Is it now the end of the beginning?

“Now this is not the end. It is not even the beginning of the end. but it is, perhaps, the end of the beginning.”
Coronavirus COVID-19 swabs from patients are kept in a plastic sealed tub as lab technicians carry out a diagnostic test for coronavirus in the microbiology laboratory inside the Specialist Virology Centre at the University Hospital of Wales in Cardiff.Coronavirus COVID-19 swabs from patients are kept in a plastic sealed tub as lab technicians carry out a diagnostic test for coronavirus in the microbiology laboratory inside the Specialist Virology Centre at the University Hospital of Wales in Cardiff.
Coronavirus COVID-19 swabs from patients are kept in a plastic sealed tub as lab technicians carry out a diagnostic test for coronavirus in the microbiology laboratory inside the Specialist Virology Centre at the University Hospital of Wales in Cardiff.

This statement by Sir Winston Churchill has an Ulster connection. In October 1942 General Montgomery led a successful campaign achieving a significant victory in Egypt at El Alamein. At the time it was a critical morale booster for the allies.

(The General was the grandson of Robert Montgomery from Inishowen who owned the New Park estate in Moville, Donegal.)

We may be approaching the end of the first phase in this episode of the Covid-19 story. We still need to adhere to the measures designed to protect ourselves, our families, our neighbours and essential services including the NHS. Without considering our own vulnerabilities we will not be able to do the right thing for ourselves, family, friends and neighbours. The desire to end “lockdown” has to be tempered with reality. The Wellcome Trust director, Sir Jeremy Farrar OBE FRCP FRS FMedSci, a British medical researcher and previously a professor of tropical medicine at the University of Oxford, has stated that ideally the time to end “lockdown” would be when the population is protected by vaccination. He has also expressed concern that the UK could at present be heading to be one of the worst affected countries in Europe.

Who to believe?

There have been many examples of false information being passed on. Sometimes it is local hearsay given a wider audience through social media. Misinformation and poor examples have come from world leaders too. Many of them have a history of erratic behaviour and “shooting from the hip” with little substance behind their rhetoric. Our closest national governments in Dublin and London have taken some time to align on many issues and even then they diverge from week to week. A quote more often read from Genesis at harvest services is perhaps the most sure bit of information around at the minute!

“As long as the earth remains, there will be planting and harvest, cold and heat, summer and winter, day and night.”

When I am trying to assess the accuracy of information I am looking at a few things to guide me. I’m sure you do this in other contexts as well.

1. Is the source an authority on the subject and has it been consistently credible before?

2. Has the author of the information enough humility to say if answers are not known at this stage? Will they be big enough to say “we don’t know but this is why we think as we do?”

3. Could the source of information have a vested interest in taking a particular view? Could economic considerations be more dominant than health factors for example?

4. Is the information consistent with opinions from other credible sources or expertise?

5. How does the advice compare with what has worked in other countries or in other similar situations in the past?

6. If the advice is not consistent with other credible sources, what is the safest action to take if one of them is wrong?

The big issues

1. Spreading the virus on. Although most people getting the virus if they are going to get symptoms will do so in 2-5 days, others may take up to 14 days. Most authorities suggest that those infected with the virus can pass it on before they get symptoms and some will do this without ever getting notable symptoms. We could possibly do this for up to two weeks from when we got infected. This is why we need to isolate to households, catch coughs, wash hands and social distance. We don’t know if we are a threat to others.

2. Spread from surfaces and air. Hard surfaces in particular, apart for copper, appear to stay contaminated for days. We don’t know if modest heat, cold and sunlight have any effect on eliminating the virus. It has also been advised that droplets/aerosols can hang in the air for up to three hours. Even outside we are better protected if the wind blows between us rather than standing up-wind or down-wind of each other. Confined spaces in which are not ventilated, such as a lift, would seem like the worst place to be, even on your own, after it has been used by others. The less time we spend in shared space the better.

3. Food. There is no evidence that Covid-19 has been spread through food but cooking food will destroy the virus. There is a risk that packaging can carry the virus if it has been contaminated.

4. Post and package delivery. Like food packaging, this represents a degree of risk. Opening outside and discarding the wrapping without touching the contents then washing hands will eliminate even this risk.

5. After symptoms of infection have settled. There are no plans that I have seen to do a subsequent test to see if someone who has had the virus is now clear of it. Although it is thought that the majority of people infected are unlikely to be spreading the virus after seven days, the World Health Organization (WHO) Director General, Tedros Adhanom Ghebreyesus, told a press conference in Geneva: “People infected with Covid-19 can still infect others after they stop feeling sick, so these measures should continue for at least two weeks after symptoms disappear.

6. If both 1. and 5. are correct. If a small number of patients don’t get symptoms for 14 days and a small number can spread it for up to 14 days after symptoms have settled, clearly the length of isolation an individual takes will have an impact on how Covid-19 is spread in communities. Other countries like Germany have advised a longer period of isolation. This, along with testing, appears to have reduced the number of deaths in that country. Many have expressed the view that the UK has been late in adopting measures including testing and social isolation.

7. Genetic influences. The BMA (British Medical Association) has commented on the fact that there has been a disproportionate number of deaths and admissions to intensive care units of our friends, colleagues and neighbours who can trace their ancestry to African and Asian origins. A full understanding of this has not been made but clearly the response we need to make is to continue to protect each other and continue to show appreciation to those in all walks of life.

8. Age, gender and infirmities. To the majority of the population this virus is not a threat to life although people of all ages have died. It has by and large not been a threat to the young or even women who are pregnant. It is more likely to be increasingly serious with age. If you are above 70 it is more of a threat than if you are in your early 60’s and so on down the decades. Men seem to be more seriously affected than women. Being overweight, having diabetes, high blood pressure and heart disease increases risk of death as does being a smoker or having lung disease. If any of these apply, you and those around you need to adhere to the best advice.

9. Immunity. The concept of “herd immunity” has been raised in the press. It is hoped that those who have been exposed to this virus and recovered will now, at least for a time, be protected from getting it again. If enough of the population is in this position, there will be insufficient people carrying the virus for it to be passed (coughed) on. We may need between 80% and 95% of the population to be immune to be in this position. Hence the pressing desire to test those who may be immune and vaccinate those who are not as soon as possible.

10. Vaccination. At the time of writing this article it has been suggested that a vaccination may be available from September this year. When it is available it will be vital that those most at risk take the opportunity to gain protection. Most vaccinations require about 2 weeks before they give the recipient immunity.

Covid-19 centres

These are not sites for testing for Covid-19. No testing is available at them for NHS staff or other patients.

Most GPs are now, as well as maintaining some degree of normality in our own practices, working in facilities established to see patients face to face who may have symptoms related to possible Covid-19 infection. The majority of people with Covid-19 symptoms are advised to consult the government web site “111” before phoning GP services as mild symptoms require the standard advice available on the website.

Patients who are seriously ill may be referred directly to their nearest hospital. The group of patients in between these two categories, who may need expertise short of a hospital admission, will be invited to attend a Covid-19 centre.

The centres have very similar criteria throughout the province.

1. Patients are only seen by appointment, It is not a drop in facility.

2. If the patient needs a family member to be present only one will be allowed in with the patient.

3. The patient (and relative) will be required to wear a mask before entering the building and use a hand sanitizer.

4. The doctor and assistant will wear a mask, visor, disposable apron and gloves over surgical scrubs. The apron and gloves will be discarded after each patient.

5. Cleaning staff will clean the room and fixtures before it is used for a subsequent patient.

6. Doctors and other staff are required to shower before getting back into their own clothes to reduce the risk transmitting the infection.

7. The facility has no waiting room and patients are to wait in the car before being prepared for direct entry to the clinical room.

8. No testing is available at these centres for Covid-19.

“The pen is mightier than the sword”

Although the police and legislation may constrain us, I hope that, armed with greater insight into what lies ahead, all of us will continue to use wisdom and altruism to do the right thing in the coming days. Governments and experts may be doing their best but can get it wrong at times. We still need to use our common sense to err on the side of safety in our daily lives for our own good and for the protection of others.