COVID-19 Update No.4, November 2020

Dear Friends & Patients,

The second wave is upon us, entirely as predicted and expected. And a second lockdown whether we agree or not.

Here are my answers to frequently asked questions (some answers will surely change as more research, information and experience become available):

• We are so much further along than we were in February/March 2020 and we must not lose sight of this. We did not know the virus nor how the health system would cope. Intensive Care capacity was increased and impressively so; so much has been learned. The private hospitals remain open. Please do not lose perspective. I feel we are in such a different place than spring 2020.
  
  
• I am continuing to see patients face to face at the practice. There is no reason not to, provided the same criteria which were in place earlier this autumn are adhered to (patients who come must not have a fever, or have had COVID-19 or been a contact for 14 days; if they do they need to have a remote consultation and/or be visited at home if required).
  
  
• Yes I am having the flu vaccine this year (difficult to source, we have had a small number and have first given them to the most vulnerable; I am told more are coming).  The flu vaccine is well tolerated. It is quoted up to 1 in 10 can develop mild flu like symptoms for 24-48 hours. My experience is it is far less.
  
  
• It looks like flu rates might be down this winter because of distancing and improved hygiene. Getting both flu and COVID-19 at the same time would really not be very good.
  
  
• Yes I had the Pneumovax vaccine (we have these) against 23 strains of pneumococcal pneumonia because I think my potential exposure is such I should have extra protection. It is certainly worth considering for people who would like some extra protection or feel at higher risk.
  
  
• No I have not had COVID-19 and I do not have antibodies. I was certainly exposed and continue to be exposed but expect I have fought it off with T cell immunity, so far.
  
  
• I am not purposely trying to get COVID-19 and do not subscribe to the “get it and be done with it” mentality; equally so it would be great to have antibodies, for however long they may last. So, I will be careful and diligent but not hysterical nor am I allowing myself to become anxious. That would be more harmful to my mental health and in turn physical health in other ways. There needs to be a balance which I feel in many contexts is missing.
  
  
• If we wish/if it is indicated, we can now check for actual IgM and IgG antibody levels so the number corresponding to low, medium, high or very high immunity to COVID-19. And no, I do not know why it took so long to arrive in the UK as I know they were able to check for this in other countries sooner. It is a good question.
  
  
• Numerous patients who tested positive for COVID-19 IgG antibodies in spring 2020 have now tested negative (about 1 in 2). Those who had a worse case of the virus in spring 2020 are more likely to still have the antibody response. That makes sense and is how our body’s immune system works. There is a very high chance that those who test negative still have some T cell immunity so if they get COVID-19 again, it will be more mild.
  
  
• I am trialling the 15 minute antigen tests. These can be a game changer for offices, schools, all of us in allowing us to function more normally.
  
  
• We should remember when vaccination against swine flu (H1N1) was first available, our first dose of the vaccine was just against H1N1. It is a virus where the immunity wears off. H1N1 has been a component in all the annual flu vaccines since then. It makes sense to me that COVID-19 will eventually become part the annual flu vaccine. So our immunity from the first vaccine can wear off, however for those vulnerable or who like to be extra cautious, if/when it is available as part of the annual flu vaccine, those who get the flu vaccine will get a “booster” dose against COVID-19 every winter.
  
  
• Yes I will get the vaccine when it is ready. I am not worried that it will contain mercury; I do trust the big pharmaceutical companies when it comes to the vaccine development and production.
  
  
• Vaccine development is going impressively fast. Realistically the COVID-19 vaccine will roll out fully 2nd half 2021.
  
  
• No we do not currently know how effective it will be, which is an important point but some protection must be helpful and as time goes on the vaccines will become even better.
  

My areas of concern:

• I am deeply concerned about mental health in all ages of patients (currently far more than I am worried about COVID-19 itself):
  
  
• I have seen more cases of self harm in adolescents in 6 weeks which started during lockdown, than I did in all of 2018 and 2019 put together.
  
  
• Many of my senior patients are isolated and not seeing family or friends, especially those in a one-person household. One patient has not seen family or friends for 8 months face-to-face. In the spring she sat on a bench outside her flat in a small but empty and distanced public space in the sunshine and read a book. Three times she was stopped by the police, told not to rest but to keep moving. She is 87. I do not understand how this prevents a virus. But the distress this causes will precipitate other diseases for sure. That too will overwhelm the health system.
  
  
• People are fed up and resentful. Many are frustrated. Some are bitter and many are angry. I have needed to prescribe more antidepressants/anxiolytics to people in their 20s over this period than ever before, of course supported by mindfulness, lifestyle measures and counselling.
  
  
• The technology children are using for school, for home work and their social lives is impacting their creativity, their social skills and they are becoming rather addicted. Please put limits on their technology if you can.
  
  
• Working at home slips too much into family time for many. It is difficult for the work life boundaries to stay in place. People feel they are as effective at home as they are at the office. Some are as effective, many are just trying to convince themselves of this. Now with the second lockdown try to have clear boundaries.
  
  
• Over 70% of my patients who do drink alcohol, are drinking more, some dangerously so.
  
  
• Do not put new symptoms on hold. I am concerned about delayed diagnosis due to delayed presentation.
  
  
  Do you have:
  
  – New headaches?
  – Any new lumps or bumps?
  – Unexplained weight loss?
  – A new full body itch?
  – Chest pain or palpitations?
  – A persistent cough (2+ weeks) or wheeze?
  – A change in bowel habit?
  – Blood in the stool?
  – Blood in the urine?
  – New urgency or frequency or needing to urinate but not being able to?
  – Persistent lethargy/fatigue?
  – New night sweats?
  
  
• In addition, any other symptoms you are worried about should be checked, and at minimum discussed.
  
  
• Many tests can be performed at home and sent straight to the lab for analysis if necessary (stool, urine, swabs). In many cases, phlebotomists can come to your house and take blood tests if indicated.
  
  
• Severity and acuteness of symptoms between patients might need to be prioritised, but you are never disturbing.
  

Simple advice for the everyday:

• Do your own personal and family risk assessment: for COVID-19, and mental health and modify behaviour accordingly. We have done it before and know how.
  
  
• Focus on your mental health:
  
  – Turn off your phone and do not watch the news for a certain number of hours a day and at the weekends. The doom and gloom is simply toxic. Sensationalism and fact are not the same.
  
  – MOVE, ideally outside. Keep active.
  
  – Listen to classical music, audiobooks, do mindfulness, stretches and yoga. Get away from screens and to do lists and continuous information feeds.
  
  – Sit and have discussions (in person or on zoom) with family and friends. At the same time we all need some personal space which should be sought out by you and respected by others.
  
  – Be careful with alcohol.
  
  – Show yourself the respect and self worth by making things beautiful around you. It is proven this improves mental well-being and stamina.
  
  – Go easy on yourself. Focus on everything you are managing. On a daily basis I remind myself: don’t let the perfect be the enemy of the good.
  
  
• Take your Vitamin D and your fish oils.
  
  
• Restock your home pharmacy cabinet: have paracetamol, ibuprofen, aspirin, vitamin C 1000 mg tablets, a thermometer and an oxygen saturation monitor at home (do check the batteries work). And if you are allergic to something or do not tolerate it, then obviously do not have it there. I will spare you repeating the full details. We are experts at this now! But if you have queries, ask.
  
  
• Check you are not about to run out of your prescription medicines.
  
  
• A large number of patients have requested blood tests to check their baseline and assess where they can optimise their health and gain reassurance nothing is being missed. For many this is a proactive and preventative mindset which I understand and agree with. We have done a lot of this during September and October 2020.
  
  
• If you have new symptoms – of possible COVID-19 or something completely different (list above) then get in touch.
  
  
• I recommend post-COVID-19 checks which we will continue to do.
  

My current practice and COVID-19:

• Since 1st week September I personally have had 19 patients with COVID-19. All but one patient was asymptomatic or had mild symptoms.
  
  
• COVID-19 remains relatively mild in children. Recently most commonly tummy ache, nausea and vomiting, fatigue. Less so but still sometimes cough, and the jury is out on whether a runny nose is a symptom in children or not.
  
  
• Mortality rates from COVID-19 in healthy people are low.
  
  
• It is very important to rest. Even with the mildest or no symptoms. I am concerned about the long-term morbidity (complication) rates and feel there is not enough discussion nor data on this point. By resting and starting treatments or preventative measures early where indicated, you help to reduce the chance of these.
  
  
• Long COVID-19 exists and is nasty; an extreme fatigue plus other symptoms. We are managing it.
  
  
• Compared to other infection, COVID-19’s inflammatory response is far reaching and persists or can flare after the infection has passed (for example after one has tested negative on a repeat antigen test). I have seen examples of the inflammation on the lungs, fibrosis of the heart, ulceration in the gastrointestinal tract, damage to the kidneys, inflammation of the joints, inflammation of the blood vessels, recurrent streptococcal or herpetic infections, plus dysfunction of the autonomic nervous system.
  
  There is also a big difference now compared to round 1, we know about these. If one picks up on long term effects early, we can manage them proactively and help the body further to heal.
  
  So if somebody has COVID-19 it is extremely important, even if it is mild, to rest, rest, rest and speak to one’s doctor. Certain treatments started early really can help. Give your body the time and space to fight the infection. Support your body, even if you have no symptoms, because it is working hard and doesn’t need to be given more to do when it is already doing a great job fighting the infection (even if you have no symptoms, it does not mean your body is not working hard). Please do not go for a jog “to sweat it out”. That will not work and you will feel worse.
  
  If you have symptoms reach out early because there is quite a lot we can do: aspirin, vitamin C, zinc, blood thinners, antibiotics (with crossover anti-viral and anti-inflammatory properties) to reduce the severity, duration and potential side effects of the infection.
  
  

And finally remember, this will pass. If you are struggling or have concerns about yourself or a family member please reach out to me, your friends or family. Even if you live alone or feel alone, I promise you that you are not.

Stay safe, and strong.

With very best wishes.

Yours sincerely,

Dr Kristina M Brovig 
MBChB DRCOG DFFP