COVID-19 Update No.3, May 2020

Dear Friends & Patients,

It has been just over a month since my last email update. These are my thoughts and experiences as of today. They are sure to change as more information and data becomes available.

This past weekend I received news regarding an exciting development on COVID 19 IgG testing, but we need to understand its limitations, as usual. 

Testing

1. COVID-19 PCR swabs have been available for just over a week by my preferred lab, which has very high reporting standards. This checks for presence of the COVID-19 antigen, i.e. active spreadable infection.
   
   A PCR throat swab is either sent to your home or can be collected (further details to be given if/when relevant); instructions are included on how to take the swab yourself from your mouth and nose. If there are any problems taking this, then I can show you via video link. You then send the swab back to the lab in the pre-addressed padded sample envelope. It is also possible to have it couriered straight to the lab if one wants the results more quickly (we have the results within 24 hours of the swab arriving at the lab). The result is either a positive or negative for current infection, and I am helping my patients to interpret the bigger picture (e.g. might they have had it before? If their current symptoms are not COVID-19 then what could they be? Alternatively, if the symptoms are really in keeping with COVID-19, could it still be COVID-19 even though one tested negative? Is it worth repeating the swab in a week if symptoms persist? etc). 
   
   It is interesting to look at the practice in other countries. In Italy, after having a confirmed case of COVID-19 on PCR swab, one is deemed no longer contagious when one has a further two negative swabs taken two weeks apart.
   
   
2. On Monday 11th May 2020 a blood test will be available to check for the COVID-19 IgG antibodies. The test has 100% specificity and 97.5% sensitivity, which is very good indeed. This test will check for previous infection/exposure to COVID-19 and confirm an antibody response. This test can be done from 14 days of onset of symptoms or 21 after known exposure.  
   
   A self-collection “Tiny” kit (i.e. one needs a tiny amount of blood) is sent to the patient. The completed request form, the label sticker and all the required kit is included for a person to prick their finger, squeeze out the blood, fill the very tiny container and then send it back to the lab to be analysed. Just as above, if one wants to collect the kit and/or get it couriered back to the lab for expediency then that is no problem to do. Here is the instruction video (you need to fill to the top line, i.e. 600 micro-millilitres).
   
   The results are predicted to be back within 24-36 hours of the lab receiving the sample and I plan to help my patients interpret their results. One tests positive or negative and here is where COVID-19 is a little tricky. One assumes if one is positive for COVID-19 IgG that one is immune. However a positive test does not confer complete immunity. We have learned that sometimes people have been exposed to COVID-19 without developing an antibody response (especially younger people). It also looks as though (in some cases) an antibody response might fade with time, so we do not know how long immunity lasts for in a particular individual. If one had symptoms months ago, perhaps one developed an immune response and it wore off. The point is a person’s results should ideally be interpreted for their individual history. 
   
   There will be circumstances when it will be appropriate to repeat tests, e.g. has my antibody response now worn off? Have I developed a delayed antibody response? 
   
   This will become all the more important once quarantine is lifted. If one develops symptoms of COVID-19 then one can ascertain quickly whether one needs to self-isolate, and, in addition, whether family members are carriers and need to self-isolate. They will also now accurately be able to see whether or not they have developed an IgG response which is key. 
   
   Ideally, when quarantine is lifted, COVID-19 PCR swabbing and IgG testing will allow us as a society to ensure that new cases are contained, and the second wave that we know will come – likely in the autumn – can be suppressed as much as possible.  I am hopeful this will be made available; we can at least ensure we do this for ourselves, our families and colleagues and do our best to prevent spread. Furthermore, now that we are finally able to accurately test to a high level, we can seek advice and guidance promptly in order to avoid/reduce the complications of COVID-19 through early intervention and proactive management in the community.  
   
   When one has COVID-19 (or other infection) one first develops IgM antibodies, the “quick response”… As time goes on one develops IgG memory antibodies (usually detectable with COIVD 19 from 21 days after exposure or 14 days after symptoms; there will be exceptions when it takes longer to show an antibody response). IgM antibodies fall again quite quickly, but the IgG antibodies stay – for a while at least. Just because we have or have previously been found to have COVID-19 IgG antibodies does not mean we are entirely immune. 
   
   We can organise for the test kits to be sent to you in advance of the launch of the test on the 11th May 2020. However, the sample must NOT arrive at the TDL laboratory before the 11th or they will not be able to be processed.  
   
   
3. As written in my previous email dated 2nd April 2020, I am not a fan of the cartridge test (rapid linear flow test) COVID-19 antibody test. I am happy to support a patient through this test but currently – and following the advice of Public Health England – I am not offering the test myself. 
   
   
4. Positive test results are shared by The Doctors Laboratory with Public Health England which is a legal requirement and important for tracking and tracing which will with time hopefully become more widespread. 

Notable Observations Over The Past Month

1.  Quite a number of people with long-lasting, non-specific symptoms have not been particularly unwell with COVID-19, but the long-term lethargy, feeling of toxicity, feeling of unease and disequilibrium (not as in their true balance – although sometimes this too – but rather in their sense of self) is marked, but non-specific and frustrating for them. The COVID-19 IgG Tinies blood test is particularly interesting for this group of patients. 
   
   
2. A number of patients who have had COVID-19 symptoms (some confirmed), have recovered completely only for the symptoms to return. The second round was not quite as strong but they did have fevers, cough, sore throat and gastro symptoms. These patients recovered fully after the second flare. They have not had increased lethargy or residual symptoms following the second flares. These are observations but small numbers so certainly not statistically significant. Trends are emerging and hopefully they will be accumulated at some point soon. 
   
   
3. I am seeing more gentlemen present with/complain of testicular pain as a symptom or persistent side effect of COVID-19 (in each of the gentleman it settled a few weeks after they recovered fully from their other COVID 19 symptoms). This makes sense as there are ACE II enzymes on the surface of cell membranes of the lungs, the gastrointestinal tract, the testes and other organs. 
   
   
4. We all now know that mortality rates in men are higher than women. Oestrogen may be protective. There needs to be more research into this. I have had a number of pregnant ladies who have had COVID-19 and their symptoms are markedly milder than their partners. Pregnant ladies have even higher levels of circulating oestrogen because they are pregnant. 
   
   
5. A few of my patients who have had COVID-19 and were tested through NHS 111 at the beginning of the COVID-19 outbreak and then recovered have been contacted to donate plasma so this can be used to treat other patients. 
   
   
6. People can complain of bouts of shortness of breath and butterflies in their chests. This can be symptomatic of micro-emboli or large pulmonary emboli or it can be a panic attack/anxiety (even if you are feeling completely relaxed), so it is good to discuss.  Blood clots can also form in other parts of the body as part of the inflammatory response caused by COVID 19. We have the option of not only investigating for blood clots (through blood tests and scans) but also of treating for these in the community prophylactically where indicated or actively if diagnosed (the dose of blood thinner will vary). I have prescribed blood thinning injections that patients can self-administer when indicated. 
   
   
7. I have seen an increased presentation of rashes with COVID-19. I have heard of cases where a rash was misdiagnosed as something else. Rashes need to be checked. An acute inflammatory response can cause platelets to drop and can separately affect clotting factors. It is possible to get bleeding into the skin and so have a rash reviewed (it is easy to see rashes on video consultation so in the first instance you do not need to leave your home). 
   
   
8. I have seen increased bruising develop after the COVID-19 clears as well. That inflammatory response in the body can persist and causes symptoms later too.  I have heard of this particularly in the hands and feet.  
   
   
9. Some people are presenting with blistering on the fingers or toes. 
   
   
10. Kidney damage is not an uncommon long-term side effect of COVID-19 in patients that have been hospitalised.
    
    
11. I am certain there will be an increased incidence of fibrotic lung disease as a long-term side effect of COVID-19 in patients who were unwell enough to be hospitalised. 
    
    
12. Some patients who have lost their sense of taste and smell take numerous weeks before it returns to normal.
    
    
13. I am seeing more people anxious about the lifting of lockdown and the restarting of schools, needing to take the tube, needing to return to commuting between work and home, be it within London, between towns and cities, or between countries. The vast majority are very keen to continue to work from home. 
    
    
14. Finally, I have many age 70-year-old and over patients who are healthier than 50-year-olds. Much of this has been kept up through their daily exercise (mental and physical) over years. Their immune system might not be as strong due to age, but I think the majority are intelligent enough to judge for themselves. Of course, it is important to not overwhelm the NHS, but would it not be fair for them to be given a time allotment to go out, when it is less busy? This is what they are doing in Spain successfully. 

COVID-19 in Children

There has been a letter circulated by the NHS North Central London Clinical Commissioning Group on the weekend of 25-26th April 2020 regarding gastrointestinal and cardiac inflammation secondary to COIVD-19 in children and a small subset of children becoming very unwell. This was circulated by WhatsApp amongst parents and the day after was in the news. This release caused quite a bit of panic amongst parents, understandably.  
 
COVID-19 remains, thankfully and in general, rather non-serious in children. It can cause flu-like symptoms, although often far more mild symptoms, but usually a child gets over them fully and quite quickly.  
 
With strong viral (and bacterial) infection, in some cases there is a surge of inflammation which can trigger a massive response in the body, in both children and adults. When there is more strong viral infection about (i.e. there are many cases of COVID-19) then we are likely to see more of this type of reaction. 
 
We must not be lulled into a false sense of security: children do not have the ACE II enzymes on the surface of their lung cells, so their risk of secondary viral pneumonia – what has been considered the main COVID-19 risk and side effect is avoided. This does not mean they are not at risk of other complications, but these are very rare indeed.  
 
Children change quickly. They can be bouncy and boisterous in the morning and in the afternoon have a temperature and rash. As always, guardians must monitor a child’s temperature, fluid intake, urination, breathing, check them for rashes (the glass test – when you roll a glass over the rash, does it temporarily go away?). Check they are responsive: do they rouse when you wake them? Check they recognise you. Is a small child consolable? Do they settle when you pick them up and cuddle them? Are they floppy?  
 
I always speak to the guardian of my children patients regarding the things to monitor and what to look out for if they are unwell at their first consultation with me. What one looks out for with COVID-19 is exactly the same as how one monitors for other infection.  
 
I have also always said a guardian needs to go with their gut instinct. If your child is not well, they need to be checked. You must speak with a doctor.  
 
I remember working in the Paediatric A+E (ER), we learned to tell parents if there was a change or a deterioration or if they were worried, to come back. We expected to see a small percentage of the children we had seen earlier in the day again. This is because children can change so quickly. I would always tell guardians, if a child changes for the worse, if they are not improving within a specified time frame (which I agreed with them) or if your gut instinct tells you something is wrong, then come back. This has always been my standard practice. If you are worried about your child, you need to let me (or another doctor) know. And if you are worried later, you need to let us know again. It is never disturbing or wasting time. 

My Current COVID-19 Management

There is much we can do in the community. There are different philosophies when it comes to practicing medicine:  

1. My belief is to be proactive, in the current circumstances, if anything, safely overtreat a little, rather than miss the opportunity of preventing a person deteriorating. 
   
   
2. When a patient has COVID-19 symptoms we have a telephone or video consultation and discuss their symptoms in depth. I inform them of things we need to look out for. We organise for medication to be collected by a friend/family member or to be delivered if necessary. 
   
   
3. Every 3-4 hours they send me a WhatsApp update which includes a brief update of: 
   
   – Temperature 
   – Pulse 
   – Oxygen saturation 
   – Symptoms 
    
   This helps me to stay in the loop and (hopefully) pick up on nuances of change before they are apparent to a patient.  
    
   (A separate example I often use: if one has migraines which are triggered by heavy pressure in the atmosphere –  a common trigger for migraine – and one reads in the paper it is going to rain in two weeks, it won’t help to take my migraine prevention medication now. If however one takes it an hour or two before the rain is due to start, it can prevent that migraine from coming on. If you take it too late you’ve missed the boat and the full blown migraine can have developed. It is all about kicking in with the right medication at the right time). 
   
   
4. I will advise on what medication to take and when, depending on the symptoms. These may include: Paracetamol, Ibuprofen, Aspirin, Dioralyte rehydration salts, Augmentin antibiotic, Azithromycin antibiotic, various types of inhalers to help open up or prevent the narrowing of the airways, cough syrups to reduce a coughing spasm, medication to clear mucus, blood thinners to prevent clots, sometimes antivirals, sometimes antihistamines (not because of COVID-19, but if the airways are irritated due to allergy or COVID-19, then the mucus membranes and airways are likely to be more sensitised/irritated, sort of chicken and egg), very rarely Hydroxychloroquine etc. There is no standard of what to do. It needs to be adapted to a patient’s current symptoms, risks and medical history.
   
   
5. We get specialists involved as and when necessary and refer to hospital as and when necessary. 

Medicines To Have In Reserve For COVID-19

I am in two minds about this. It is not correct to stockpile medications. Then again if one lives more remotely, if one lives alone, if one has other pathology and so is at a higher risk, it makes sense to have medication in reserve to be able to treat at the first onset of symptoms, should it be necessary. The entire point of this however is to not treat yourself, but to discuss with the doctor along the way.

My Current Practice

1. Video consultations are up and running and they are working very well indeed; a close second to the real thing.
   
   
2. Many patients are worried of disturbing their doctor with minor ailments understanding there are other more pressing matters at the moment. It is however never a disturbance and important not to ignore any ailments/concerns (whether COVID-19 and not); it is not the time to let easily manageable things escalate. Seek advice/treatment promptly.
   
   
3. We are currently not allowed to do face-to-face routine screening such as to protect patients. It is a directive from government level. 
   
   
4. I refer patients to specialists who are also doing remote consultations when necessary to have specialist input.
   
   
5. We will need to catch up with: 
    
   – Screening (mammograms, breast ultrasound scans, PSA tests, FOB (faecal occult blood tests), colonoscopies, urine cytology, transvaginal scans, smears and HPV testing, routine medicals etc); 
    
   – Monitoring/follow-up of issues we are currently managing; 
    
   – Smears: these will be done in order of necessity – everybody will be invited back, and if a lady has a high-risk HPV strain this will are prioritised for follow up; 
    
   – Vaccines (paediatric, Gardasil (against HPV given to adolescents/teenagers), second or third doses of travel vaccines where indicated); I am recommending most paediatric vaccines be delayed with the exception of newborn vaccines which if a child is going to be exposed, must be done; 
    
   I will be contacting my patients regarding this and will have dedicated clinics to help you catch up with these. In all likelihood these will start in earnest in the autumn, second wave allowing, but we will do what is possible before then. I just wanted you to know, I am on it. If you have concerns let me know. If you have new symptoms, then these should be discussed before then. Please liaise with my secretary Jade (available on our new email ([email protected]) and new phone number (+44 (0) 20 3005 4330), please make note). 
   
   
6. There are a number of things we can do in the community now, if indicated and if a person would like. They are not urgent, but sensible to do so as not to lose momentum and as a matter of efficiency. I always write to a patient that they should make a note of when a recall is due, and I will make a note as well; I will start recalling for tests shortly. If we are sending you a test for a blood check, then please would you let us know if you are not at your usual postal address. 
    
   Samples can be taken at home – so you do not need to go out for simple tests – and will be sent onwards to the lab. I receive the results, interpret them, and write to a patient with advice and an action plan as usual.  
    
   Urgent cases and results will need to be prioritised over these less urgent follow-up issues, but I would prefer where possible not to fall behind on all of the hard work and time we have spent on optimising a person’s levels. In addition, with certain medication it is very important to ensure we keep diligently monitoring for side effects. 
    
   Examples of what can be done are: 
    
   – By Tinies blood tests we can do follow up cholesterol and lipid checks, monitoring of liver and kidney function, PSA (prostate specific antigen), thyroid function and antibodies, Vitamin D, Vitamin B12, cancer markers, PLAC tests, Omega 6/3 ratio checks; we can only request one or two tests per sample;  
    
   – On vaginal swabs a lady can obtain the sample to check for the presence of human papilloma virus (HPV). For example if a lady is known to be HPV positive, she can do a sample to recheck whether this has cleared or not. If it has not, we need to invite her in for a repeat smear as a priority when it is possible to do so. In addition, if it is a persistent HPV which is not clearing, then we might organise for a colposcopy appointment (looking more closely at the cervix with a camera) by a gynaecologist set up for when quarantine is lifted. 
    
   – Samples for tests on urine and stool can be collected at home eg faecal occult blood monitoring as a colon cancer screening and urine cytology to look at the cells shed from the bladder into the urine. The samples for then sent back to the lab by post (or again if you prefer to courier you can organise this). 
    
   I will write to you if you are a candidate for this. If you would like to get something specifically checked or monitored in this way, then you are welcome of course to reach out.  
   
   
7. It is still possible to go to the lab directly to get blood tests done (provided one is well, and free of COVID-19 symptoms).

General Commonsense Points

• Face masks: of course wear them. Don’t touch your face with your hands. 
  
• Hand washing: nothing has changed. Do it. Frequently.
  
• Groceries: wipe them down.
  
• Deliveries: if not perishable, leave them by the front door for 12 hours or until the next day. The virus half-life is such that, if on the surface, a significant amount will die during this time frame. Does it make a massive difference? We do not know. But why not do it? It’s an inconvenience, but so what, it is manageable.
  
• Oxygen saturation monitors: If you do not have one by now, it really is time to get one! Go to Amazon.

Quarantine will be lifted and we need to overcome our fear of going out and integrating back into society. Hopefully we will gain more confidence to do this once a logical and clear government plan is proposed. Now, with the possibility of testing and not having to leave our homes to do so, we can know when we are at risk of putting other people at risk, and we will be able to behave accordingly by self-isolating. We are then also able to seek medical advice more promptly. Hopefully this can be rolled out on a greater scale shortly. It is unhealthy, mentally and physically and for all age groups, not to have the stimulus of the outside world. If you don’t use it, you lose it. For me a hug from a friend or loved one I have not seen for a long time, can be extremely therapeutic. We are still far from there, but hopefully the latest news on testing brings us a little closer. 

Please take care of yourselves. 
 

With very best wishes.  
 
Yours sincerely, 

Kristina

Dr Kristina M Brovig 
MBChB DRCOG DFFP