Understanding COVID-19 in at-risk patients

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) was first identified in China following investigation into a number of cases of pneumonia of unknown cause. Early cases were thought to have originated from a market in Wuhan, which was subsequently closed. It quickly became apparent that infection with this new virus heralded serious consequences. By mid-February, China had identified 50 000 laboratory confirmed infections, of which 1600 had died, and within 1 month the disease had spread to all 34 provinces of the country (Zhang et al, 2020). Since then the disease, named COVID-19, has surfaced all over the world and statistics from the World Health Organization issued on 14 September reported an estimated 917 417 deaths globally, of which 41 623 have occurred across the UK (World Health Organization, 2020a). The UK media has continually updated the public on the disease, and it is very clear that few countries have been spared. The UK has continued to experience a rising number of both confirmed cases and deaths, many of the latter among the elderly, and people with underlying health conditions. This article aims to give practice nurses an update on this disease, with a focus on its effect on vulnerable groups.

Pathophysiology

Because COVID-19 is a new disease, there is still a huge amount to learn, and scientists are desperately trying to uncover many of the unknown elements. What is known is that there are a number of different coronaviruses, of which a few are capable of causing disease in humans. Some coronaviruses, which are known to infect animals, have been able evolve to cause infections in humans. Scientists were able to determine that this was the case with both SARS (severe acute respiratory syndrome) and MERS (Middle East respiratory syndrome) and it is thought that this same mechanism forms the underlying process of the appearance of COVID-19.

Mode of spread

The infection is thought to spread via droplets expelled from the respiratory tract, through coughing and sneezing, as is the case with other respiratory tract infections. Any virus released in droplets can potentially cause infection in other individuals by direct contact with mucous membranes. Because so little was known initially about COVID-19, data collected from studies into other coronaviruses have been used to assess the behaviour of this novel coronavirus. It is known that the virus is able to survive on inanimate objects for varying lengths of time depending on the surface type. Experimental studies have reported viability on plastic for up to 72 hours, 48 hours on stainless steel, and up to 8 hours on copper (Public Health England, 2020a). There is also concern that asymptomatic transmission may be possible; however, further study is required to determine the frequency, importance and impact of asymptomatic and pre-symptomatic infection, in terms of transmission risks (Public Health England, 2020a). Information gained so far from the ongoing COVID-19 pandemic suggests that this virus is spreading more efficiently than influenza, but not as efficiently as measles, which is highly contagious and, in general, the more closely a person interacts with others and the longer that interaction, the higher the risk of COVID-19 transmission (Centers for Disease Control and Prevention, 2020a).

Signs and symptoms

Like many other diseases, the presentation of COVID-19 varies greatly, and can range from the affected individual being asymptomatic or having mild symptoms, to a much more unpleasant illness leading to serious complications and, in some cases, death.

Signs and symptoms have been well documented in the media, and as more becomes known about the disease, these have been updated (Table 1).

Incubation period

The incubation period relates to the time between actually catching the virus and the subsequent onset of any symptoms of the illness. Because of the newness of the disease, the exact incubation period is not known, but the WHO estimate that it is between 1–14 days, but most likely to be around 5 days (WHO, 2020b).

Vulnerable patients

Since the first deaths were recorded in the UK, it became apparent that the majority of victims (although not all) had underlying health conditions, which raised concerns that certain patients were at a much higher risk of a poor outcome, should they be unfortunate enough to develop the disease. Public Health England have therefore identified a number of conditions which place people at greater risk of serious complications, and possibly death, should they develop symptoms of the illness (Public Health England, 2020b). These include all those aged 70 years or over, irrespective of whether they have any medical conditions, and people below the age of 70 years who have any of the following conditions:

• Chronic respiratory diseases (e.g. chronic obstructive pulmonary disease [COPD], chronic asthma, emphysema)
• Chronic kidney disease (CKD)
• Diabetes
• Chronic neurological diseases (e.g. multiple sclerosis, motor neurone disease, Parkinson's disease)
• Spleen problems (e.g. Sickle cell disease or splenectomy)
• Chronic liver disease
• Learning difficulties
• Lowered immunity occurring as a result of chemotherapy, HIV or AIDS or cause by certain medications (e.g. oral steroids)
• Obesity
• Pregnant women.

In addition, a number of other complex conditions have been identified as potentially placing patients at an even higher risk of serious complications, should they develop COVID-19 (Table 2).

Why the concern?

A study conducted in China on patients with a confirmed laboratory diagnosis of COVID-19 reported that those with at least one co-morbid condition had poorer clinical outcomes, but more importantly the greater the number of comorbidities any one person had, the worse the outcome. Guan et al (2020) found that patients with two or more comorbidities had a significantly escalated risk of becoming severely unwell. Significantly more patients who had two or more comorbidities from any of hypertension, cardiovascular diseases, cerebrovascular diseases, diabetes, COPD, CKD and malignancy, were more likely to require admission to an intensive care unit, or invasive ventilation, or to die when compared to those who had only one comorbidity.

Ethnicity

Statistics have shown a worrying association between a higher risk of developing—and dying from—COVID-19, among black, Asian and ethnic minority groups. A recent Public Health England review of disparities in the risk and outcomes of COVID-19 showed an association between belonging to some ethnic groups and the likelihood of testing positive and dying with COVID-19, with data indicating that severe infection may be linked to high rates of underlying health problems such as diabetes and obesity (Public Health England, 2020c).

Protecting the vulnerable

The need to keep everyone safe has been at the forefront of Government policy. All patients who fall into the very vulnerable category were notified and advised to take extra steps to protect themselves for 12 weeks until 1 August 2020. This was known as shielding. In England, the risk of getting coronavirus is now low enough that these people are no longer advised to shield, although advice varies depending on location. Those living in a local lockdown area should check their local authority's website (Public Health England, 2020b).

In Scotland (Scottish Government, 2020), Wales (Welsh Government, 2020) and Northern Ireland (NI Direct, 2020), shielding has also been paused.

It is important to note that this advice could change at any time. In England, the names of those in the very vulnerable category will be kept securely on the shielded patient list by NHS Digital. NHS Digital will write to those affected if the advice changes (Public Health England, 2020b).

Loneliness and isolation

One of the concerns, particularly for those who were asked to stay in isolation for 12 weeks, is the impact this might have had on their mental health and wellbeing. The risk that susceptible individuals may become increasingly anxious, develop low mood or have disturbed sleep patterns is concerning. This has been recognised and acknowledged by the Government whose advice is to:

• Keep active wherever possible, either by taking a walk (as long as 2 metre distance from others is maintained)
• Do things which the person enjoys: reading, cooking, watching television or reading
• Keep the mind active with crossword puzzles, drawing, painting or sudoku, for example
• Maintain a healthy diet and avoid smoking, alcohol or taking drugs
• Spend time in the garden if this is possible
• Keep in contact with friends and family by phone, email text messaging or other options such as Skype.

Alterations to the guidance have been aimed to address isolation and include:

• Meeting outdoors in a group of up to 6 people with those from other households observing social distancing guidelines (unless in a local lockdown area)
• Single adult households (adults who live alone or with dependent children only) can form a ‘support bubble’ with one other household. This will allow those in a support bubble to be able to spend time together inside each others homes, including overnight, without needing to stay 2 metres apart.

Medical management

Up until recently, there has been no available drug treatment to treat coronavirus and the strategy has centred around supportive care and hospitalisation, and ventilation for more serious cases. However, intense efforts to find a treatment have led to positive results in clinical trials for an antiviral drug, remdesivir, which will be made available to patients meeting certain clinical criteria to support their recovery in hospital. Clinical trials have shown the drug can shorten the time to recovery by approximately 4 days, but because of limited supplies, its use will be limited to those who it is thought will derive the greatest benefit (Department of Health and Social Care, 2020). A more recent development has been the discovery that dexamethasone (normally used for other medical conditions) has been shown to significantly reduce the risk of death.

The future

As well as the hope that a vaccine can be developed, the UK Government is also currently looking at a number of other options in an attempt to tackle the threat posed by this disease. Additional strategies include the possibility that drugs which are available for the treatment of other conditions may also be effective in tackling coronavirus. The UK Recovery Trial has recently begun testing monoclonal antibodies in a phase 3 trial of patients hospitalised with COVID-19 (University of Oxford, 2020).

Table 3 gives a brief summary of some of the research studies being undertaken by UK scientists.

Conclusion

This new disease has had an enormous impact on the UK and the world, causing death and devastation. As well as its impact on individuals and families it is clear that it has, in addition, had a huge financial impact on economies on a global scale. Health services around the world have been stretched to the limit as they try to deal with the most serious cases requiring hospitalisation. Much of the available information is based on what is known about other coronaviruses. Researchers therefore face an enormous task in trying to find out more about the virus and the disease it causes, and putting this together with finding effective treatment options, whether these are new drugs to be developed, or existing medications used to treat other illnesses. The race to develop a vaccine is underway in many countries and once available, nurses will no doubt be involved on a mass scale to deliver it as soon as possible. We are all waiting for things to change and until then all of those on the frontline will continue to work tirelessly.

KEY POINTS:

• As COVID-19 is a new disease, there is still a huge amount to learn and new research is being published constantly
• The presentation of COVID-19 varies greatly, and can range from the affected individual being asymptomatic or having mild symptoms, to a much more unpleasant illness leading to serious complications and, in some cases, death
• The majority (although not all) of victims have had underlying health conditions. Research found that the greater the number of comorbidities any one person had, the worse their outcome

CPD reflective practice:

• How has the pandemic affected work and how have practice nurses coped with this?
• What impact has shielding had on your vulnerable patients?
• How can practice nurses plan for a second wave and what strategies could help you to cope if this occurs?