Within a few months the global coronavirus pandemic (COVID-19) has spread around the world and numbers continue to escalate in most affected countries. Deborah Bellamy reviews current the information available about the virus and what the public health concerns are for the UK.

Current position on Coronavirus (COVID-19)

On 11 March, the World Health Organisation formally declared the COVID-19 outbreak to be a pandemic, defined as when a new disease for which people do not have immunity spreads around the world beyond expectations. This is the first pandemic caused by a coronavirus, according to the WHO.

On 11 March, the WHO formally declared the COVID-19 outbreak to be a pandemic which can be defined as when a new disease for which people do not have immunity spreads around the world beyond expectations.

As from 19 March 2020, COVID-19 is no longer considered to be a high consequence infectious disease (HCID) in the UK. Now more is known about COVID-19, the public health bodies in the UK reviewed information about COVID-19 against the UK HCID criteria and determined several features had changed, including greater clinical awareness and specific and sensitive laboratory tests, the availability of which continues to increase.

Patients with COVID-19 are no longer being solely managed by HCID treatment centres due to the numbers involved. All healthcare workers managing possible and confirmed cases must adhere to updated national infection and prevention (IPC) guidance. This guidance includes instructions about different personal protective equipment (PPE) ensembles that are appropriate for different clinical scenarios and is regularly updated.

From Monday 23 March, everyone in the UK is required to stay at home, except for very limited purposes. There have been closures of shops, businesses and venues, and all gatherings of more than two people in public stopped.

In addition to self-isolation and social distancing, the public can currently exercise outside once a day, travel to and from work where "absolutely necessary" if unable to work from home, shop for essential items and fulfil any medical or care needs.

Relevant authorities, including the police, have been given the powers to enforce restrictions via fines and dispersal of gatherings.

In the UK, the Government are constantly re-assessing scientific evidence and the country remains in the delay phase. The predicted peak of COVID-19 cases may be within the next two to four weeks. The strategy of suppressing this peak, however, may cause it to broaden. It is possible there may be more cases in the coming weeks before the impact of social distancing can be fully assessed.

Guidance has been published by Public Health England (PHE) and Health Protection Scotland (HPS) to provide healthcare providers in all settings with information around guidance on the assessment and management of suspected UK cases, and specific guidance for primary care, social and residential settings.

Such guidance is being reviewed and updated constantly and should be referred to on a regular basis as the situation is evolving daily.

A key priority is to ensure healthcare workers are protected in all work environments and that hospitals remain safe. As a consequence, different personal protective equipment (PPE) and mask and respirator combinations are being recommended for varying clinical situations and areas which take into consideration the infection status of confirmed cases versus possible cases and the risk of exposure to aerosols containing the virus. There are reports of issues with obtaining adequate PPE which raises concerns for all staff.

With the peak of the pandemic predicted with the next month, epidemiological information is updated with the most recent official information from the Department of Health and Social Care, NHS England (NHSE) and PHE through their websites.

What is a coronavirus?

A novel coronavirus is a new coronavirus, not previously identified. The virus causing coronavirus disease 2019 (COVID-19) is different from other coronaviruses that commonly circulate.

Generally, coronavirus can cause more extreme symptoms in individuals with weakened immune systems, older people, and those with long-term conditions like diabetes, cancer and chronic lung disease, such as chronic obstructive pulmonary disease (COPD).

How is it spread?

According to PHE, coronaviruses are essentially transmitted by large respiratory droplets and direct or indirect contact with infected secretions. They have been detected in blood, faeces and urine and, under certain circumstances, airborne transmission is thought to have occurred from aerosolised respiratory secretions and faecal material. In addition, the virus can survive for a certain amount of time out of the body on surfaces (up to 72 hours).

Respiratory secretions produced when an infected person coughs or sneezes containing the virus are thought to be the main cause of transmission when there is close contact of within two metres or less with an infected person. This risk is liable to increase the longer the contact period with an infected person and for longer than 15 minutes.

Individuals can catch COVID-19 if they breathe in the droplets or touch infected surfaces and then touch their eyes, nose or mouth.

The incubation period for COVID-19 and onset of symptoms is estimated between 0 and 14 days. The estimated average is 5–6 days. Most patients are usually considered infectious while they have symptoms and how infectious they are dependent on the severity of their symptoms and stage of their illness.

The median time from symptom onset to clinical recovery for mild cases is approximately two weeks and 3–6 weeks for more severe or critical cases. There have been reports of infectivity during the asymptomatic period and some patients may be completely asymptomatic, rendering infection control more complex.

Current guidance is based on knowledge gained from experience in responding to coronaviruses with significant epidemic potential such as Middle East Respiratory Syndrome Coronavirus (MERS-CoV) and Severe Acute Respiratory Syndrome Coronavirus (SARS-CoV). Both prompted global collaboration to reduce spread between people and to protect healthcare workers.

Updated case definition

Public Health England (PHE) updated possible COVID-19 case definition, guidance on testing and which cases should be reported to local health protection teams.

The Government issued stay at home guidance for households where a household member meets the possible case definition, and this should be adhered to along with restricted movement.

Travel history is no longer relevant to the possible case definition.

Staff who meet the possible COVID-19 case definition will need to stay at home but can work remotely if well enough to do so.

Patients self-isolating, but not unwell enough to be admitted, are not prioritised for testing.

Testing

The testing capacity in the UK is increasing daily with priority being given to those in hospital and NHS and social care staff to enable them to return to work more swiftly if self-isolating. The Government has pledged to increase testing massively.

Identifying how many people have had COVID-19 without showing symptoms and which NHS workers are likely to be immune is crucial. If it can be shown that a healthcare worker has developed antibodies to COVID-19 then this could mean a safer, speedier return to work which will be essential in the forthcoming weeks.

Current guidance provides a priority order of testing for periods when demand for diagnostic testing may exceed local laboratory capacities and triaging of requests is required.

  • Group 1: patient requiring critical care for the management of pneumonia, acute respiratory distress syndrome (ARDS) or influenza like illness (ILI), or an alternative indication of severe illness has been provided, for example severe pneumonia or ARDS.

  • Group 2: all other patients requiring admission to hospital for management of pneumonia, ARDS or ILI.

  • Group 3: clusters of disease in residential or care settings, for example long term care facilities and prison.

Some manufacturers are selling products for the diagnosis of COVID-19 infection in community settings, such as pharmacies. The current view by PHE is that use of these products is not advised.

Detailed information on case definition can be found at https://www.gov.uk/government/publications/wuhan-novel-coronavirus-initial-investigation-ofpossible-cases.

This is the same for all nations.

As it is still unknown how many have been infected worldwide, an antibody test would enable researchers to see a proper picture. New coronavirus tests may involve a simple finger prick, but such tests need to be clinically evaluated for efficacy and reliability.

Is there a cure for the coronavirus?

As a newly identified virus there is known no human immunity and as a viral infection, antibiotics are not an effective treatment.

Whilst no current pharmaceutical products have been shown to be safe and effective for the treatment of COVID-19, according to the WHO a number of medicines have been suggested as potential investigational therapies, which are now being or will soon be studied in clinical trials, including the SOLIDARITY trial co-sponsored by WHO and participating countries.

The UK government has invested massively into finding a vaccine for the virus, which is undergoing clinical testing and likely to still be several months away.

Which patients are at more at risk?

Generally, elderly patients and those with underlying health conditions, such as hypertension, diabetes, cardiovascular disease, chronic respiratory disease and cancer are considered to be more at increased risk developing severe symptoms.

How to protect those at high risk

For the elderly or those in vulnerable category, and therefore at increased risk of becoming seriously ill from coronavirus, additional precautions include:

  • not leaving home for three months

  • staying at least two metres (three steps) away from others in their home as much as possible

  • asking friends, family or neighbours to pick up shopping and medicines and leaving them outside the door.

If help is needed getting deliveries of essential supplies like food, elderly or vulnerable patients should be signposted to local charities and schemes.

What should everyone do?

In the UK, the NHS advice states anyone with symptoms should self-isolate and stay at home for at least 7 days. If they live with others, they should stay at home for at least 14 days, to avoid spreading the infection outside the home. This applies to everyone, regardless of whether they have travelled abroad.

Patients should be directed toward the dedicated coronavirus NHS 111 website for information. The advice is if their condition worsens or symptoms last longer than seven days, they should call NHS 111.

Symptoms to look out for

The most common symptoms are fever ≥37.8°C and at least one of the following respiratory symptoms, which must be of acute onset.

  • Persistent cough (with or without sputum).

  • Hoarseness, nasal discharge or congestion.

  • Shortness of breath.

  • Sore throat.

  • Wheezing.

  • Sneezing.

Some may also have generalised aches and pains and diarrhoea.

Public Health England are clear, no one should leave their home if they have either:

  • a high temperature — which means you feel hot to touch on your chest or back. You do not need to check your temperature if you do not have a thermometer.

  • a new, continuous cough — which means coughing a lot for more than an hour, or three or more coughing episodes in 24 hours. If you have an existing or usual cough, it may be worse than normal.

Advice in other parts of the UK includes the following.

  • Check your symptoms in Scotland.

  • Check your symptoms in Wales.

  • Northern Ireland: call 111.

If patients do not have no internet access, they should call NHS 111 or for a medical emergency dial 999.

For region specific information and advice in:

  • England visit nhs.uk

  • Wales visit phw.nhs.wales

  • Scotland visit nhsinform.scot

  • Northern Ireland visit HSC

  • Ireland visit HSE.

Information for Primary Care

General practice and the NHS will be considerably challenged by the volume of patients with coronavirus (COVID-19) over the forthcoming weeks and months.

Adherence to high standards of infection prevention and control, as well as complying with social distancing rules are the best way to prevent the person-to-person spread of pathogens, such as coronavirus.

All patients should be remotely triaged to assess whether a face-to-face appointment is deemed clinically necessary or whether follow up care and advice can be given using remote consultation methods.

To protect staff and patients and enable effective social distancing, practices can indicate recommended distances by way of signs or tape on floors placed at least two metres apart.

To achieve effective infection control, infection control policies and procedures must be implemented in full, especially those related to effective use of PPE, hand hygiene, sanitisation and environmental cleaning.

In the majority of cases, COVID–19 will cause mild to moderate illness. Initial data shows in excess of 80% of patients are either asymptomatic or have a mild form of COVID–19 and recover. Around 15% may get pneumonia, and of these approximately 5% become critically unwell with severe effects such as septic shock, multi-organ and respiratory failure.

There may be additional country specific guidance to each in the United Kingdom, as this guidance was written by Public Health England primarily for an English health professional audience. Managers are advised to check if country specific information is available as necessary and should please refer to Health Protection Scotland, Public Health Wales, or Public Health Agency in Northern Ireland.

To find local Health Protection Teams (HPTs) on www.gov.uk/health-protection-team, practices can type in their postcode to access further local advice/support.

Further information, in other parts of the UK may be accessed from:

  • Public Health Wales

  • Health Protection Scotland

  • Public Health Agency (Northern Ireland).

Interim guidance for Primary Care has been issued and is available on the PHE website.

NHS 111

NHS 111 has an online coronavirus service that can tell people if they need medical help and advise them what to do.

Current advice is not to leave home if anyone thinks they have coronavirus symptoms and to protect others by doing the following.

  • Do not go to places such as the GP surgery, pharmacy or hospital. Stay at home.

  • Use the 111 online coronavirus service to find out what to do.

  • Only call 111 if you cannot get help online.

Staff should refer to Guidance to assist professionals in advising the general public published by Public Health England and available at www.gov.uk.

Main principles

The main principles remain the same, namely to:

  • identify potential cases as soon as possible

  • prevent potential transmission of infection to other patients and staff

  • avoid direct physical contact, including physical examination, and exposures to respiratory secretions

  • isolate the patient, obtain specialist advice and determine if the patient is at risk of COVID-19.

COVID-19: interim guidance for primary care, published by PHE, provides details on dealing with patients and guidance on environmental cleaning.

According to the guidance:

  • patients booking in by telephone who meet the case definition should be directed to stay at home, or to contact NHS 111 online if they are getting worse

  • an unwell patient with relevant symptoms should be identified if they present at reception and immediately placed in a room away from other patients and staff

  • if COVID-19 is considered possible when a consultation is already in progress, withdraw from the room, close the door and wash your hands thoroughly with soap and water

  • the patient should remain in the room with the door closed. Belongings and waste should remain in the room. The patient and any accompanying family should remain in the room with the door closed while they are remotely assessed by a clinician in the practice

  • should the patient need to use the toilet, they should be allocated one for their sole use. Instruct the patient to wash their hands thoroughly after using the toilet and return directly to the room they have been isolated in and close the door. The toilet should be taken out of use until cleaned and disinfected following the decontamination guidance

  • if following remote consultation, the patient needs face-to-face assessment, staff must wear personal PPE in line with standard infection control precautions.

If the disease appears mild, the patient may be advised to go straight home to self-isolate, bearing in mind avoiding taxis or public transport.

Practice preparedness measures

Practices should:

  • have clear guidance for their staff based up national information and guidance available and updated as necessary.

  • use telephone triage, online consultations and Skype to the optimum capacity to protect staff and other patients. For staff who are self-isolating they can still work in this way.

  • ensure bank staff are kept up to date with local policies on COVID-19 in case they are needed to provide cover at short notice. Flexibility is needed within the Rota to allow for childcare or self-isolation to be taken into consideration.

There are other practical elements practices can put in place, these include the following.

  • Displaying posters at all entry points to the practice and prominent notice on practice website and online booking systems.

  • Messages recorded on practice phone systems.

  • Sending patients SMS (text) messages.

  • If a patient presents at reception, not previously being triaged, the receptionist should ask “do you have a high temperature or cough or breathlessness?” or “have you been in close contact with someone with coronavirus infection?” – if so the patients should immediately isolated.

  • Display of “Catch it. Bin it. Kill it” posters.

  • Alcohol-based hand gel for use on entry to and exit from the practice.

  • Ensure all staff know where the designated isolation room or area is and have access to contact numbers for HPE.

  • Laminated effective handwashing posters in the toilet areas.

  • If there is likely to be a delay with repeat prescriptions or routine appointments due to additional work pressure publicise this.

Patient information posters should be displayed in the practice. Suggested wording for practice websites and other communications channels as well as materials to display in practices are available from: https://www.england.nhs.uk/coronavirus/primary-care/.

Patient transfers to secondary care

If the patient is critically ill and requires an urgent ambulance transfer to a hospital, practice staff must ensure they inform the ambulance call handler of the concerns about COVID-19.

In all other instances, the case must be discussed with the hospital initially so that they are aware that COVID-19 is being considered and the method of transport to secondary care agreed.

Anyone with suspected COVID-19 should be instructed not to use public transport or taxis to get to hospital.

Following the patient transfer from the practice, the room should be closed and should not be used again until appropriately cleaned. Detailed information is available on PHE website and includes waste disposal.

Personal protective equipment for COVID-19 in primary care

Preventing transmission of COVID-19 requires both droplet and contact precautions. If an aerosol generating procedure is being undertaken then airborne precautions are required in addition to contact precautions, whilst this is unlikely in primary care, additional guidance should be sought.

PHE has published guidance on putting on and removing PPE which should be followed and PPE kit for general practice staff should be available.

If there concerns around the availability of PPE, the practice should contact the NHS National Supply Disruption line on 0800 915 9964 or email supplydisruptionservice@nhsbsa.nhs.uk.

All contact precautions need to be used to prevent and control infection transmission via direct contact or indirectly from the immediate care environment (including care equipment).

If there is any unavoidable contact with the patient, staff must minimise time spent with the patients, wear PPE in line with the standard infection control precautions, such as gloves, apron, and a standard fluid resistant surgical mask.

All staff should have access to and be trained in the proper use of PPE which should be disposed in the clinical waste after being removed. Hands must be washed with soap and water after all PPE has been removed and disposed of.

The current list of PPE for possible COVID-19 patients in primary care is as follows.

  • Disposable plastic aprons.

  • Disposable gloves.

  • Fluid-resistant surgical mask (FRSM).

  • Eye protection, depending on risk of being splashed by bodily secretions.

Eye/face protection should be worn when there is a risk of contamination to the eyes from splashing of secretions (including respiratory secretions), blood, body fluids or excretions.

Staff who have had and recovered from COVID-19 should continue to follow infection control precautions, including the PPE recommended.

Guidance for infection prevention and control in healthcare settings, adapted from Pandemic Influenza: Guidance for Infection prevention and control in healthcare settings 2020.

COVID-19: interim guidance for primary care, published by PHE, provides details on dealing with patients and also guidance on environmental cleaning.

Are face masks recommended for practice support staff and patients?

NHS guidance still states reception staff do not need to wear PPE.

Some practices have sourced protective screens for reception staff to help protect them from airborne particles.

If an individual patient is infected, the use of surgical face masks may reduce the risk of them infecting others. There is no clinical evidence that normal face masks will effectively prevent individuals from becoming infected.

PHE recommends that the best way to reduce any risk of infection is good hygiene and avoiding direct or close contact (closer than two metres) with any potentially infected person.

It is thought in some instances use of face masks may increase the risk of infection due to a false sense of security and increased contact between hands, mouth and eyes.

Environmental cleaning following a possible case

Once the patient has been transferred, the room where the patient was should not be used, the room door should remain shut, with windows opened and the air conditioning switched off until it has been cleaned with detergent and disinfectant. Once this procedure has been completed, the room can be used again.

Advice on cleaning of communal areas such as waiting rooms or toilets is also given in the PHE Interim guidance for Primary Care, but practices should also check if any updated guidance or information is available.

Dedicated or disposable equipment (such as mop heads, cloths) must be used for environmental decontamination. Any reusable equipment (such as mop handles, buckets) must be decontaminated after use with a chlorine-based disinfectant, as per current guidance. Communal cleaning trollies should not enter the room.

Day to day cleansing and disinfection of the practice environment will be increased in frequency, especially in areas such as treatment rooms, waiting rooms and toilets. Where re-useable equipment is used it should be decontaminated according to the manufacturer’s instructions.

Infection control

Hand hygiene is essential to reduce the transmission of infection in health and other care settings remains the critical element of standard infection control precautions (SICPs) for both health care professionals and the public. All staff, patients and visitors should decontaminate their hands with alcohol-based hand rub (ABHR) when entering and leaving practices.

Infection prevention and control recommendations are being constantly reviewed as the outbreak evolves and the country moves through the phases described in the coronavirus action plan.

Effective infection prevention and control measures, including transmission-based precautions (airborne, droplet and contact precautions) with the recommended personal protective equipment (PPE) is essential to minimise risks but cannot eliminate it.

Are children and pregnant women at risk of infection?

There is no published evidence, yet, on the severity of illness among pregnant women after COVID-19 infection.

Children can catch coronavirus but seem unlikely to have severe symptoms but their role in the spread of the virus is not yet understood.

Emerging scientific literature will continue to be scrutinised and it is suggested pregnant women follow the same precautions for the prevention of COVID-19, including regular handwashing, avoiding individuals who are unwell and self-isolating and to consult a healthcare provider by telephone for advice if concerned especially those with other underlying health conditions.

CQC Inspections

The CQC wrote to all registered providers outlining changes to their regulatory approach in response to the coronavirus (COVID-19) outbreak. This included stopping routine inspections and provider information collections (PIC).

Interim methodology is currently being developed which will involve a shift towards other, remote methods to give assurance regarding safety and quality of care.

In order to reduce duplication and avoid unnecessary burden for providers the decision was made to stop Annual Regulatory Reviews (ARRs) from 1 April.

Practices are encouraged to continue to submit statutory notifications and we encourage you to maintain contact with you inspector relationship owner through this period and they will make themselves available to support you.

Information Governance

Information governance is key to ensure data is managed and shared appropriately.

Covid-19 Information Governance Advice is available on the NHS website.

  • Advice for health and care professionals.

  • Advice for the social care sector.

  • Advice for IG professionals.

NHSX is developing information governance resources and information which will become available.

In the interim, if the practices Data Protection Officer or Caldicott Guardian is unsure of appropriate action to take, Information Governance questions can be directed to: NHSX IG team.

Travel restrictions

Many countries have imposed travel bans and lockdown conditions in order to try and halt the spread of the pandemic.

The Foreign Office has advised that British nationals avoid all non-essential foreign travel to tackle the spread of coronavirus,

Travel history is no longer relevant for diagnosis.

Latest travel advice can be found on the GOV.UK web platform.

The Health Protection (Coronavirus) Regulations 2020 supplement the health protection regime found in Part 2A of the Public Health (Control of Disease) Act 1984. These Regulations may be cited as the Health Protection (Coronavirus) Regulations 2020 and came into force immediately.

What next

The WHO has launched dedicated messaging services in Arabic, French and Spanish with partners WhatsApp and Facebook to keep people safe from coronavirus. This easy-to-use messaging service has the potential to reach 2 billion people and enables WHO to get information directly into the hands of the people that need it.

The service can be accessed by a link that opens a conversation on WhatsApp. Practices can advise users to type in: “hi”, "salut", "hola" or "مرحبا" to activate the conversation, prompting a menu of options that can help answer their questions about COVID-19.

Retired NHS staff or those who had left have been called "back to duty" to support the inevitable surge in demand.

NHS Volunteer Responders has been set up to support the NHS and the care sector during the COVID-19 outbreak. to date there have been over 750,000 sign up as volunteers to support those at most risk. Once this becomes established those working in general practice, local authorities and other professionals, will be able to refer people to NHS Volunteer Responders and be confident that they have been matched with a reliable, named volunteer.

Accessibility resources are available to support effective communication around COVID-19.

  • Public Health England stay at home guidance, translated and in easy read.

  • Public Health England guidance on social distancing, translated.

  • NHS guidelines translated into 32 languages by Doctors of the World.

  • Easy read information on COVID-19 from Mencap.

  • Public Health England resources in accessible formats.

COVID-19 guidance for providers of services for people experiencing rough sleeping. Latest up to date clinical guidance for England is provided on the NHS website at www.england.nhs.uk.

Last reviewed 31 March 2020