COVID-19 Update No.5, December 2020

Dear Friends & Patients,

There is much excitement about the new COVID-19 vaccine(s) and the return to normal life which will follow. I think it is imperative not to underestimate the enormous logistical challenge that administering so many millions of vaccines poses; it can and will be done. It will take time. I am still of the opinion that the vaccine will be more widely available by second quarter 2021. If people are offered it (and chose to get it which I generally encourage) earlier that is a bonus, but I think it is important to keep our expectations in check.
 
The UK government is centralising the administration of the vaccine and is deciding who will get the vaccines and when, based on their risk assessment. In the first instance the vaccine will only be available through the NHS. The first group of the population who will be offered this are the most elderly, vulnerable and some health care workers/care home staff. Vaccinating just this first group will take time.
 
Particularly for vulnerable and high-risk people, I would encourage you to ensure you are registered with a local NHS practice too such that you can be put into a priority group and allocated a vaccine at an early stage.  I have encouraged especially this group of patients to also register with the NHS, so in all likelihood you have already done this. If you are a high risk person and already registered, call them and ask what their vaccination plans are. 

Separately if you are a low-risk person but are interested in getting the vaccine, I would encourage you to register with the NHS if you are not to ensure access to the vaccine as we do not know when the vaccine will be available privately.

If you are not registered with a local NHS GP, click here to find one: Find an NHS GP

And here is this form you need to complete once you have spoken to the practice you identify in the first link and ensure they are taking on new patients: NHS Registration Form

Eventually the COVID-19 vaccines will likely be available privately as well. If you are interested in having one do let us know, we will put you on our waiting list and when we source the vaccine, if you have not had one on the NHS already, we will invite you in.


Heading up to the holiday season, please ensure you have your medication and request any prescriptions you need ideally now. Go check your stock. 
 
I will be away over Christmas and New Years however there are two lovely GPs covering the practice (Dr Khaleeda Siraj and Dr Leah Austin) and Jade will be answering your calls and emails. If reception is decent, I do my best to still be available to continue to support patients who test positive for COVID-19 especially. 


COVID-19 numbers are likely to go up over the holidays. I have already seen a spike amongst my patients in the past seven days. Even if you test negative on a COVID-19 PCR / rapid flow test / the new saliva COVID-19 test ( I am not familiar with the new salvia test so cannot recommend it), whatever you use, if you do not feel well, then you should not see others. Don’t forget a negative COVID-19 test is great news but not a 150% all clear. We must use common sense. Whether you know you have recent exposure or not, COVID-19 is still around and your body can be working hard to fight it. I have seen the most cautious of households and individuals get COVID-19. And I have plenty of patients who tested negative for COVID-19 but did indeed have it. That’s okay, but err on caution. If you do not feel well: for example tired, achy, headache, not just the classic symptoms of cough and fever and the others we are all familiar with, then you should stay away from family and friends. This is especially true if they are vulnerable.
 
We all are desperate to see family again, those of us who have been unable, and ultimately many of us who have been spent far less time together with the people we care for, and who care for us. I continue to see much evidence of this mental toll. I believe we must continue to each do our own personal and family risk assessment.

As a little holiday treat, I attach a meditation by the wonderful Sir Nick Pearson, renowned psychotherapist and my dear friend, who has helped so many of my patients with guided meditations and deep relaxation, learning to calm the mind when there is too much going on. He has kindly created a guided mediation to help us switch off, reset and breathe. Give it a go, maybe it’s for you and if not maybe you know somebody who this might help: Download Guided Meditation

For those who are saturated, exhausted and having a challenging time, hang in there; not only is 2021 a new year, it will undoubtedly be a much brighter one. 

Wishing you a healthy and safe holiday season.

With very best wishes.

Yours sincerely,

Kristina

Dr Kristina M Brovig 
MBChB DRCOG DFFP 

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 

Relocation September 2020

We are growing as a practice and adapting to the new normal.

To enable us to provide the same personalised patient care, effective 2nd September 2020 we are moving to 102 Sydney Street (opposite Chelsea Town Hall on Kings Road).

102 Sydney Street is an excellent HCA facility. We will remain independent but have access to (although not limited to) their specialists and facilities and where possible aim to achieve a “one-stop” patient experience when you come in.

We will combine both video and face to face consultations to ensure the upmost patient and staff safety, and distancing. Face to face consultations will be alternated with video consultations. Appointments will be spaced to ensure there is proper distancing in waiting rooms and consultation rooms will be cleaned between each patient. Staff will be routinely swabbed to ensure they remain covid-19 free and are not silent carriers. This is particularly important for our immunocompromised and higher risk patients.

All attending will have their temperature checked, wash hands and be given face masks on arrival as part of a new normal.

We will be returning to routine screening and plenty of “catching up” for medical issues which have been on hold during the first wave of covid-19.

We would be delighted to see you there.

We know that COVID-19 remains in many people’s thoughts – feeling worried, saturated, or a bit of both! I will be writing an update shortly with information to bear in mind as we go into the autumn and winter months.

This Time Is Precious

Reposted with permission from Sara Vicente at Make Space for Growth – makespaceforgrowth.com

I had a thrilling conversation with Dr. Kristina Brovig. Kristina is a GP in the UK and I was so grateful she shared with me the other side of life as a doctor – the life side. And how in fact, in times like this, that all gets very muddled.

Signs of Crisis

Kristina got warning of the health crisis very early on. Married to an Italian, she was close to the developments in Italy and knew it was a matter of time until the crisis reached the UK. After the early ski-season, one of the many ways that helped Covid-19 ‘globalise’, she started tightening precautions at her practice and ramped-up on tech to be ready for what was to come.

As Covid-19 hit London, Kristina was able to give care to her patients remotely. Despite the government’s choice to centralise all testing, she was able to provide extra support to the anxious patients who were told to dial 111 and just wait. In fact, she believes the usage of preventative measurements assisted her patients in staying away from hospital.

As to her usual patients, most interrupted regular care and more difficult cases had to be carefully evaluated to balance the risks.

At the peak of the crisis

During the hardest times, Kristina got short spells of sleep as she got her patients to keep her updated on their key metrics every 4 hours through WhatsApp. At a time where this was the only way, patients would self-check temperature and oxygen saturation and as needed record themselves coughing.

I have talked to many businesses where the practices had to change. But, as a doctor, all of Kristina’s business practices had to change. Prevented from seeing patients, it was technology that led the way. 

Helping patients manage anxiety

Care is due to those who are ill and need it, but also to those who are worried about an illness that presents very little answers. One of the new things Kristina did was a newsletter out to patients. She felt people were not getting sufficient information and put it out there to her patients on what to worry about and what not to worry.

She got an overwhelming response and the emails even went viral, which served the intended purpose of helping inform people and, at the same time, reduce the anxiety. Whilst it is not a practice she will continue post the end of this crisis (whenever that is), it was something that clearly put her in a differentiated position with her patients.

After the crisis

Care is not back to normal. People are not wanting to go back to the doctor just yet. Her practice is finding creative quick ways to get tests done, in a socially distanced manner. But the truth is, people want a break from worrying about health for the summer. Who can blame them? However, Kristina is increasingly concerned about the speed at which people started socialising and what that can do to the tail of the wave.

Looking forward, Kristina believes a lot will change in the way medicine is conducted and even in the way practices organise themselves. A large part of good care is the ability to investigate history and symptoms. Everyone’s time can be saved as these things can happen remotely. Also, when emergencies hit, time can be saved by “seeing” a patient remotely at first to help manage the symptoms. Kristina is really hoping these new practices can help her run less late in general!

However, soon part of the care can not be changed – if there is no examination, the breast lump may be missed. A scan may not be part of a regular check. Then what?

A doctor’s life

As the crisis kicked in, one thing that Kristina knew she had to sacrifice was everything else! She ran non-stop for weeks trying to care for c. 40-50 ill patients at one time.

Her husband, who is usually in Milan was now at home. Her son, age 12, started according to her own words, homeschooling himself. In fact, she is convinced he took a course on Minecraft, and excelled at it! However, it was better to be on Minecraft with 8 friends than completely isolated. When asked about screen time in times like these, Kristina is clearly more worried about personal isolation, especially for youngsters or those with no siblings.

The family also benefited from space and sought to have a floor in the house for each, especially a space where they could close the door to their ‘mess’.  Deliveroo also became their best friend. Amongst the chaos, they sought to make mealtime sacred, and Kristina reckons she only missed a few.

Ploughing through

These were unprecedented times. When I asked Kristina about how she managed through and stayed productive, her honest answer?

I just ploughed through it!

Sometimes, she even brushed her teeth with her phone on mute. People were scared and there was no other way. From someone who always wanted to be a doctor, this is no surprise.

Keeping perfectionism at bay

This crisis has been particularly hard for mental health. Whether people had previous issues, or for those facing a newly found anxiety or personal isolation, or simply for those trying to manage the same but all more intensely, these were uneasy times. For Kristina, the key was “don’t let the perfect be the enemy of the good“. What mattered was that the family was together and safe.

As a perfectionist, she had to constantly remind herself of that. And rely on Deliveroo or Minecraft more than before. It was hard to let go of the fear of letting someone down and just trusting you can only do your best.

Remembering precious times

As Kristina drove with her husband one day and he talked about the future when their son turned 18, Kristina was sure she did not want to focus on that. Rather, she wanted to focus on the upcoming 6 years instead and all the things she would do with him. This crisis had the effect of making us stop and think about what matters to us, what we value, what we want to keep, and we what we want to lock away indefinitely. All these things that you keep delaying, they are not a choice, they are life today. These are precious times.

I was so happy Kristina could share these thoughts with us.

Kristina’s Lockdown List

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 

COVID-19 Update No.2, April 2020

Dear Friends and Patients, 

It’s been a long two weeks since my first email sent morning 15th of March 2020. I have been requested to write an update. These are my thoughts and experiences, the answers to frequently asked questions from my patients as of morning 2nd April 2020. 

My answer when asked about my experiences so far with COVID19: 
 

  • Most importantly, the vast majority of cases really are quite mild. Perhaps not pleasant, but bearable.  
     
  • People are confused about isolation. Basically, we are now all isolating in our homes. If we develop COVID-19 symptoms, or if somebody in our household does, we should then avoid the grocery/pharmacist (if possible) /our daily outside x 1 exercise.  
     
  • For people who have been in touch with someone with COVID-19/suspected COVID-19, they must self-isolate for fourteen days from the last time that they saw that person.  
     
  • If symptoms come on during the course of these fourteen days, then one resets the counter and needs to isolate for seven days from the onset of symptoms i.e. if I see somebody with COVID-19 on the 1st of April I should isolate entirely for fourteen days; if however I develop symptoms on the 6th of April then I need to press reset and quarantine for seven days from the 6th so until the 13th April. So in actual fact the isolation from onset of symptoms is shorter than the duration of isolation if one is exposed as one might be shedding before symptoms appear. 
     
  • Some people are complaining of only headaches and/or loss of taste or smell. Great thirst is not uncommon. 
     
  • I am starting to see more patients who have already been isolating for over a week with symptoms creeping on. They can start quite mildly and then become more severe at day five/six. Also, I have seen where they can be quite severe and then start to get better, and then flare again with more significant symptoms. 
     
  • From the day one develops symptoms, one is contagious for seven days. One needs to self-quarantine for seven days and then no longer needs to isolate from day eight, provided one is feeling better. 
     
  • Presenting with fever, dry cough, body aches and pains is most frequent. 
     
  • I am surprised to have seen several patients presenting with symptoms of diarrhoea/abdominal ache.  
     
  • Some patients are presenting with fatigue, dizziness and feeling faint (a few have actually fainted). 
     
  • Some people are complaining of only headaches and/or loss of taste or smell. 
     
  • Some of the people I have seen most unwell have surprisingly not had a fever, although fever and dry cough remain the most common symptoms. 
     
  • The chest pain/discomfort/heaviness/tightness and acute shortness of breath can come on suddenly. Just because one was fine yesterday or earlier in the day does not mean that one should ignore acute breathlessness or assume it will pass. One should speak to the doctor. 
     
  • Although less common, we are hearing of more young people being admitted to Intensive Care Units, and also those without underlying pathology. It is important that people in their teens/twenties/thirties do not feel invulnerable to COVID-19. 
     
  • I have had fifteen patients in the age group 21-30 with significant symptoms in the past week. 
     
  • Symptoms can last up to 25 days (usually not this long).  
     
  • It is not infrequent to experience a post-infective cough which persists, secondary to residual airways inflammation.  This type of cough is not unique to COVID-19. I cannot comment yet if this seems more frequent with COVID-19. 
     
     

What is the status of the private sector? 
 

  • The private hospitals have now been requisitioned by the NHS. My understanding is initially they will treat acute surgical and medical emergencies, then recovering COVID-19 patients, and then eventually, if required, acute COVID-19 patients. 
     
  • Routine medical care has been suspended as the advice of Public Health England. 
     
  • There is no private facility for treating COVID-19 in hospital. 
     
     

Obs and Gynae: 
 

  • Contraception: take the pill on time, and do not run out of the pill if you do not want a surprise. 
     
  • Pregnant ladies: liaise with your antenatal team to see if your outpatient clinics will be going ahead or if remote consultations are an option. For patients who have private obstetric care, you should liaise directly with your Consultant Obstetrician who will guide you. 
     
     

What about the Nurofen/Ibuprofen/Brufen/Aspirin/Non-steroidal anti-inflammatory drugs (NSAIDs) debate?  

  • After my email sent on the 15th of March 2020, the French Health Minister tweeted to be careful with Ibuprofen. I was contacted by numerous concerned patients.  
     
  • Three separate points have arisen: 
     
    1. Concern that Ibuprofen increases susceptibility of the lungs to COVID-19: there is no significant evidence that taking NSAIDs (non-steroidal anti-inflammatory drugs) increases the risk of lung complications in people who are fit and well and “normally tolerate these medicines”. People with established asthma and emphysema sometimes do not tolerate them and they will be aware of this through the previous management of their respiratory disease with their doctor. Many of them have no problem with NSAIDs but we always say to be careful (as per my email 15th March 2020).  
       
    2. Following the tweet and concern that circulated, in many countries advice changed: to mainly take paracetamol and the was caution about NSAIDs. This is to avoid the side effects of NSAIDs, which will increase if they are not taken with care and as increased numbers of people take them, not because COVID 19 increases the risk of respiratory complications. This has not been made clear and as a result many people who would benefit from taking NSAIDs to help alleviate symptoms are now afraid to do so which is a shame. NSAIDs are often more effective at lowering a fever and reducing muscle aches and pains. I know of Intensitivists in Italy telling their family to take an NSAID at the first onset of symptoms to help protect the lungs, and they have the most experience with severely ill patients with COVID 19 at present. My point is advice varies, experience is evolving and so one needs to tailor this bespoke for oneself and one’s family, which is what I aim to do for my patients. 
       
      My advice, as a doctor written to my patients in email 15th March 2020, was purposely more informative to avoid the pitfalls associated with non-steroidal anti-inflammatories (which include Ibuprofen and Aspirin). The side-effects of NSAIDs have been known for a long time. The fact they may affect the immune system has also been known for a long time. There were/and there remain conditions to taking these medicines:  
       
      • “Speak to a doctor after taking them for 2-3 days”   
        (nothing is missed, you are not self-medicating ad infinitum; there is a reason in the UK Nurofen is sold in boxes of (usually) a half dose and there are only between 10-16 tablets in a box, which gives 2.5-4 days of the medicine if taken regularly: it is to prevent people from taking too many)  
         
      • “Do not take them if you have asthma or kidney disease or are known not to tolerate them”  
        (if you know a medicine makes you feel unwell you should not take it; if you know you have a stomach ulcer you will have been told you cannot take this group of medicines; if you know you are taking other medication which interacts, e.g. blood thinners, you know you cannot take NSAIDs; if you are pregnant you do not take Ibuprofen and other NSAIDs (it’s one of the first things I tell a lady when she wants to become pregnant (and then there are even some cases when aspirin, another NSAID is actually prescribed in pregnancy: there are always exceptions!)); if you are known to be allergic then do not take them (obviously); if you have asthma or lung disease, in some people it can exacerbate the symptoms, but in many it does not so they know they can take them) 
         
      • “Take them after food” 
        (prevents irritation to the tummy, gastritis and stomach ulcers) 
         
    3. There are multiple emails and WhatsApps circulating allegedly originating in Cork and Vienna that people who died of COVID-19 were found to have Ibuprofen in their system.  These have been proven to be false information fabricated on the web (The Irish Health Minister made a statement about this as the data was supposed to come from Cork) however I would like to make a point:  
       
      I would expect a person who had become so severely ill from COVID-19 that he/she tragically passed away to have so many medicines in his/her body: Paracetamol, Ibuprofen/Aspirin, Hydroxychloroquine/Chloroquine, antibiotics (probably several of them), antivirals (several), Morphine, paralytics and numerous of the medications mentioned in the list below. I do not think it would be the Ibuprofen or other NSAID which would have caused this. A normally fit person would not have passed away from a few doses of an NSAID (unless they were for example allergic and did not know this, which is a risk of any medication). 
       
  • I feel the NSAIDs issue has been blown entirely out of proportion and this was triggered by a tweet. If there are any concerns whether or not you can take this, (or any medication), it should be discussed with your doctor, which was also written in email 15 March 2020. Importantly, if there is a medication you feel uncomfortable taking, then of course you must not take it. There is nothing new which in a way is reassuring. 
     
     

The experience of my COVID19 patients: 
 

  • When a patient develops symptoms they are concerned about, I speak with them either by telephone or by FaceTime/video consultation to assess how they are doing. We discuss their symptoms and get certain measurements. We make an action plan based on their health and past medical history. 
     
  • Medication is either delivered to them or faxed/telephoned/emailed through to their nearest pharmacy which is likely to have the medicines in stock. The post is currently delayed so less favourable if the medication is urgently required.   
     
  • Patients are WhatsApping me (on a number they get given if they are unwell) from once daily to once every few hours, depending on their symptoms and what I ask them to do. If they are deteriorating, they reach out sooner. Please do not use this number for any admin whatsoever. It is for clinical issues. If I do not get back to them within five minutes, they know to contact the practice directly to liaise with my secretary Jade or access the on-call doctor. 
     
  • In the updates they send me their temperature, pulse, oxygen saturation, and symptoms. We adapt the management/treatment as much as we are able to in the community by supportive measures. 
     
  • Many patients are asking how they can be tested for COVID-19. There are a few facilities which are providing this by post. This is completely separate from myself at present. We are unable to offer this testing yet. A significant limiting factor is the delays in the post. I have some patients where their tests have arrived, they have been able to post the test results back, and the results are through. Most are still waiting for either the swabs or the test results to arrive. 
     
  • If there is a special way to take some of the medication I prescribe (for example, inhalers) then a video demonstration is sent. 
     
  • If a person is deteriorating or we are concerned and further investigation such as chest- X-ray, CT scan and/or arterial blood sample is indicated, then a person is sent to hospital. 
     
  • Currently when one is seen in hospital – in A&E – a COVID-19 test is not available. It is only available if a person is admitted to hospital, and even then it depends on the hospital whether or not the tests are available.  
     
    The patient may be diagnosed with COVID-19 based on chest X-ray results and the change in inflammatory markers and effects on white cells seen on the blood tests. 
     
    I do not think these clinically confirmed cases are included in the UK numbers as positive cases as they have not actually tested positive, as there is no test available. The doctors too are frustrated these tests are not available for their patients, and themselves/their families. 
     
  • Once patients have left hospital, we continue to support them and to monitor their symptoms closely. 
     
     

Testing: 

  • There are two types of testing currently: 
     
    • One is the nasal/throat swab which quite a number of patients have ordered themselves. This tells us if you have evidence of COVID-19 RNA in these passageways. It gives us an idea of what is going on here and now. 
       
    • There are now antibody finger prick tests. You place a drop of blood on to what looks much like a pregnancy test. These tests have false positives of up to 9% and false negatives about 2%. There are a few different ones and they should be readily available in the next week or two online. They are not entirely clear cut to interpret – so if you are early in the infection, and not yet producing antibodies, this might not be picked up. If people are unclear about the results, it should be discussed with one’s doctor/the company who produces the test. Many of these tests have information on how to interpret your results on their websites.   
       
  • I know labs abroad are extremely close to developing an actual blood tests which measure the antibody levels in the serum (so a normal blood test from your arm). It is the same type of test as when we check if somebody is immune to chicken pox or rubella for example. This test is the deal breaker: it will tell us when it is safe for somebody to return to work and help to get the economy going again. In Germany they are discussing giving “Immunity Passports/Certificates”. Super idea. It is prudent in my opinion to get these tests and many of them as soon as available. 
     
      

Negative effects of isolation: 
 

  • I am worried for all of the other medical issues that are being left untreated/missed/under prioritised: heart attacks, strokes, serious infection, cancers, long-term aliments that cannot currently be monitored, screening (albeit a “luxury” to be able to do) not being done etc. Once isolation/quarantine is over, we must play “catch up” where we can in earnest and really try to undo some of the other damage which is being done. 
     
  • I am concerned anxiety and/or depression will be exacerbated in those who already suffer from this. If you are having a hard time reach out. I am contacting my patients with anxiety and/or depression to ensure they are coping. 
     
  • I think the incidence of new cases of anxiety and depression will increase as isolation is prolonged, as stress increases and once social distancing is over, as people try to rebuild their businesses and lives. 
     
     

Medications for treating COVID-19 (simplified): 
  

The following medications are being used in various capacities: 
 

  • Azithromycin/Zithromax, (also referred to as Z-pack (some hospitals are also giving Clarithromycin/Klaricid which is in the same group of medicines as Azithromycin)): this is an antibiotic which has anti-inflammatory properties on the lungs and also has some crossover antiviral activity. 
     
  • Hydroxychloroquine/Chloroquine phosphate (sometimes being used in combination with Azithromycin):  old anti-malarials, makes it more acidic around the cells so the virus has a tougher time attaching. There has been an interesting study done in France on a very small group of patients which showed quite promising results. There was however no control in this group. Donald Trump picked up on this trial and announced to the world that all people in America would have access to Hydroxychloroquine/Chloroquine phosphate. Unfortunately it is not a clear-cut miracle treatment. Larger trials are being done. 
     
  • Remdesivir/Favipiravir (and less so Oseltamivir which is Tamiflu used for treatment of Swine Flu): antivirals which have been/are being used and have shown some promise. Used to treat flu. In Italy, family doctors (GPs) will soon be prescribing Remdesivir to COVID-19 patients in the community. In Japan they are very excited about Favipiravir (Avigan). 
     
  • Ritonavir/Lopinavir: medicines used to treat HIV which are being used on some COVID-19 patients. 
     
  • Tocilizumab: a drug to the Interleukin-6 receptor. Also has immunosuppressant properties. Used normally for adolescents and adults to manage their Arthritis (which is an auto-immune condition). 
     
  • Corticosteroids: have anti-inflammatory properties although can impact immunity so it is a balance. The doctors know this. 
     
  • Baricitinib: a tumour necrosis agonist again used for treatment of arthritis. 
     
  • Camostat mesylate: this medicine blocks certain protease enzymes. It is used for example to treat some cancers, it can be used as an antiviral (here obviously) and in some conditions where organs in the body, such as the pancreas, are chronically inflamed. I understand to be less promising. 
     
  • Antibody-rich plasma for people who have recovered from COVID-19: this is being experimented on in patients who have active COVID-19 to help their body fight the disease. 
     
  • Various types of ventilation. 
     
     

Over-the-counter support to help support one’s resistance at this time: 
 

  • Vitamin C 1000mg daily 
     
    • Ideally after food (to protect your tummy). 
       
    • If symptoms of COVID-19 develop: an adult can increase this to 1000mg after breakfast, lunch, and dinner. 
       
    • Vitamin C can make diarrhoea worse so be careful. 
       
    • Vitamin C can be hard on the kidneys, so one does not want to be taking higher doses for more than a week without speaking with a doctor. 
       
    • Do not take high doses of Vitamin C if you have kidney disease. 
       
  • Vitamin D3 
     
    • My patients know that I have been banging on about vitamin D for years. It is thought to be good for immunity and have anti-inflammatory properties. 
       
    • There was a report out in Italy this past week explaining a very high proportion of people going into intensive care due to SARS secondary to COVID-19 had low levels of vitamin D. 
       
    • I recommend Vitamin D3 3000-4000 iu daily currently. If you spend time in the sun, reduce this dose. 
       
    • Patients who have sarcoidosis or other forms of sarcoid should not be taking vitamin D supplementation without discussing with their doctor as it can trigger a flare of sarcoidosis. 
       
  • Magnesium 
     
    • Can be helpful for achy muscles. 
       
    • It is however also a natural laxative, so if you take too much be close to the loo. 
       
    • Any good quality over-the-counter brand such as Magnesium citrate 400 mg once daily. 
       
  •  Zinc 
     
    • Thought to be good for immunity. Do not take more than the dose recommended on the bottle, obviously.  
       
    • Sometimes being used in a hospital setting with Hydroxychloroquine and Azithromycin as is thought to interfere with the RNA replication, but there are no studies on this yet. 
       
  • Turmeric 
     
    • There are no trials on this, however it is a naturally occurring anti-inflammatory. Extra can easily be added to your food. 
       
  • Omega-3 
     
    • Omega 3 has anti-inflammatory properties (Omega 6 is pro-inflammatory, it is the ratio between the two which is important, but that for another time); 
       
    • I usually recommend that my patients take a good-quality preparation of omega-3, 2000mg daily. Even in people who eat plenty of fish. 

Taking the above supplements will not treat COVID-19 and will not stop somebody from getting it. The idea is to support the body as much as is possible in a safe way through supplementation which some people find particularly beneficial. 
 
A final thought for the university students/secondary school students whose exams have been cancelled and do not have closure to their years of study working towards their degree: do something useful with this time. It will help you to process the unexpected changes. It does not need to be grand or important, but fulfilling to you in some way. I am certain in future you will be asked what you did with this time. I expect we will all be. 

With very best wishes. 

Yours sincerely,  

Kristina 

Dr Kristina Brovig 
MBChB DRCOG DFFP

COVID-19 Update No.1, March 2020

Dear Friends and Patients, 
 

A challenging time awaits us. In addition to the practical logistic information which has already been circulated, I wanted to send you some advice and share some of my personal thoughts regarding the current COVID-19 situation and risks, particularly regarding in the UK. These are my own thoughts and understandings as of the morning of the 15th March 2020. There will be other opinions, and statistics will change. 
 

This is what I am telling my family: 
 

  • Wash hands. The importance of this cannot be underlined enough. Twenty seconds, count out loud, include wrists. Again and again. Just do it. No exceptions. 
     
  • Symptoms of COVID-19 are fever (above 37.8C) and dry cough, often painful, shortness of breath, fatigue and can also be sore throat, runny nose, headache. It does not need to be all of these symptoms, but does tend to be fever, cough and shortness of breath. 
     
  • The infection is spread by water droplets when somebody cough or sneezes. The virus can last in the air for ten minutes after being coughed/sneezed out. It can last on hard surfaces for four days and soft surfaces for up to nine days.  
     
  • A mask will protect you from somebody who coughs or sneezes straight at you, but not from the sides. You must not touch your face as infection on your hands can spread to your eyes, nose and mouth easily – and is most likely transmissible by your hands after touching something. If the mask is worn for awhile it becomes moist and permeable and not protective. Fiddling with a mask increases the risk of infection. (if you are prone to touching your face, as most of us are, practice not to at home by putting vinegar on your hands to make you realise how much you touch your face and help you to break the habit). 
     
  • Once infected, symptoms manifest themselves on average on day five after exposure, but from day two up to day fourteen. There are apparently a few cases in China of it presenting at 21+ days post exposure, but this is the exception. 
     
  • Children particularly under the age of fifteen do not have the protein in their lungs that COVID-19 attaches to, so they are generally more protected. They can/will get a more mild flu like illness but unlikely therefore to get the secondary viral pneumonia we are worried about. They are however still vectors for infection and will be shedding and spreading the virus. So they can bring it into households, to the immuno-supressed and the elderly. If a family member is unwell at home (elderly/adult/adolescent or child), all family members, including children in the same household should also be at home for seven days. Only remote playdates by FaceTime or Skype. No playdates for children in person at all, at any time. 
     
  • The data from Italy is extensively published; analysis of morbidity and mortality figures updated twice-weekly by age, group and by region.  
     
  • As of 12th March 2020 nobody has died under the age of thirty. Out of 1016 deaths at that time, between age 30-39 there were two deaths, between the age of 40-49 there have been four deaths, between the age of 50-59  there have been 25 deaths, between age 60-69 there were eighty deaths, between age 70-79 there were 362 deaths and the remaining deaths were over this age.  The mortality rate increases for each decade above this and with increasing pathology. Protecting our older population is imperative. 
     
  • Over the past few days it looks like more young (20-49) people are getting infected but numbers are thankfully still relatively small. 
     
  • I am concerned numbers will get worse as more data comes through and access to healthcare and respirators decreases due to sheer volume.  
     
  • If one has had the infection once, one cannot get it again. This is generally the idea. There are reports from China of people being infected for a second time but few.  
     
  • But there is rumour the virus is mutating and if one has COVID-19 once, then one is not immune to the mutated form. The original and mutated strain will ultimately be related and it makes sense that the original infection will at least provide some immunity but not complete immunity.  
     
  • Immunosuppressed patients –  I have already been in touch with my patients who are immunosuppressed. If you have not been contacted please contact my secretary. If indicated they have been prescribed a course of antibiotics in reserve to start at the onset of infective symptoms. You should speak with me/your doctor about this at the time. The main complication of Corona virus is viral pneumonia and antibiotics do not help with this. Immuno-supressed patients and people particularly with lung and/or cardiovascular disease and/or diabetes have an increased risk of developing a secondary bacterial pneumonia in 12-17% (it looks like) of cases. It is for this reason they have the antibiotics in reserve to start at the onset of symptoms, to reduce the incidence of this happening. 
     
  • People under the care of specialists for ESTABLISHED lung disease, immunosuppression, cancer, diabetes, rheumatological disease, cardiovascular disease etc should be in touch with their specialist/GP. Doctors are being inundated and should ideally not be contacted by the worried well unless necessary. That does NOT mean you should not disturb the doctor. It just means a conversation is not for a social reassuring chat. 
     
  • Do not visit elderly relatives in their homes, and especially nursing homes. Call regularly though, be in close contact. It can get lonely and they can be scared. Offer kindness and support. Don’t talk about doom and gloom. Try to stay upbeat and keep them upbeat. Skype and FaceTime can be a great company. 
     
  • Over the years I have given boosters vaccine against Pneumonia and flu injections to the over 65 population and at risk patients who were willing to have this. So the majority of my patents who fall into this category have this extra protection. 
     
  • Do not stop or change your usual medication without speaking to your doctor. There is a rumour certain blood pressure medicines make you more susceptible to infection. This does not appear to be the case. 
     
  • People 60 and over: STAY HOME. If you need to go out, do so only every few days, plan what you need to do, what you are going to buy ahead of time, get there quickly, avoid other people, pay contactless ideally, then go home, wash your hands and do not touch your face. Try to stay 2 metres (6 feet) away from other people in shops and on the street. Get family and friends to deliver things and leave it on your door step. Order online. And DO NOT go out if you have cold or flu symptoms. Full stop. 
     
  • You should of course avoid crowds. 
     
  • Travelling abroad for work or pleasure – do not do it.  
     
  • Travelling abroad to go home/abroad – do it now. Do not delay. Many borders are already closed. It is important to be settled quickly and isolate. If travelling to elderly parents, self-isolate for 14 days before seeing them. 
     
  • The UK not testing for COVID-19: this is a decision at government level. It is frustrating and I do not agree with it.  
     
  • The UK’s decision not to close schools now: again this is a decision at government level. They are very likely to close, just not yet. There has been a call for the government to publish the models they are basing their predictions and advice upon. Hopefully this will be published shortly and will help to instil confidence in their decisions. Current guidelines are different that what the WHO is advising and this is understandably making the public uneasy.  
     
    I received an email late last night that my son’s school is now closed until mid-April and likely longer. I am relieved.  
     
  • In the UK private hospitals are not currently taking COVID-19 patients; they will manage other medical issues.  
     

What to do if you fear you have COVID-19: 
 

  • If you are unwell, with fever and cough, or however mild cold/flu symptoms, self-isolate. This means stay home for seven days. Even if you are feeling well within 24 hours. No flexibility or exceptions to this. In the UK we will not know if your infection symptoms are due to COVID-19 or not, so always assume it is. If you get mild symptoms then that is good – you will have developed some immunity. But you need to do this self-isolation for every cold/infection you get… as you will not know if that particular time was COVID-19 or not, as there will be no test available to confirm. If testing becomes more widely available this will change. Only people in hospital are being tested. Currently there is no testing available privately either. 
     
  • It is not a time to be stoic and “sweat out a cold”. If one developed symptoms of cold/flu then by using symptomatic relief, this can help to keep a fever down, it helps us to feel a little better, be able to drink more, eat more, sleep better and this in turn supports our body to help fight the virus.  
     
  • I often explain it as: if the medicines can help reduce one’s fever a little, the body saves some energy which can be better used to fight the virus instead of using those resources on fighting the fever. Taking over the counter cold and flu medications are not strong enough to mask anything sinister; but they can take the edge off things and help us support our bodies better whilst it fights the infection. 
     
  • Drink plenty of fluids. With fever we have an increased risk of dehydration. Sip little and often.  
     
  • Do NOT “starve a fever”; eat small amounts often – dry toast, broth/soup with noodles/rice, crackers etc. Avoid milk and dairy (unless you really feel like it and your body is telling you it wants it). For children then important thing is they eat – so whatever they will eat is acceptable. 
     
  • At the first onset of symptoms take Ibuprofen (if you are NOT allergic and DO NOT have a stomach ulcer or asthma and are known to tolerate this) after food three times daily, ideally at 6-8 hours intervals. You can do this for 2-3 days as “self-medication”. If you need this for longer you should speak with a doctor. One can also  take Paracetamol/Panadol/Day Nurse & Night Nurse or what your chemist advises every 4-6 hours. Maximum 4 times in 24 hours. Importantly, take the dose advised. Do not take one 500mg paracetamol instead of the full 1 gram (2x 500mg). Don’t tickle the problem but rather take the advised dose for maximum effect. This is not the time for “I really do not like taking medicines” (I don’t either, but we can do this for another infection, not this one). 
     
  • If you have previously been told you cannot take the above medicines, or medications in these groups (i.e. so you cannot take non steroid anti-inflammatory drugs, abbreviated to NSAIDs, classically asthmatics cannot unless they have previously taken them without a problem) then it is not the time to start and you should speak with your doctor before deciding what to take. 
     
  • If you have infection, it is best to sleep in a separate bedroom from everybody else at home, and have your own bathroom to use if possible. You should stay at 5 m distance from people in the home ideally. Your food should be left outside your door. This should be for 7 days. Obviously a parent or guardian must stay with a child. 
     
     

Medical Care Plans: 
 

  • Stay home and self-isolate. 
     
  • If you are unwell call your doctor. (You can also call NHS 111 for advice). 
     
  • You will be given an initial triage. You will be offered a Telephone/FaceTime consultation with the doctor. The doctor will prioritise these by order of who is most unwell. If you are deteriorating please call back. 
     
  • We will liaise with all patients who need to speak with a doctor by telephone/FaceTime who are worried they are unwell and/or deteriorating. We will give you a time frame in which we will contact you. Unfortunately we are anticipating a large volume of Telephone/FaceTime consultations and it is not possible to give an exact time you will receive your call. We will ask you your temperature (so know what it is and monitor it) to tell us if you are eating/drinking, if you are passing urine etc.  
     
  • We might send you some equipment to test a few measurements yourself which might include an oxygen saturation monitor (which is indicated in particular for somebody with an underlying lung condition): 
     

Some people are choosing to purchase oxygen saturation monitors themselves to have in reserve. An oxygen saturation monitor is clipped onto the end of a person’s finger.  
 
It works as follows:  

When we breathe in, our lungs pick up oxygen and this goes into the arterial blood stream and is delivered around the body. The most accurate way of checking a persons oxygen saturation (how much of the blood is saturated with oxygen) is via a blood sample from an artery (this is done in hospital). A more rudimentary check is by checking one’s peripheral oxygen saturation (if one is wearing nail varnish, then this will interfere with the measurement. If one’s finger is cold – often when we have a fever our hands and feet can be cold – this will interfere with the measurement. It is important to heat up the fingers).  With a bad lung infection the oxygen saturation goes down. It is possible to get an idea of the level of oxygen in the blood by checking with the oxygen saturation monitor.
 

Normal levels tend to be 96% and above (we do not usually get to 100% unless we are on oxygen). It can be lower in a person with lung disease. When we have infection our levels dip lower than this. If one is developing a secondary significant chest infection or Pneumonia (or for example during other respiratory compromise, so for example an asthma attack), one’s levels will dip much further. 
 

Some people are choosing to buy the oxygen saturation monitor themselves online – I know Amazon has very many, as do many pharmacies, the practice has some. Basically, should you purchase an oxygen saturation monitor and become unwell, then we can advise you on the monitoring of your oxygen saturation. Some people find it a useful piece of equipment to have in reserve. 

  • If you require examination, we will advise you where to go to have this done (touched upon in email sent overnight). 

Finally, the responsibility for all of us who are well: 

  • As much as possible, keep healthy: sleep, do not skip meals, do some exercises and stretches at home (but don’t suddenly decide to train for the olympics and injure yourself, it is not the time for this), do some deep breathing, there are so many relaxation apps (don’t just download them, use them), speak with friends and family and be positive. Plan what you will do, the amazing places you travel to, and friends and family you will see again when this is over. Sit as a family to eat meals. Please do not dramatise the apocalypse now. We are so so far from there. We just need to be sensible, cautious and importantly considerate to those who are less immune and more vulnerable. 

Dr Kristina Brovig

MBChB DRCOG DFFP

  • General Practitioner: Qualified in 1998, Ninewells Hospital and Medical School, Dundee, Scotland.
  • Interests: Family Medicine, Obstetrics & Gynaecology, Paediatrics, Fertility, Disease Prevention, Mental Health.
  • Completed postgraduate specialist training in Paediatrics with Neonates, Obstetrics & Gynaecology, Care of the Elderly, General Medicine, Acute Medicine, and Accident & Emergency.
  • Worked as a GP in the local area for the past sixteen years.
  • Dr Brovig is married to an Italian, has a son and lives locally.
  • GMC Registration: 4539834