Coming Down the Mountain

2nd February 2021

UK COVID Deaths – Daily 1449 / 7-Day average 1122

Total UK COVID Deaths within 28 days – 108,013

Total UK Deaths with COVID-19 on the death certificate – 112,660 (up to 22nd Jan)

James Cook Hospital – Total COVID deaths – 513

All COVID cases within South Tees Hospitals Trust – 201

James Cook Critical Care

COVID cases – 33 (18 ventilated)

Non-COVID cases – 32 (11 ventilated)

The mood amongst a lot of the ICU staff has perhaps lifted a little over the past week. The hospital has seen the number of patients admitted with COVID-19 continue to fall. There are now just over 20 patients being admitted each day which is significantly fewer than the number we were seeing a fortnight ago.

The number of COVID patients within Critical Care remains unchanged but when I arrived at work this morning, I discovered that one of our three Surge ICUs is currently empty. Whether it will stay that way for long is unclear. In the interests of efficiency, we try to amalgamate all our patients into as few separate areas as possible but it would only take one particularly busy shift to require us to bring these beds back into play. We continue to hope that by next week, the reduction in the number of patients coming into hospital will ultimately result in fewer Critical Care patients.

This would be welcome. Everyone very much wants to see things quieten down. There is the physical weariness, of course, but the high death rate that we have experienced over the past few weeks seems to have taken its toll on everyone’s morale. We are trying to make more of an effort to focus on the many patients that we have been able to help rather than those that we have lost but it is not easy to do.

Today, I was on-call for emergencies again. I reviewed the CPAP patients on the ward with Jane and the rest of the Outreach Team. I’m pleased to report that there were only eight of them to see today and none of them were looking like they needed admission to ICU. There was even time for a coffee-break later on. The afternoon was spent seeing non-COVID patients for a change. It was quite a novelty to be treating patients with diabetic ketoacidosis, sickle-cell crises, bacterial pneumonias and various assorted flavours of sepsis.

It was a much calmer day than I have been used to and I was even finding the time to catch up on some gossip in A&E when I heard the sad news that Captain Tom Moore had died after becoming unwell with pneumonia before contracting COVID-19. This news spread quickly throughout the hospital and made for a sombre afternoon.

Beyond the hospital walls, there is a lot of ongoing debate about the effectiveness of the world’s vaccination programmes. The good news is that, in Israel, where vaccination is proceeding at a rapid pace, there has been a big fall in the number of infections occurring in those over 60 years of age. The Israeli Ministry of Health revealed that out of nearly 750,000 vaccinated people over the age of 60, only 531 tested positive for coronavirus, and only 38 of these required admission to hospital. There were three deaths but it is possible that these patients may have been infected before they had achieved full protection. The data suggests that infections and illnesses fell from 14 days after the first dose of the vaccine and the effect was most pronounced in areas with a large vaccination uptake.

The Israeli vaccination programme was conducted using two doses of the Pfizer-BioNTech vaccine. Maximum protection was evident at seven days after the second dose when the data collection finished. Another study conducted by an Israeli Healthcare Provider looked at the level of protection that occurred more than a week after the second dose. It showed that only 66 out of 248,000 vaccinated people caught COVID-19 but none of these required admission to hospital. They estimated that the vaccine was 92% effective.

However, elsewhere in the world, there may be darker clouds on the horizon. Of concern is the ongoing proliferation of the South African or B.1.351 variant. Whilst there is no evidence that it is more deadly, it is thought to be more infectious. A mutation of the virus’ spike protein, the E484K mutation, means that there is a chance that vaccines may be less effective.

Worries arose after laboratory work showed that the South African variant was resistant to many of the antibodies produced by people who had recovered from previous COVID-19 infections or had been vaccinated. There have now been a number of cases of this variant within the UK. Eleven of these cases have not been linked to foreign travel, meaning that community transmission must already be occurring. The UK Government is attempting to limit the spread of this variant by mass-testing anyone who lives in an affected area.

The Novavax vaccine, which is to be manufactured on Teesside, is the first vaccine that has been shown to be effective against this South African variant. However, this efficacy was significantly reduced when compared with its action on other viral variants. This vaccine works in a slightly different way from its rivals; it consists of a laboratory-made formulation of the coronavirus spike protein and an adjuvant which amplifies the subsequent immune response. It has been shown to be more than 85% effective against the UK or Kent Variant (also known as variant B.1.1.7) but only 60% effective against the South African variant.

Whilst this is disappointing, there is no data on how much protection is offered against severe infection and it may be that the vaccine is more effective at doing this. An efficacy of 60% is still enough to have an impact on the rate of hospitalisation and death. After all, the efficacy of Influenza vaccination changes year on year but, overall, it has been estimated at around 67%.

More information regarding other vaccines should be available soon. This has become more important following today’s unsettling announcement that there are signs that the already mutated B.1.1.7 variant of COVID-19 (the UK variant) has been mutating further. The important E484K mutation has been seen in many new cases of the UK variant, meaning that it is now beginning to resemble the South African one. Regrettably it would appear that the continued high prevalence of the virus in the UK is an ideal breeding ground for these new variants.

The UK’s vaccination programme is continuing well with plans to vaccinate all the over-65’s by the end of February. Given that an awful lot of our ICU patients are below this age, it will be the effects of lockdown and social-distancing that will play more of a role in reducing our patient numbers over the next month. New variants notwithstanding, we should then hopefully start to see results similar to those achieved in Israel although it is still unclear just how much protection will ultimately be offered by the UK’s delayed second-dose strategy.