Roller-Coaster

12th October 2021

UK COVID Deaths – Daily 181 / 7-Day average 113

Total UK COVID Deaths within 28 days – 137,944

Total UK Deaths with COVID-19 on the death certificate – 161,798 (up to 1 Oct)

James Cook Hospital – Total COVID deaths – 682

All COVID cases within South Tees Hospitals Trust – 58

James Cook Critical Care

COVID cases – 6 (4 ventilated)

Non-COVID cases – 47 (27 ventilated)

To be perfectly honest, I’m not entirely sure where we currently are with COVID. It used to be pretty easy to predict what was going to happen. With the first two waves it was no great act of precognition to know what was coming. Big rises in case numbers as a result of the population mixing gave way to sharp falls as soon as lockdown started to bite. As a result of these peaks and troughs, the nation’s COVID data graphs came to resemble a white-knuckle roller-coaster. However, the situation has changed such that the COVID graphs currently resemble a much more lacklustre thrill; less like the Oblivion ride at Alton Towers and more like the Junior Ice Dragon at Stokesley Fair.

Last month, the Scientific Advisory Group for Emergencies (SAGE) warned us that we may see a dramatic rise in cases in October. So far there has been little sign of that; over the past fortnight, case numbers stopped rising and even fell briefly before beginning to slowly rise again. More importantly, we have seen the number of people being admitted to hospital and the number dying all decrease.

It’s been over a month since schoolchildren returned to the classroom and it appears that the growth in COVID cases within schools is outpacing the child vaccination programme. One in fourteen pupils were infected last week and the biggest increase in infections is occurring in those aged 11-15. Many pupils have been absent from school. Not all of these absences have been due to COVID-19 of course. Other viruses are available and there seems to be a large amount of non-COVID illness circulating at the moment. My youngest daughter brought home a cold from school last week and slowly but surely, one by one, we all caught it. No surprises there, of course; the number of upper respiratory tract infections always increases at this time of year. However, we may be in for a particularly sniffly winter. After over eighteen months of social-distancing and mask-wearing, our collective immunity may be significantly reduced and we may be less able to fight off a rise in non-COVID infections. This reduction in immunity could also contribute to a surge in cases of ‘flu later in the year although expert opinion is divided on this. It’s just as possible that there might be fewer cases than expected; very little ‘flu was circulating last year and this may prevent infections rising too much this winter.

At the hospital, the last few weeks have brought fewer COVID patients on the wards, fewer COVID patients requiring CPAP and, ultimately, fewer COVID patients on ventilators. As a result we are currently managing our COVID patients within a single ICU again. Last week was relatively calm and we were even able to close the Surge ICU and confine ourselves to our usual bed-base. The brief respite was nice while it lasted but the last 72 hours have been much busier. We have been admitting increasing amounts of non-COVID patients. A lot of these patients are very unwell and have required ventilation and I believe that the pandemic is partly to blame. Over the past eighteen months, many patients have been unwilling or unable to get appropriate care for their chronic conditions; others have been ignoring new symptoms, or delaying seeking medical attention. As a result, more and more people are becoming very sick.

Over the past few days we have had to transfer some patients out to other hospitals to create room for the new admissions. Some of these patients have moved to nearby Intensive Care Units but others have moved further afield. We regularly get patients who do not live locally and have become ill whilst visiting the area. Their plans clearly never included spending time in a Middlesbrough Intensive Care Unit and so, once they are more stable, we try to transfer them to a hospital that is nearer their home. Conversely we accept transfers of any local who might find themselves in an Intensive Care Unit far from home, be it elsewhere in the UK or abroad.

We have had a varied mix of COVID patients recently. They are mostly in their 60’s and 70’s and, at times, over two-thirds of them have been fully vaccinated. All of these vaccinated patients have existing health problems and a lot have conditions or are taking medications that suppress their immune system. Others have the usual age-appropriate illnesses such as diabetes, hypertension, Chronic Obstructive Pulmonary Disease (COPD) and angina.

Whilst you may find it surprising that a significant number of vaccinated people with COVID pneumonitis are still being ventilated, it’s worth remembering that the number of such patients is still relatively low. Back before vaccination, if we had opened society fully, we would have been deluged with patients, all of whom would have been much sicker than the ones we are seeing now. Far fewer of our patients require prone ventilation and very few are developing multiple organ failure. That’s not to say that they aren’t dangerously ill but, on the whole, our current vaccinated patients are often less sick than those patients we saw back in 2020.

Despite vaccination, there remains a risk of developing severe illness following infection with COVID-19. This risk is higher in some individuals than others. Back in the first wave, the QCovid risk assessment tool was developed at Oxford University to identify which patients were most at risk of hospital admission and death. The tool was used to identify particularly vulnerable patients who were then added to the national shielding list and prioritise them for vaccination. The tool has now been used to identify which vaccinated patients may be less protected than others.

The study looked at the period between 8th December 2020 (the date that vaccines were first offered to the population) and 15th June 2021. It included nearly 7 million patients, 74% of whom had been fully vaccinated. Of the 1929 patients who were admitted to hospital following infection with COVID-19, 3.7% had been doubly vaccinated. Of the 2031 patients in the study who died, 4% had been doubly vaccinated.

The mean age of the patients in the study was 52 years. The patients who appeared most at risk of severe illness and death were those with Down’s Syndrome. They were followed (in descending order of risk) by kidney transplant patients, those with sickle-cell disease, patients receiving chemotherapy, those in care homes, those with HIV or AIDS, cirrhosis or neurological conditions. Next came bone marrow or organ transplant patients, dementia sufferers and patients with Parkinson’s disease.

The study also confirmed previous findings that the risk of death following infection with COVID-19 increased with age, social deprivation, being male, and was higher for people of Indian and Pakistani ethnicity. This increased risk of hospitalisation and/or death incorporates the risk of exposure to COVID-19, the risk of becoming infected if exposed and the risk of any infection becoming severe. Those who are most at risk could be advised to continue to take appropriate precautions. The QCovid tool can also help to identify those who should receive booster vaccinations and/or early effective treatments such as antiviral and/or immunomodulatory drugs which can reduce the likelihood of developing severe illness.

There is no doubting the effectiveness of vaccination in preventing severe illness and death in the overwhelming majority of the population. However, it is not a silver bullet and we can still expect to admit vaccinated patients to ICU this winter. With just over two weeks to go before the end of the month, it looks like SAGE’s worst fears will not come to pass. This is a relief but cases are bound to increase. How big an increase we will see is unclear. We still don’t know if there is enough immunity within the population to prevent a sustained rise in hospital admissions as we move into winter. All we can do is hope that the COVID rollercoaster will continue to remain a relatively dull and unexciting ride.