5 Things Everyone Should Know About the Coronavirus Outbreak
Pipette adding fluid to one of several test tubes, possibly to test for COVID-19
While news about the coronavirus has been evolving, doctors say the best advice is to follow public health directives and take care of yourself.
COVID-19 continues to change daily life in the United States as SARS-CoV-2, the virus responsible for spreading the disease sweeps across the country. The U.S. declared a national emergency in mid-March, and Americans have been adjusting to strict guidelines and mandates instructing them to stay home, avoid unnecessary travel, and stay 6 feet away from other people.
In early March, the World Health Organization (WHO) declared COVID-19 a pandemic—a disease outbreak occurring over a wide geographic area and affecting an exceptionally high proportion of the population. According to the WHO, there are more than 2.6 million confirmed cases of people with COVID-19 and more than 180,000 people have died from the disease—a death toll that has far surpassed that of the severe acute respiratory syndrome (SARS) epidemic that occurred in 2002 and 2003. (While some news sources report different numbers, the WHO provides official counts of confirmed cases once a day.)
In the U.S., the numbers are multiplying, as different parts of the country experience varied levels of COVID-19 activity. All 50 states have reported community spread (meaning the source of infection is unknown), and there have been large clusters in certain areas of the country. The Centers for Disease Control and Prevention (CDC) currently provides a rough picture of the outbreak in the U.S. here, currently putting the total confirmed and probable cases at more than 865,000, and estimating almost 49,000 deaths. If there are any discrepancies, data provided by state public health departments should be considered the most up to date, according to the agency.
SARS-CoV-2 is a virus that scientists haven’t seen before. Like other viruses, it is believed to have started in animals and spread to humans. Animal-to-person spread was suspected after the initial outbreak in December among people who had a link to a large seafood and live animal market in Wuhan, China.
Scientists and public health officials are working as quickly as possible to find answers to key questions about the severity of the disease and its transmission. They are investigating treatments and a potential vaccine for the disease.
Below is a list of five things you should know about the coronavirus outbreak.
1. What we know about COVID-19 is changing rapidly
What we do know about coronaviruses is that they cause respiratory tract illnesses that range from the common cold to such potentially deadly illnesses as SARS, which killed almost 800 people. COVID-19 is the first pandemic known to be caused by the emergence of a new coronavirus—novel influenza viruses caused four pandemics in the last century (which is why the response to the new disease is being adapted from existing guidance developed in anticipation of an influenza pandemic).
According to the CDC, reported COVID-19 illnesses have ranged from mild (with no reported symptoms in some cases) to severe, including illness resulting in death. People ages 65 and older, those living in a nursing home or long-term care facility, and people of all ages with underlying health conditions seem to be at higher risk of developing serious illness. But doctors are still working to develop a complete clinical picture of COVID-19, as evidenced by a CDC report noting that 20% of those who have been hospitalized for the disease in the U.S. are younger adults (between 20 and 44 years old).
“I think there are two main questions,” says Richard Martinello, MD, a Yale Medicine infectious diseases specialist and medical director of infection prevention at Yale New Haven Health. “First, we need to know how this virus is transmitted between people so we can be more precise in our efforts to stop its spread. Data is needed not only to better understand when those who become ill shed the virus, but also which body fluids contain the virus and how those may contaminate surfaces and even the air surrounding them,” says Dr. Martinello. “Second, there needs to be a better understanding of the pathogenesis of the infection and resulting inflammatory response, so that knowledge can drive the development of therapeutic and preventive medications.”
More information is becoming available. The American Academy of Otolaryngology has called for adding anosmia (loss of smell) to a list of screening tools for COVID-19, and while evidence is still preliminary, the WHO says it is probing a possible link between the disease and the symptom.
Meanwhile, a letter to the editor published in The New England Journal of Medicine in mid-March showed the virus that causes COVID-19 may be stable for several hours in aerosols and for several hours to days on surfaces. Scientists from National Institutes of Health (NIH), CDC, UCLA, and Princeton University who participated in the analysis found SARS-CoV-2 was detectable in aerosols for up to three hours, copper up to four hours, cardboard up to 24 hours, and plastic and stainless steel up to two to three days. While there is much to learn, scientists involved in the analysis observed that emerging evidence suggests people who are infected might be spreading the virus without recognizing, or prior to recognizing, symptoms, according to the NIH.
But Yale Medicine Infectious Diseases specialist Jaimie Meyer, MD, MS, notes, “A lot of times people will make basic science observations in the research lab, but it takes time for us to figure out how clinically relevant it is. So, we don’t know yet know what this study means for transmissibility. Until we understand more about the granular details of how SARS-CoV-2 passes from person to person, public health dictates that people maintain social distancing, wash hands, and frequently disinfect high-touch surfaces."
2. Strict measures are critical for slowing the disease
While no one knows for sure how the situation will progress around COVID-19, studies of influenza have shown that pandemics begin with an “investigation” phase, followed by “recognition,” “initiation,” and “acceleration” phases, according to the CDC, and that is followed by deceleration, during which there is a decrease in illnesses. Finally, there is a "preparation" phase, where the pandemic has subsided, and public health officials monitor virus activity and prepare for possible additional waves of infection. Different parts of the country can be in different phases of the pandemic, and the length of each phase can vary depending, in part, on the public health response.
The U.S. is currently in an acceleration phase, when the peak of illnesses occurs, and efforts are aimed at “flattening the curve.” If you map the number of COVID-19 cases over time, the expectation is that it will peak at some point—on a graph this peak would mirror a surge in patients (which could overwhelm hospitals and health care providers). Flattening the curve would mean there would be fewer patients during that period, and hospitals would be better able to manage the demands of patients who are sick with COVID-19 and other illnesses.
Guidelines from the White House call for "30 Days to Slow the Spread” a plan that has been extended through the month of April that stresses avoiding social gatherings of more than 10 people; maintaining a social distance of at least 6 feet from other people; working from home, if possible; practicing strict personal hygiene; using drive-thru, pick-up, or delivery options instead of eating in restaurants; and keeping your entire family home if someone tests positive for COVID-19. Many state and local authorities have taken stronger steps—Connecticut is prohibiting gatherings of groups of more than five people and directing people to wear face coverings in public when a six-foot distance is unavoidable, including in the workplace, and is extending its guidelines through May 20.
3. Infection prevention is key
There are many things you can do to protect yourself and the people you interact with. As with a cold, a flu vaccine won’t protect people from developing COVID-19. “The best thing you can do at this point is take care of yourself the way you would to prevent yourself from getting the flu,” says Yale Medicine infectious diseases specialist Joseph Vinetz, MD. “You know you can get the flu when people sneeze and cough on you, or when you touch a doorknob. Washing hands—especially before eating and touching your face, and after going to the bathroom—and avoiding other people who have flu-like symptoms are the best strategies at this point.”
The CDC also recommends the following preventive actions:
Wash hands with soap and water for at least 20 seconds. Dry them thoroughly with an air dryer or clean towel. If soap isn’t available, use a hand sanitizer with at least 60% alcohol.
Stay home if you’re sick.
Avoid touching nose, eyes, and mouth. Use a tissue to cover a cough or sneeze, then dispose of it in the trash.
Use a household wipe or spray to disinfect doorknobs, light switches, desks, keyboards, sinks, toilets, cell phones, and other objects and surfaces that are frequently touched.
It may also be important to create a household plan of action. You should talk with people who need to be included in your plan, plan ways to care for those who might be at greater risk for serious complications, get to know your neighbors, and make sure you and your family have a household plan that includes ways to care for loved ones if they get sick. This includes planning a way to separate a family member who gets sick from those who are healthy, if the need arises.
Some cities and states in the U.S. are requiring residents to wear masks in certain public places, like grocery stories and pharmacies. The CDC recommends that everyone voluntarily wear cloth face masks in public settings where other social distancing measures are difficult to maintain, especially in areas where there is significant community-based transmission. A cloth mask is not meant to protect the wearer from infection, but to slow the spread of the virus (if people who have the virus and do not know it wear masks, they may be less likely to transmit it to others). The CDC advises making face coverings at home from simple materials, and reserving surgical masks and N95 respirators for health care workers and other medical first responders.
While everyone should take precautions, measures may be critical for adults over 65 years old (the risk seems to gradually increase with age starting at age 40, according to the WHO) and those with chronic conditions (such as diabetes, heart disease, and lung disease). People in these categories especially should stock up on household items, groceries, medications, and other supplies in case they need to stay home for an extended period.
4. Experts are working rapidly to find solutions
In the U.S., widely available testing will be important in understanding how the disease is transmitted and the true infection and mortality rates. In addition to COVID-19 testing being done by the CDC, state and local public health labs in all 50 states and the District of Columbia are currently using the CDC's COVID-19 diagnostic tests, although the number of available tests is still limited. Until there can be comprehensive testing for COVID-19, it's difficult to know how many cases have not been identified. One recent development is the first in-home test for the coronavirus. The nasal swab kit, approved by the Food and Drug Administration in mid-April, will be made available to health care and emergency workers who may have been exposed or have symptoms of the virus before it is released to the public at a later date.
Meanwhile, scientists are studying the virus closely. “With the new virus in a culture dish, they are looking at the biology and working to make drugs to treat it,” says Dr. Vinetz. There is also a great deal of effort underway to assess drugs in development (and some medications currently available) to determine if they are beneficial for treating patients infected with COVID-19, adds Dr. Martinello.
While no pharmaceutical products have yet been shown to be safe and effective for COVID-19, a number of existing medicines have been suggested as potential investigational therapies. An important effort is a clinical trial evaluating different potential therapeutics at the University of Nebraska Medical Center in Omaha, the first of which is remdesivir, says Yale Medicine infectious disease specialist Manisha Juthani, MD. Remdesivir is an antiviral treatment that, according to the National Institutes of Health, was previously tested in humans with Ebola virus disease and has shown promise in animal models for treating SARS and Middle Eastern Respiratory Syndrome (MERS), a deadly virus that was first reported in Saudi Arabia in 2012.
In mid-March, the National Institute of Allergy and Infectious Diseases (NIAID) announced the first testing in humans of an experimental vaccine called mRNA-1273 developed by NIAID scientists and their collaborators at the biotechnology company Moderna, Inc. The first trial is testing the vaccine on 45 healthy adult volunteers, ages 18 to 55, over approximately 6 weeks. But it could take at least a year before all the necessary phases of the investigation can be completed to ensure the vaccine is safe and effective enough to make publicly available.
5. If you feel ill, here's what you should do
So far, information shows the severity of COVID-19 infection ranges from very mild (sometimes with no reported symptoms at all) to severe to the point of requiring hospitalization. Symptoms can appear anywhere between 2 to 14 days after exposure, and may include:
You should call your medical provider for advice if you experience these symptoms, especially if you have been in close contact with a person known to have COVID-19 or live in an area with ongoing spread of the disease.
Most people will have a mild illness and can recover at home without medical care. Seek medical attention immediately if you are at home and experience emergency warning signs, including difficulty breathing or shortness of breath, persistent pain or pressure in the chest, new confusion or ability to arouse, or bluish lips or face. This list is not inclusive, so consult your medical provider if you notice other concerning symptoms.
Patients and members of the community can call the Yale Medicine/Yale New Haven Health Call Center at COVID-19 hotline of Yale New Haven Health at 203-688-1700 (toll-free, 833-484-1200) if they have questions.
Be aware of the information and resources that are available to you
Because knowledge about the new virus is evolving rapidly, you can expect information and recommendations to change frequently. Threats like COVID-19 can lead to the circulation of misinformation, so it’s important to trust information only from reputable health organizations and government sources such as the CDC and the WHO. “The public health infrastructure in the U.S. is a critical resource for leading the federal, state, and local response,” Dr. Martinello says.
Yale Medicine doctors are advising anyone who has concerns about COVID-19 exposure or symptoms to call their primary care doctor for instructions. Doctors at Yale Medicine and Yale New Haven Health also are encouraging all patients to sign up for MyChart, a secure online portal that allows patients to manage and receive information about their health, and enables telehealth visits (by phone or video), which is how Yale Medicine specialists currently are delivering most care not related to COVID-19.
Health officials recognize that the outbreak has been stressful for everyone, and this can have serious impacts on mental health. If you, or someone you care about, are feeling overwhelmed with emotions like sadness, depression, or anxiety, or feel like you want to harm yourself or others, call 911, or the Substance Abuse and Mental Health Administration’s Disaster Distress Helpline: 1-800-985-5990 or text TalkWithUs to 66746. (TTY 1-800-846-8517). You can call the National Domestic Violence Hotline at 1-800-799-7233 (TTY: 1-800-787-3224.)
Everything you should know about the coronavirus outbreak
The Pharmaceutical Journal24 APR 2020By Kristoffer Stewart
, Dawn Connelly
, Julia Robinson
The latest information about the novel coronavirus identified in Wuhan, China, and advice on how pharmacists can help concerned patients and the public.
Open access article
The Royal Pharmaceutical Society has made this feature article free to access in order to help healthcare professionals stay informed about an issue of national importance.
To learn more about coronavirus, please visit: https://www.rpharms.com/resources/pharmacy-guides/wuhan-novel-coronavirus.
Sick man on subway wearing mask
Source: Shutterstock.com
Measures to guard against the infection work under the current assumption that SARS-CoV-2 is spread by respiratory droplets, although face masks are unlikely to prevent infection
A novel strain of coronavirus — SARS-CoV-2 — was first detected in December 2019 in Wuhan, a city in China’s Hubei province with a population of 11 million, after an outbreak of pneumonia without an obvious cause. The virus has now spread to over 200 countries and territories across the globe, and was characterised as a pandemic by the World Health Organization (WHO) on 11 March 2020[1],[2].
As of 9:00 on 23 April 2020, there were 2,544,792 laboratory-confirmed cases of coronavirus disease 2019 (COVID-19) infection globally, with 175,694 reported deaths. The number of cases and deaths outside of China overtook those within the country on 16 March 2020[3].
As of 9:00 on 23 April 2020, there were 138,078 confirmed cases of the virus in the UK and, as of 17:00 on 22 April 2020, 18,738 of those hospitalised with COVID-19 have died.
This article gives a brief overview of the new virus and what to look out for, and will be updated daily. It provides answers to the following questions:
What are coronaviruses?
Where has the new coronavirus come from?
How contagious is COVID-19?
How is COVID-19 diagnosed?
What social distancing measures are being taken in the UK?
What is happening with testing for COVID-19?
What should I do if a patient thinks they have COVID-19?
What can I do to protect myself and my staff?
What about ‘business as usual’ during the pandemic?
Will the government provide financial help during the pandemic?
How can cross-infection be prevented?
There has been a lot of talk in the news and on social media about how certain medications can exacerbate the symptoms of COVID-19, what is the current advice around these medications?
Where can I find information on managing COVID-19 patients?
Is the coronavirus pandemic likely to precipitate medicines shortages?
What are coronaviruses?
SARS-CoV-2 belongs to a family of single-stranded RNA viruses known as coronaviridae, a common type of virus which affects mammals, birds and reptiles.
In humans, it commonly causes mild infections, similar to the common cold, and accounts for 10–30% of upper respiratory tract infections in adults[4]. More serious infections are rare, although coronaviruses can cause enteric and neurological disease[5]. The incubation period of a coronavirus varies but is generally up to two weeks[6].
Previous coronavirus outbreaks include Middle East respiratory syndrome (MERS), first reported in Saudi Arabia in September 2012, and severe acute respiratory syndrome (SARS), identified in southern China in 2003[7],[8]. MERS infected around 2,500 people and led to more than 850 deaths while SARS infected more than 8,000 people and resulted in nearly 800 deaths[9],[10]. The case fatality rates for these conditions were 35% and 10%, respectively.
SARS-CoV-2 is a new strain of coronavirus that has not been previously identified in humans. Although the incubation period of this strain is currently unknown, the United States Centers for Disease Control and Prevention indicate that symptoms may appear in as few as 2 days or as long as 14 days after exposure[6]. Chinese researchers have indicated that SARS-CoV-2 may be infectious during its incubation period[11].
The number of cases and deaths outside of China overtook those within it on 16 March 2020
Where has the new coronavirus come from?
It is currently unclear where the virus has come from. Originally, the virus was understood to have originated in a food market in Wuhan and subsequently spread from animal to human. Some research has claimed that the cross-species transmission may be between snake and human; however, this claim has been contested[12],[13].
Mammals such as camels and bats have been implicated in previous coronavirus outbreaks, but it is not yet clear the exact animal origin, if any, of SARS-CoV-2[14].
How contagious is COVID-19?
Increasing numbers of confirmed diagnoses, including in healthcare professionals, has indicated that person-to-person spread of SARS-CoV-2 is occurring[15]. The preliminary reproduction number (i.e. the average number of cases a single case generates over the course of its infectious period) is currently estimated to be between 1.4 to 2.5, meaning that each infected individual could infect between 1.4 and 2.5 people[16].
Similarly to other common respiratory tract infections, MERS and SARS are spread by respiratory droplets produced by an infected person when they sneeze or cough[17]. Measures to guard against the infection work under the current assumption that SARS-CoV-2 is spread in the same manner.
How is COVID-19 diagnosed?
As this coronavirus affects the respiratory tract, common presenting symptoms include fever and dry cough, with some patients presenting with respiratory symptoms (e.g. sore throat, nasal congestion, malaise, headache and myalgia) or even struggling for breath.
In severe cases, the coronavirus can cause pneumonia, severe acute respiratory syndrome, kidney failure and death[18].
The case definition for COVID-19 was amended on 13 March 2020 and is now based on symptoms regardless of travel history or contact with confirmed cases. Diagnosis is suspected in patients requiring admission to hospital with signs and symptoms of pneumonia, acute respiratory distress syndrome or influenza, and in those with a new, continuous cough or fever who are well enough to stay in the community (see Box 1). A diagnostic test has been developed, and countries are quarantining suspected cases[19].
Box 1: Who qualifies as a suspected COVID-19 case?
Patients who meet the following criteria (inpatient definition):
Those requiring admission to hospital AND
Those who have either clinical or radiological evidence of pneumonia OR
Acute respiratory distress syndrome OR
Influenza like illness (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).
Patients who meet the following criteria and are well enough to remain in the community:
New continuous cough AND/OR
High temperature
Individuals with a cough or fever who live alone should now stay at home for 7 days from the onset of symptoms. Households should all self-isolate for 14 days if one member shows symptoms.
Clinicians should be alert to the possibility of atypical presentations in patients who are immunocompromised. Alternative clinical diagnoses and epidemiological risk factors should be considered.
Source: Department of Health and Social Care
What social distancing measures are being taken in the UK?
The government launched its coronavirus action plan on 3 March 2020, which details four stages: contain, delay, mitigate, research[20]. On 12 March 2020, the UK moved to the delay phase of the plan and raised the risk level to ‘high’.
On 16 March 2020, Johnson said that the UK is “now approaching the fast growth part of the upward curve” and, without drastic action, cases could double every 5 or 6 days. He announced social distancing measures, such as working from home and avoiding social gatherings, as well as household isolation for those with symptoms[21],[22].
Further social distancing measures were announced on 18 March 2020, including closing all schools in the UK except for vulnerable children and those of key workers, such as pharmacists and other health and social care staff, teachers and delivery drivers. Restaurants, cafes, pubs, leisure centres, nightclubs, cinemas, theatres, museums and other businesses were also told to close.
On 22 March 2020, Johnson announced that the most vulnerable people, including those who have received organ transplants, are living with severe respiratory conditions or specific cancers, and some people taking immunosuppressants, should stay in their homes for at least the next 12 weeks.
And on 23 March 2020, Johnson warned that, without a huge national effort to halt the growth of coronavirus, “there will come a moment when no health service in the world could possibly cope; because there won’t be enough ventilators, enough intensive care beds, enough doctors and nurses”.
He announced a strict lockdown of the UK to be enforced by police, instructing people to stay at home except to buy essential food and medicines, one form of exercise a day, any medical need, and travelling to and from essential work. He said that all gatherings of more than two people in public must stop and, with immediate effect, all shops selling non-essential goods, libraries, playgrounds, outdoor gyms and places of worship must close. All social events, including weddings, baptisms and other ceremonies, but excluding funerals must be cancelled, he added.
On 16 April 2020, the lockdown was extended for at least another three weeks.
What is happening with testing for COVID-19?
As of 23 April 2020, 425,821 people had been tested for COVID-19 in the UK. Testing has switched from testing all suspected cases to focussing on patients who are admitted to hospital with respiratory illnesses.
On 18 March 2020, the Department of Health and Social Care announced that officials are working to increase the number of tests that can be conducted by Public Health England (PHE) and the NHS to 25,000 a day over the next four weeks. And on 2 April 2020, health secretary Matt Hancock outlined plans to dramatically increase testing in England to 100,000 tests a day by the end of the month.
The government is also working with companies to rapidly develop a test to establish whether people have developed immunity, which it said “will help get NHS and other critical public sector staff back to work as fast as they can”. At the 18 March 2020 daily government press conference, Patrick Vallance, the government’s chief scientific adviser, referred to the antibody test as a “game changer” and said that work was progressing very fast, with PHE “looking at this today”.
The increased testing will also include developing a point-of-care swab test outside of hospitals, so people with suspected symptoms can quickly find out if they have coronavirus.
On 27 March 2020, Hancock announced that NHS staff will be first in line for a new coronavirus testing program being developed in collaboration with the government and industry. The testing will be carried out in three new hub laboratories, with partners including Amazon, Royal Mail and Boots, which has been supporting initial trials by supplying volunteer healthcare clinicians — both from Boots and the wider community — as testers.
Testing will begin with staff in critical care, emergency departments and ambulance services who have been forced to self-isolate at home for 14 days. On 23 April 2020, testing was extended to all essential workers in England — including NHS and care staff, teachers, hospital cleaners, public servants, the emergency services, supermarket staff, delivery drivers, and other critical infrastructure staff — and members of their households who have symptoms.
Pharmacists in Wales with symptoms of COVID-19 are able to access testing through their Local Health Board. Community pharmacy staff in England who have symptoms are able to access testing via an online portal developed by the Care Quality Commission. Details about how to connect to the portal were sent to pharmacy contractors on 18 April 2020.
What should I do if a patient thinks they have COVID-19?
Patients have been advised not to go to their community pharmacy if they are concerned that they have COVID-19. Those with a new, continuous cough or a high temperature who live alone should self-isolate for seven days from the onset of symptoms. Households should all self-isolate for 14 days if one member shows symptoms[22]. There is no need for people with minor symptoms to telephone NHS 111 or to be tested for COVID-19.
However, given the outbreak has coincided with the cold and flu season, it is likely that patients may present in the pharmacy with queries about the virus, or with concerns about their cold or flu symptoms.
Community pharmacies were told by NHS England and NHS Improvement on 27 February 2020 that, in the unlikely event that a suspected case does present, they must prepare a “designated isolation space”[23].
If the pharmacy does not have a suitable room to isolate a suspected patient, an area that would keep a patient at least two metres away from staff and other patients in the pharmacy should be prepared so that it can be cordoned off.
Patients who present with a new, continuous cough or a high temperature should be told to return home immediately and self-isolate. If, in the clinical judgement of the pharmacist, the person is too unwell to return home, they and any accompanying family should be invited into the designated isolation space where emergency services should be contacted.
The Royal Pharmaceutical Society is publishing ongoing guidance on contingency planning for COVID-19, which includes measures to protect the pharmacy team, such as limiting the number of people within the pharmacy at the same time, keeping at least two metres apart from staff and people coming into the pharmacy, and sectioning the pharmacy to encourage social distancing with floor markings (using tape) or barriers. The RPS has also produced a table to help pharmacists distinguish between COVID-19, a cold, the flu and hayfever.
Those with cold and flu symptoms that are not indicative of COVID-19 should be managed as usual, or using the pathway developed by The Pharmaceutical Journal.
The General Pharmaceutical Council said on 3 March 2020 that it recognises pharmacists may need to depart from established procedures in order to care for patients during the coronavirus outbreak and that regulatory standards are designed to be flexible and to provide a framework for decision-making in a wide range of situations.
In a joint statement with ten other health regulators, the GPhC said: “Where a concern is raised about a registered professional, it will always be considered on the specific facts of the case, taking into account the factors relevant to the environment in which the professional is working”.
What can I do to protect myself and my staff?
An updated standard operating procedure (SOP) for community pharmacies, published on 22 March 2020, sets out measures to protect pharmacy staff, including advising customers to keep a distance of at least two metres from other people, limiting entry and exit to the pharmacy and installing full screens to protect members of staff from airborne particles (see Learning article section ‘Enforcing social distancing’ for further details).
There has been some confusion around advice on personal protective equipment (PPE) for community pharmacists published by Public Health England. Guidance originally published on 2 April 2020 was updated on 10 April 2020, to recommend that pharmacy staff should only wear PPE when in “contact with possible or confirmed cases of COVID-19”. The original version of the guidance simply stated that fluid-resistant (Type IIR) surgical masks (FRSM) were recommended if social distancing could not be maintained.
The updated guidance now states: “If social distancing of 2m is maintained there is no indication for PPE in a pharmacy setting. If social distancing is not maintained, though, direct care is not provided, sessional use of FRSM is recommended for contact with possible or confirmed cases of COVID-19”. Sessional use means for the duration of duties in a specific clinical care setting or exposure environment.
The guidance from PHE differs from that of the RPS, which says that pharmacy staff working in community pharmacies and general practice should wear FRSMs if they are unable to maintain a social distance of 2 metres from patients and staff, and emphasises that it is still important to try to maintain social distance when wearing surgical masks wherever possible. The RPS also advises that gloves, apron and surgical masks should be worn by staff in direct contact with a patient, for example, when a person is too unwell to go home and is being cared for in the designated isolation space.
For hospital pharmacists, specific recommendations on PPE apply depending on the context, eg, inpatient areas, emergency departments, etc.
Staff who have symptoms of COVID-19, or live with someone experiencing symptoms, should stay at home. Those who fall into one of the vulnerable groups at particular risk of complications from COVID-19 should not see patients face-to-face, regardless of whether the patient has possible COVID-19. Remote working should be prioritised for these staff.
What about ‘business as usual’ during the pandemic?
Pharmacies are on the frontline of the fight against coronavirus and demand for services is high. The updated standard operating procedure (SOP) for community pharmacies specifies that, if under significant pressure, pharmacies may adjust their opening hours to cope with demand.
A number of contractual services have been put on hold and others have been brought forward (see Learning article section ‘Adjusting opening hours and pharmacy services’ for further details).
On 24 March 2020, health secretary Matt Hancock announced that ‘NHS Volunteer Responders’ will help to deliver medicines to patients’ homes on behalf of community pharmacies in England (see Learning article section ‘Communicating with patients’ for further details). Community pharmacies are expected to ensure that the 1.5 million patients who are shielding from COVID-19 are able to receive their prescription medicines, either through friends and family or volunteers, or via an advanced pandemic delivery service that is being commissioned by NHS England and NHS Improvement from 9 April 2020. Pharmacies will be paid a monthly allowance as well as a payment per delivery for the advanced service.
In Wales, the government is identifying a cohort of DBS checked volunteers through British Red Cross to help vulnerable people with no existing social network to obtain medicines supplies. One volunteer with be “buddied up” with each community pharmacy and available, if needed, to provide an additional 10 deliveries each day. A logistics software package, Pro Delivery Manager (PDM), will be installed in community pharmacies to provide an audit trail for medicines, and assist with scheduling of delivery routes. It is, the Welsh government said, appropriate for patients to nominate their own community volunteer to collect their medicines. The Welsh government will cover the cost of the Pro Delivery licences, and also six months of expenses for volunteers’ expenses: although this may be extended.
The Scottish government has worked with Community Pharmacy Scotland (CPS) to make arrangements for delivery to shielded patients, and together they have developed a flow chart to help decide how to support these patients. If a shielded patient currently has no “prescription buddy”, and if their pharmacy is not able to make deliveries, then volunteers from local humanitarian hubs across each local authority area will step in, as part of a medicines collection service being developed by the government, CPS and health and social care partnerships. Volunteer drivers will need to be Disclosure Scotland checked, and patients will need to give consent to be included in the volunteer delivery service.
The General Pharmaceutical Council has stopped all routine inspections of pharmacies and submission of revalidation records has been postponed.
On 26 March 2020, the GPhC announced that the pharmacy pre-registration assessments for June and September 2020 have been postponed and will be rescheduled for the end of 2020, or early in 2021.
More than 6,200 pharmacy professionals who left the register within the past three years have been given temporary registration so that they can to return to work during the COVID-19 pandemic, if they wish to do so. And in guidance published on 9 April 2020, final year pharmacy students were told they can join their arranged preregistration workplace ahead of the scheduled start date to help deal with the COVID-19 pandemic.
Will the government provide financial help during the pandemic?
The PSNC has announced that community pharmacies in England will be given cash advances totalling £300.0m over the next two months to help with cashflow during the pandemic, but no extra funding has been negotiated so far. Advance payments have also been agreed for community pharmacies in Scotland and Wales.
Additional funding of an initial £5.6m was agreed in Scotland on 7 April 2020 to support unparalleled levels of activity within community pharmacy during the pandemic. The funding will cover equipment costs, adaptations to premises, additional staffing and locum fees.
On 2 April 2020, the government announced that it had written off £13.4bn of debt as part of a major financial reset for NHS providers.
How can cross-infection be prevented?
The WHO has created a range of infographics to illustrate how patients can protect themselves and others from getting sick; however, most of the advice is similar to what would be provided for colds and flu (see Figure)[24].
SHOW FULLSCREEN
How to reduce the risk of coronavirus infection
Figure: Infographic – How to reduce the risk of coronavirus infection
Source: Source: World Health Organization; 2020. Licence: CC BY-NC-SA 3.0 IGO.
There is no specific treatment for COVID-19. Although vaccines can be developed to treat viruses, owing to the novel nature of this infection, no vaccine has currently been developed and the process to develop one may take 12 to 18 months[18]. As an example, many antiviral agents have been identified to inhibit SARS in vitro, but there are currently no approved antiviral agents or vaccines available to tackle any potential SARS or SARS-like outbreaks, such as MERS or SARS-CoV-2[25].
There has been a lot of talk in the news and on social media about how certain medications can exacerbate the symptoms of COVID-19, what is the current advice around these medications?
On 16 March 2020, the British Cardiovascular Society and the British Society for Heart Failure published a statement saying that patients should continue treatment with angiotensin converting enzyme inhibitors and angiotensin receptor blockers unless “specifically advised to stop by their medical team”.
The advice was issued following concerns circulated on social media that these medicines could predispose them to adverse outcomes should they become infected with COVID-19.
Both societies recommended that patients taking these medicines who present as unwell, or with a suspected or known COVID-19 infection, should be assessed on an individual basis and their medication managed according to established guidance. Inappropriate cessation of therapy could lead to a decline in control of blood pressure, heart failure or any other condition the individuals takes these medicines for.
Similar concerns have also arisen around the use of ibuprofen following unverified claims, backed by Oliver Veran, France’s health minister, that ibuprofen may exacerbate symptoms of the virus.
On 14 April 2020, the Committee of Human Medicines (CHM) — an advisory body of Medicines and Healthcare products Regulatory Agency — and the National Institute for Health and Care Excellence both published reviews, which concluded that there is insufficient evidence to establish a link between use of ibuprofen, or other NSAIDs, and susceptibility to contracting COVID-19 or the worsening of its symptoms.
A rapid policy statement published by NHS England on the same date, highlighted that there had been some reports of possible adverse effects of the use of NSAIDs in acute respiratory tract infections more generally, which had led to suggestions to use paracetamol preferentially for fever/pain in such situations. However, it said that there was currently no evidence that the acute use of NSAIDs caused an increased risk of developing COVID-19 or of developing a more severe COVID-19 disease.
Where can I find information on managing COVID-19 patients?
The Royal Pharmaceutical Society has collated resources for hospital pharmacists on the clinical management of patients with COVID-19, including treatments, use of experimental therapies, and evidence-based summaries.
The resources also include information on critical care services during the pandemic and guidance on COVID-19 in special populations, such as children, pregnant women, patients taking warfarin and those with cancer, respiratory conditions, diabetes, rheumatological conditions and HIV.
The National Institute for Health and Care Excellence has produced COVID-19 rapid guidelines covering a number of areas, including critical care in adults, delivery of systemic anticancer treatment, severe asthma, pneumonia, rheumatological disorders, chronic obstructive pulmonary disease, cystic fibrosis, dermatological conditions, gastrointestinal and liver conditions treated with drugs affecting the immune response, acute myocardial injury and symptom management in community settings.
NHS England has published several “specialty guides” aimed at specialists working in hospitals during the pandemic. The guides cover areas such as adult critical care, cancer, musculoskeletal, children, general medicine and palliative care.
Is the coronavirus pandemic likely to precipitate medicines shortages?
The government banned the parallel export of chloroquine, as well as the antiretroviral lopinavir/ritonavir, on 26 February 2020 because they are being tested as possible treatments for COVID-19. There has been a lot of attention in the media on the potential benefits of chloroquine and hydroxychloroquine in treating patients with COVID-19 but the Medicines and Healthcare Regulatory Agency has warned that these medicines are not licensed to treat COVID-19 related symptoms or prevent infection and, until there is clear, definitive evidence that these treatments are safe and effective for the treatment of COVID-19, they should only be used for this purpose within a clinical trial.
On 20 March 2020, the government banned from parallel export more than 80 medicines used to treat patients in intensive care units. The restrictions cover crucial medicines such as adrenaline, insulin, paracetamol and morphine and are designed to prevent medicines shortages. A further 52 medicines, including a number of respiratory medicines, antibiotics, analgesics and insulin products, were banned from export on 1 April 2020.
Community pharmacists have been experiencing huge demand for paracetamol and many have reported shortages of paracetamol tablets 500mg as pharmacy and general sales list packs. The National Pharmacy Association and the GPhC have both said that pharmacies are able to break down larger packs to prepare supplies of a non-prescription items for retail sale.
Shortages of Chiesi’s Clenil and Fostair inhalers, along with inhalers from other brands, have been noticed by pharmacists as patients begin to panic and order inhalers they potentially do not need. The wholesaler AAH Pharmaceuticals placed 11 inhalers on its “out of stock” list on the 30 March 2020. NHS England wrote to healthcare professionals working in primary care on 31 March 2020, asking them not to overprescribe or over-order during this time, as this will create further pressures on the supply chain.
References:
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