their grief.

But like so much during this pandemic, none of that is straightforward.

“The most harrowing thing is knowing that many said goodbye to their loved ones in an ambulance,” he says.

Despite staff “going above and beyond” to support patients in desperate times, using mobile phones and iPads to connect seriously ill patients and their families, contact is just not always possible.

Even after a patient’s death, social distancing has meant grieving relatives are left in limbo.

“Normally, registering a death is done face-to-face with relatives,” Dr Kennea says.

“They come in, talk through the admin and how to plan for after death.

“Now, it’s all done on the phone.”

‘Share the burden’

Dr Kennea’s job is to take an overview of all deaths at the hospital. It’s a relatively new role in the UK, introduced last year, which is independent of trusts.

Previously he was a specialist in the care of newborn babies.

Now, Dr Kennea discusses each death at the hospital with the doctors and nurses involved in that patient’s care, making sure death certificates are completed correctly and consistently.

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With Covid-19 deaths so closely scrutinised, there is added pressure and “some are complicated”, he says.

There is still so much doctors are learning about the virus and its effects on people’s bodies – such as heart failure, thrombosis, kidney problems and pneumonia.

But, Dr Kennea says: “If a test for coronavirus has been carried out and is positive, that goes on the death certificate as it is likely to have contributed to the death.”

And the hospital aims to report these deaths to national bodies on the day they happen.

Although those that seem unnatural or have no certain cause must be referred to a coroner.

But the role he is most proud of is supporting bereaved families – talking to them about what is on the certificate, the care the patient received and next steps for the funeral.

“We share the burden together,” he says.

‘Human touch’

These conversations with families are when life stories are told and memories shared. There is often laughter too.

And there is now more demand than ever for hospitals to have good communication skills and show sensitivity towards families.

“We are better at this than we were six weeks ago,” Dr Kennea says.

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St George’s Hospital

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Dr Kennea and the medical examiner team contact families after a death

“So many people are so grateful for our support.

“And they often say they appreciated the human touch,” he says.

St George’s Hospital had its first Covid-19 death on 12 March.

Since then, 250 people have died with the illness at the hospital, while more than 600 have recovered and been discharged.

In the worst week, 60 patients died with Covid-19.

By turning normal wards into intensive care units and training up staff to work there, this large hospital has coped through all the turmoil.

And it has even been able to take Covid-19 patients needing dialysis from other London hospitals.

But there has been immense pressure on front-line staff, kitted out in personal protective equipment day in, day out.

When Dr Kennea goes into Covid-19 areas, he too wears full PPE – but it has its limits when communicating with patients.

“It’s hard to share a smile behind a mask and goggles,” he says.

‘Violent tragedy’

Now, 60 patients with Covid-19 are being ventilated in the hospital’s intensive care unit.

At the peak, it was 120.

There is a sense the situation is improving and that is “really gratifying”, Dr Kennea says.

Yet there is so much from the past few months he will never forget.

He has marvelled at human powers of recovery – sometimes in the most unexpected places, such as among the very elderly.

But at the same time, he has seen younger people whose lives have been cruelly taken.

“It is just a violent tragedy,” he says.

“It is such an exceptional time for lives being snatched away.”

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Coronavirus: How long does it take to recover?

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More than one million people around the world are known to have recovered from coronavirus, according to Johns Hopkins University. But the road back to full health is not the same for everyone.

Recovery time will depend on how sick you became in the first place. Some people will shrug off the illness quickly, but for others it could leave lasting problems.

Age, gender and other health issues all increase the risk of becoming more seriously ill from Covid-19.

The more invasive the treatment you receive, and the longer it is performed, the longer recovery is likely to take.

What if I have only mild symptoms?

Most people who get Covid-19 will develop only the main symptoms – a cough or fever. But they could experience body aches, fatigue, sore throat and headache.

The cough is initially dry, but some people will eventually start coughing up mucus containing dead lung cells killed by the virus.

These symptoms are treated with bed rest, plenty of fluids and pain relief such as paracetamol.

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People with mild symptoms should make a good and speedy recovery.

The fever should settle in less than a week, although the cough may linger. A World Health Organization (WHO) analysis of Chinese data says it takes two weeks on average to recover.

What if I have more serious symptoms?

The disease can become much more serious for some. This tends to happen about seven to 10 days into the infection.

The transformation can be sudden. Breathing becomes difficult and the lungs get inflamed. This is because although the body’s immune system is trying to fight back – it’s actually overreacting and the body experiences collateral damage.

Some people will need to be in hospital for oxygen therapy.

GP Sarah Jarvis says: “The shortness of breath may take some considerable time to improve… the body is getting over scarring and inflammation.”

She says it could take two to eight weeks to recover, with tiredness lingering.

What if I need intensive care?

The WHO estimates one person in 20 will need intensive care treatment, which can include being sedated and put on a ventilator.

It will take time to recover from any spell in an intensive or critical care unit (ICU), no matter what the illness. Patients are moved to a regular ward before going home.

Dr Alison Pittard, Dean of the Faculty of Intensive Care Medicine, says it can take 12 to 18 months to get back to normal after any spell in critical care.

Spending a long time in a hospital bed leads to muscle mass loss. Patients will be weak and muscle will take time to build up again. Some people will need physiotherapy to walk again.

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Coronavirus rehabilitation in France

Because of what the body goes through in ICU, there’s also the possibility of delirium and psychological disorders.

“There does seem to be an added element with this disease – viral fatigue is definitely a huge factor,” says Paul Twose, critical care physiotherapist at Cardiff and Vale University Health Board.

There have been reports from China and Italy of whole-body weakness, shortness of breath after any level of exertion, persistent coughing and irregular breathing. Plus needing a lot of sleep.

“We do know patients take a considerable period, potentially months, to recover.”

But it is hard to generalise. Some people spend relatively short periods in critical care, while others are ventilated for weeks.

Will coronavirus affect my health long-term?

We don’t know for sure as there is no long-term data, but we can look at other conditions.

Acute respiratory distress syndrome (called Ards) develops in patients whose immune systems go into overdrive, causing damage to the lungs.

“There is really good data that, even five years down the line, people can have ongoing physical and psychological difficulties,” says Mr Twose.

Dr James Gill, a GP and lecturer at Warwick Medical School, says people also need mental health support to improve recovery.

“You’re finding breathing difficult, then the doctor says ‘We need to put you on a ventilator. We need to put you to sleep. Do you want to say goodbye to your family?’.

“PTSD [post-traumatic stress disorder] in these most severe patients is not unsurprising. There will be significant psychological scars for many.”

There remains the possibility that even some mild cases may leave patients with long-term health problems – such as fatigue.

How many people have recovered?

Getting an accurate figure is difficult.

As of 1 May, Johns Hopkins University reported more than 1,021,000 people had recovered out of 3.2 million people known to have been infected around the world.

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A Covid-19 gives prostration of thanks on leaving hospital in Morocco

But countries use different recording methods. Some are not publishing recovery figures and many mild infections will be missed.

Mathematical models have estimated between 99-99.5% of people recover.

Can I catch Covid-19 again?

There has been much speculation, but little evidence, on how durable any immunity is. If patients have successfully fought off the virus, they must have built up an immune response.

Reports of patients being infected twice may just be down to tests incorrectly recording they were free of the virus.

The immunity question is vital for understanding whether people can be reinfected and how effective any vaccine may be.

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