e27 Covid. Is it still a thing?

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Does Covid still matter?

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[00:00:05] Munir Adam: Hi guys, it's Munir Adam and welcome back and let's continue season two of Primary Care UK, brought in collaboration with Integrated Care Support Services. Today, it's about COVID 19. And I'm joined by Emma Borders, who you may know and remember from episode 18, and who is part of our team as well.

[00:00:21] Emma: Hi, yeah, I'm Emma Borders. I'm a general practice nurse and senior educator for the Cornwall Primary Care Training Hub, and as part of that role, I have designed and delivered immunization training for primary care in Cornwall since 2020, which was a really interesting time to become the immunization trainer.

[00:00:39] So we now have a virtual interprofessional interactive training offer, which I'm actually really proud of, and I consider myself to be a vaccine ambassador so that's why I'm speaking about this today.

[00:00:49] Munir Adam: Brilliant. So, an update on COVID and COVID vaccines in particular. 

[00:00:53] So, COVID came with a vengeance. It caused havoc, and then it went away. Or at least, that's how it feels to me. Schools were shut. Nobody was going out anywhere. There was fear in everybody's hearts, well, a lot of people. And then the mass vaccination.

[00:01:19] And then on the other side, there were conspiracy theories and all sorts of crazy ideas about it, social distancing, long queues in supermarkets. I hated that part of it. And then, you know, things about people having Christmas parties when they shouldn't be, and so on. It was all we ever heard about in the news, really, wasn't it?

[00:01:36] And with some 7 million deaths worldwide, and what, a quarter of a million in the UK? So we're talking about big numbers. But that was all then. All of those things I said have gone back to normal now. So, why does it matter now?

[00:01:48] Emma: Yeah, I mean, it's a really good point. And I think actually when you say that, it makes me think about that period in January 2020, when we were all a little bit in denial that it was even going to happen here, because we saw Italy and everything was happening there. And we didn't really believe that, you know, see what was happening, but we didn't really believe that that could happen here.

[00:02:05] And I don't know if I look at where we are now and think we've almost just slinked back into that way of thinking almost, but as you say a quarter of a million deaths, uh, 20 million confirmed cases. And the reason COVID is still an issue and something we should think about, it's an incredibly infectious disease. 

[00:02:22] So Those are numbers that we used to hear so much about. So for every person who has it, how many people will they infect? Well, original COVID strain was about an R rate of around about three. Then we had the Delta that was an R rate of five. And then we had the Omicron, which is an R rate of 9. 5. And to put that into context, flu's only got an R rate of about 1. 2,, something like that on average.

[00:02:42] Munir Adam: Oh, I see.

[00:02:42] Emma: So it's really, really infectious. So we obviously worry about flu, but COVID is so much more infectious. So it's unsurprising that the vast majority of people got COVID and most people are fine, aren't they? They recover, mild illness, self limiting, don't need hospital. But when we're talking about those numbers, we're talking about a lot of deaths.

[00:03:02] And when we're talking about that many deaths, we have an NHS that's already under a lot of pressure and is at a real risk of becoming overwhelmed again. So, I guess you could then say, well, we have immunity now, we've had this vaccine campaign and booster vaccines. But, as we know, it's an incredibly variable disease.

[00:03:18] And natural immunity begins to wane after about a year. So, that means that immune escape happens. So, with each of these new variants that's coming about and this waning immunity, we are going to see resurgence of COVID. And that's what we are seeing when you look at the graphs. 

[00:03:35] We've had a really nice little quiet period since the last spike in April. So numbers had really dropped right down and we've all gotten comfortable again. But we've got a new novel strain that's out there at the minute, the BA. 2. 86.

[00:03:48] Munir Adam: Gosh, no.

[00:03:49] Emma: So it's not officially a variant of concern yet, but it is under monitoring. And if you look at the graphs over the past three months, we are back up on an upward trajectory.

[00:03:58] And the reason that the BA 2. 86 is a strain it is distant, uh, antigenetically from the Omicron virus. So the XBB variant. And it has a slightly higher ACE2 binding affinity. And the reason that's a problem is because that's related to transmissibility. So we said Omicron was R rated 9. 5 and this potentially might be more transmissible.

[00:04:21] So there's a significant amount of change in mutations. So we're seeing the numbers go up, but it's really hard to predict now what's going to happen because we no longer test and we don't have a sequencing anymore.

[00:04:32] Munir Adam: Do we think that this variant is going to be more pathogenic?

[00:04:35] Emma: They don't know. We are sort of seeing science unfold as it happens and that's what makes this really challenging. What we're seeing is in the last three months, we had hospitalizations rates about three months prior, about 900 weekly, and we're up to about 4, 000 now. And the deaths are following on a similar trajectory.

[00:04:53] So we're starting at a very low level. But if things continue to move at that trajectory , it wouldn't be long until we were back in trouble again. And that's why they brought the flu and COVID vaccination program forward, because of this BA 2. 86 strain.

Not testing for Covid

[00:05:09] Munir Adam: And we'll talk more about the vaccination program in a few minutes, but you mentioned just a minute ago about the fact that compared to then and now, then we all had tests, and we were able to access them for free and test whenever we needed to and now we don't. Do you think this is something that should be brought back in and would it make a difference?

[00:05:24] Emma: So it is really interesting. I think they have to weigh up the cost of programs like that with the benefits of them. A little bit later when I talk about the vaccine, there's something very exciting in the future for vaccines, but that's only possible because of all the sequencing we did with the PCR testing. So by doing that, we could have potentially unlocked a longer term vaccine. But, you know, it's weighing up the benefits financially and the practicalities of it. Um, because as well, you've got to think every time someone tests and then they're positive, do they then have to be off sick from work? So that's, they don't really want us testing do they?

[00:05:56] Munir Adam: Exactly. It's the implication of a positive. I know I feel double minded about it myself. Do I want to necessarily have people tested every single time. I mean, even if the authorities don't force you to, you might feel guilty going to work or going to school or wherever, and then it creates all sorts of dilemmas.

[00:06:10] Okay. Looking at myself as a clinician, yes, number one, what I need to do is think about it. It hasn't completely gone away, as you say, with the trajectory going up. And then obviously, as I would always do, if somebody is really seriously ill or I can see red flags, I would refer them straight into hospital. 

[00:06:27] And then symptoms dragging on and on and on. When that happens, we think about things like long COVID, but other than that, what should we be doing differently or what should we be thinking about?

Vaccination update

[00:06:38] Emma: Well, I mean, it's not going to surprise you that now I'm just going to sort of bang the drum again for vaccines, but you know, they are probably the most impactful thing, which I think we as primary care clinicians can actually be doing. So being a sort of vaccine champions.

[00:06:52] Munir Adam: Are they? Are they impactful? Do they, do they even work?

[00:06:54] Emma: Ah, yeah...

[00:06:55] Munir Adam: Um, you know, because I did see a lot of people, they got vaccinated and then they still got COVID again.

[00:06:59] Emma: Yeah, that's true, and I think if you're thinking about vaccines as a whole, they're probably one of the most effective healthcare prevention strategies that we've had after clean water, they've saved the most lives. They've reduced infant deaths by about 50 percent over the past 30 years. We've eradicated smallpox. So vaccines as a whole, we would probably argue are a good thing. 

[00:07:18] I think when you come to COVID, if you look at the graphs and the dates, when the vaccine campaign started and the drop off, it's hard to deny their effectiveness. They are definitely effective. It's an interesting question what you say, and it's because it's hard to evaluate the impact of a vaccine campaign.

[00:07:36] But what we do know is, is people who've had a dose of that vaccine are anywhere between 40 and 80 percent, depending on the study that you look at, less likely to end up in hospital or die. I would say that's, that's not bad. That's worthwhile doing, especially because they're so safe.

[00:07:49] Munir Adam: Yeah, and even if you're a little bit skeptical about some of these benefits, I think at the end of the day, the vast majority of people did get vaccinated and are walking and talking normally. So I certainly don't subscribe to the idea that this vaccine is somehow going to eradicate humanity or, or is some kind of crazy thing at all.

[00:08:05] The vast majority of people are absolutely fine and certainly people who are high risk, I would encourage them. So who, who should it be for then? Who should be getting vaccinated?

[00:08:12] Emma: So as of this autumn campaign, it has now moved to a single dose booster campaign. So the way I think about this, that makes it easy to remember, it's gone to a similar thing as flu. So if somebody presents initially for their flu vaccine, you would just give them one. You wouldn't bother with primary doses and this sort of thing.

[00:08:29] And now that's the same for COVID vaccines. Everybody's gone to a single dose and that's because we think everybody's had the disease and has some natural immunity. Most people who are at risk have had boosters now, and one dose will offer most people a good level of protection. 

[00:08:43] So what it comes down to now is, who as a JCVI recommended has it? And that's everyone over 65, everyone in a clinical at risk group, people in care homes, carers, people caring for people who are immunosuppressed. The full list is obviously in the green book and I would urge people to always go and have a look at it, put it on your toolbar.

[00:09:01] Munir Adam: So just to see, I've got this right. It's regardless of whether you've been vaccinated before, regardless of whether you're sure whether you had COVID or didn't have, you would have it just like the flu jab, you would have one dose. 

[00:09:11] And would you have that at the same time as the flu jab? Or

[00:09:14] Emma: Yes, you know what, I'm really glad you've asked that because one of the things that I have been encountering is this sort of common misconception that people should separate them. There's been different guidance in the past because it was a new vaccine and them trying to be cautious. As we stand currently, a person could come and they could have all of the vaccines that you'd commonly have around this time.

[00:09:33] So they could come and have their flu, COVID, pneumonia, and shingles all in one sitting. And there's absolutely no reason not to. One year old babies have four vaccines at one go to protect against seven diseases, and they're absolutely fine. 

[00:09:46] They're completely safe. Um, and your immune system encounters so many germs on a daily basis, there's no upper limit of vaccines that you could have that would overwhelm your immune system.

[00:09:56] , All you're limited by is where you'd put them because you can't really fit more than two in each deltoid. We really need to be promoting. It's safe to have them at the same time. There's really no reason, no research, nothing indicates it's not safe.

[00:10:08] Munir Adam: That's really good to hear from you, actually. I guess the practical benefits of that are huge, aren't they, for patients as well?

[00:10:13] Emma: Yeah, I say you'll save you a trip. You know, you're not going to have any stronger an immune response. Part of a natural immune response is that you're going to have a sore arm and maybe feel run down for the next day or two as your immune system kicks in and makes those antibodies. Well, you get that overall all in one go. So that's a benefit. 

[00:10:28] The only thing about injecting into the deltoid and two, you just have to have them two and a half centimeters apart. And document which one was upper and lower. That, that's also good practice.

[00:10:37] Munir Adam: Are there any other practical considerations in relation to these vaccines?

[00:10:41] Emma: Probably did want to just touch upon contraindications, because I think that's something that we really worry about. So we've currently got two vaccines that are licensed that we're commonly using, the Pfizer BioNTech Cominarty and the Moderna spike vax. They're both mRNA vaccines, and there is a Vigpreft and Sanofi vaccine that's also out there, but won't be as widely used.

[00:11:00] Munir Adam: So what happened to the AstraZeneca?

[00:11:02] Emma: So the AstraZeneca is still there and it is still licensed, but this season there's not been any procured, so no one will be giving that AstraZeneca. That's the one that you know when you go capillary leak syndrome, Guillain Barre syndrome, uh, thrombocytopenia. Those are the ones that we have to start thinking about all those things.

[00:11:17] As soon as that's not on the table anymore, it makes your life as a screener a little bit easier. So the only contraindications now: they've had a previous systemic allergic reaction like anaphylaxis to the vaccine or a component of the vaccine; they experienced myocarditis or pericarditis that was linked to having the vaccine or they are acutely unwell, and by acutely unwell we mean they have a fever and they're probably so unwell they wouldn't have made it to your clinic and the only reason really for that is that we don't want any of that illness that they've got to be associated and attributed later by them to the vaccine.

[00:11:53] So those are the contraindications, but even with those people, if you identify one of those, you should probably speak to your local immunization team or their specialists, because it might be they would still consider vaccinating them, but in a hospital setting. So those are the contraindications, and on a practical level, I think there's just a few target questions that you can ask that will answer that.

[00:12:13] So my first question is, have you had a COVID vaccine before? Yes. Did you have any allergic reactions to that vaccine? No. Have you had any allergic reactions, serious allergic reactions to anything? No. Then you know, you've pretty much answered all your questions there and they're safe and you don't need to be going through all this.

[00:12:29] Now there is precautions as well, but again, refer back to your green book and the things that you're looking out for, are PEG allergy with the mRNA vaccines. That's very, very rare though. Um, and then as I mentioned before, capillary release in. Thrombocytopenia, thrombosis, Guillain Barre syndrome, pericarditis, endocarditis. And if you identify anyone with those things, check your green book on how to proceed, you might need specialist advice. But the vast majority of people are completely safe to have a vaccine.

[00:12:57] Munir Adam: All right. So Green Book is the place to get all of those nitty gritty details. And also in answer to my next question, I guess as well, look at the Green Book for the whole variety of side effects that you might get. Do you normally give a handout and say, well, look here, the list of side effects, or do you feel that you verbally have to cover every single one? That wouldn't be practical, would it?

[00:13:14] Emma: So it is handy to give people the leaflet and signpost them to that, but I think if we're thinking about informed consent, you know, you probably need to be giving them some advice beforehand. What you don't want is talking about side effects to become a barrier to vaccination. So it is being mindful of that.

[00:13:27] You can't possibly go into every single thing that a manufacturer has listed on the things, but the common aside, you need to be aware that anaphylaxis is a risk, but it's treatable and only about 0. 6 to 1 cases per million doses of vaccine administered. So incredibly rare. And also that the risks of the vaccine are much smaller than the risks of getting the actual disease in the case of every single vaccine as well.

[00:13:50] So I normally talk about the common reactions, which are localized reactions at the site. So your sore arm, which can be worse. with every booster because you get a bigger localized reaction at the site with booster doses and with adjuvanted vaccines that it might be more sore like your flu vaccines. So that's worthwhile telling people and that people might get part of that immune response temperature, feel a little unwell, that sort of thing in the next couple of days.

[00:14:12] And other than that, then giving people a leaflet.

[00:14:15] Munir Adam: Thanks for that. That's already a lot more information than perhaps the average clinician who maybe isn't involved with vaccination needs to know. But it's nice to be aware of some of these things because patients might discuss them with us. Is there anything else that you think you would say for the rest of us?

[00:14:29] I'd like to hope that I don't need to know anything about this. I'm not involved and I just leave it to those who are.

[00:14:35] Emma: Yeah.

[00:14:35] Munir Adam: What would you say?

[00:14:37] Emma: Leave it to the nursing team. I mean, I would say, especially now, there is a lot more people involved in this vaccination effort than there ever has been previously. And historically, it has been a nurse led intervention. But I would say now the primary care teams widened so much. As an immunization trainer, I have been hoping to see, and I'm starting to see, more of the other sort of allied health professionals, NAS roles coming through the training, um, and helping.

[00:15:01] So not just COVID and flu, but, but all sorts of things really, you know, uh, dependent on their role. Like you think, oh, for all those paramedics, physiotherapists and whatnot seeing patients, you know, wouldn't it be great if they could start opportunistically saying to people, Oh, you do a pneumonia vaccine, you're do a shingles vaccine, let me give that to you. And I wanted to mention healthcare support workers, so people who are non registered professionals, can only operate off a prescription or what we call a patient specific direction. 

[00:15:24] But there is a whole list of registered professionals who can operate off patient group directions. So it makes it a lot easier for them to give vaccines. So podiatrists, dieticians, midwives, nurses, occupational therapists, paramedics, pharmacists, physiotherapists, and speech and language therapists. They are all named in law as people who can work off PGD. So there's no reason that any of these people can't get the training and then give any of the vaccines on the routine immunization schedule.

[00:15:49] Munir Adam: That creates a lot of flexibility, doesn't it, in terms of how any practice might want to fulfill this requirement. Okay, so how would you summarize it?

[00:15:58] Emma: I think going back to that message about being a vaccine champion, I think that's really, really important. There is an anti vaccine movement. There is things circulating on social media. There is a lot of misinformation, and healthcare professionals are one of the most trusted sources, and people do believe what we say.

[00:16:12] So, you know, we should be well informed, knowledgeable, and be able to have these conversations and promote vaccinations like the COVID vaccine. And I think as well, not bury our heads in the sand and think that this... is just going to go away. 

[00:16:26] I did want to say as like a happy ending to everything because I realise it all sounds a bit grim, what I'm saying and like...

[00:16:32] Munir Adam: We need it. Go on.

[00:16:33] Emma: Yeah, yeah, I wanted to say that there is some Cambridge scientists, and this is really exciting that because of all that sequencing that I mentioned with the PCR testing, there is parts of viruses that hide themselves from the immune system and they obviously cleverly do this because these parts of the virus need to remain the same for it to continue its function as the virus.

[00:16:52] But with the sequencing that we did, they found these sort of Achilles heels of the virus and they have actually started, they've started animal trials and those vaccines are looking to provide immunity of anywhere up to two years. So even if the virus mutates and changes, because it targets the parts of the virus that don't mutate and change, it would still be effective.

[00:17:11] Munir Adam: Brilliant. Okay. So watch this space. And at this stage, we have what we have. We have the vaccines that do need to be given. And as you say, there are some who are very anti vaccine as well. And so hopefully this episode will have helped convince listeners who do have some doubt about this. So I think we've done our good deed for the day.

Resources for further info

[00:17:30] Munir Adam: Can you think of any resources or anywhere people can find out more about this? Other than the Green Book,

[00:17:33] Emma: Green So I think if people are interested in, they think, right, actually, I do immunize or I want to immunize and perhaps I haven't actually really done any formal training, which I think probably is the case for lots of people other than nurses, the e- learning- for- health site, and they have a fantastic immunization module just called the immunization code IMM, that covers all the core topics.

[00:17:52] There's a lovely infographic for the COVID vaccines called which COVID 19 vaccine; and I was going to share, if you're interested in putting up there I have created like an hour long video that's like a breakdown of all the core topics of immunization which is on YouTube but I can share the link.

[00:18:05] Munir Adam: Yeah, we'll include that.

[00:18:06] Emma: Yeah and then finally there is a website called the Vaccine Knowledge Project and they have a really good FAQs page which has like listed really commonly asked questions by patients and gives you like a response of how to answer those. And I think that's a really useful page, you know, like the immune system question that we talked about earlier, you know, like, will it overload my immune system and worthwhile reading those as well.

[00:18:27] Munir Adam: Oh, that's good. Fantastic. Okay, so that's it for today. Thanks a million, Emma. 

[00:18:32] And that's it for now. All right, guys. We all need to know about this, whether we're involved directly or not, and we can all make that difference. So until next time, keep well and keep safe.

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Disclaimer

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