The burning building
BMJ 2020; 368 doi: https://doi.org/10.1136/bmj.m1101 (Published 19 March 2020) Cite this as: BMJ 2020;368:m1101
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Dear Editor;
Handwashing is an excellent strategy to prevent Healthcare Associated Infections (HAIs). Handwashing protocols have been created with little success and at the expense of great efforts and hard work from different organisations and Health Ministries. The culture of Security, in particular HAIs prevention, is still not optimal.
In 2009, during the Influenza epidemic, resources were mobilized in order to avoid a negative impact, but this time, instead of just containing the Influenza virus, other HAIs diminished. Everyone, patients, the community and healthcare workers, were conscious of handwashing not only saving the lives of patients, but also their own. The rest of the citizens understood it equally: if I wash my hands, I save my life and the life of those around me. Antibacterial gel aimed at hand hygiene started to appear everywhere. Even if, after the epidemic, the conscious effort of spreading the message of handwashing slowly decreased, everyone was still concerned with it. Strategies, which reminded both patients and healthcare workers about handwashing, were implemented, and health systems started to be more open with the existence of HAIs. Patients and their families are a highly motivated and abundant resource which is not often used in strategies aimed at HAIs prevention, however, its inclusion can have clear positive effects in healthcare systems, such as: providing a different perspective for the analysis and design of policies aimed at reducing HAIs, and lowering costs for healthcare systems and patients.
In various health centres and institutions, the strategy of patients reminding healthcare workers to wash their hands was attempted, which was an important start. This implementation, however, was not well received, as some healthcare workers felt very uncomfortable; consequently, I believe a previous preparation of professional workers in order to accept suggestions from patients should be considered. In view of that, patients, families, and healthcare professionals analysed a new strategy based on the experience of the Pan American Network of Patients for Patient Security. The integration of the patientss and their families in order to improve hand washing adherence requires a five-pillar programme:
1-Health literacy. To promote hand hygiene, patients and their families should receive more information regarding HAIs.
2-Involvement. Identify and include leaders in patients and families as well as in healthcare workers with the common goal of working together.
3-Workshops. Mixed workshops, consisting of patients, healthcare workers, and experts, should be regularly promoted in order to create a constructive relationship, receive feedback from policies and educational programmes implemented, and to learn from each perspective.
4.-Promote the recognition of patients and families, and health personnel, who work as leaders through some incentives -not necessarily financial- so that they can actively participate.
5.-Increase the Work Networks. Organize testimonies from patients with adverse and positive experiences in schools and universities in order to increase student awareness, and to let them know the relevance of both the handwashing strategy and that of patient participation with the aim of promoting a culture of prevention and working together.
Now, in the face of the COVID19 pandemic, we can integrate patients and families, as, at the moment, there is massive awareness of the importance of proper hand washing, the use of antibacterial gel, etc.
The interest within health establishments was resumed, and it was implicitly assumed: I wash my hands, I protect my life and that of others ... there is clarity about the importance of hygiene, as the pandemic has taken lives.
The proposal for adherence to handwashing should also explain that implementing it not only saves the lives of others, that is, of patients; but also of healthcare professionals and their own families, which may be affected by a contagion that can be life-threatening. It is the right moment to include families and patients, and for it to be a joint activity.
Competing interests: No competing interests
Dear Editor,
The burning building: recruiting recovered Covid-19 patients to the frontline by issuing certificates and offering voluntary registration
As I said in my rapid response on 21 March 2020, and echoing the BMJ, these are extraordinary times that demand imaginative responses. Our emergency has deepened and we desperately need exit strategies out of our burning building.
People who have recovered from proven COVID-19, and are not shedding virus and hence are no longer at risk of transmitting the infection, are a potentially invaluable asset. As they have recovered, by inference, they must have immunity although we are not sure how long this will last. I recommended we issue them with a certificate indicating this. These people will almost certainly be largely if not wholly immune to a second infection this year. We anticipate reliable antibody testing will become available and that will provide for the reassurance on immune status. They could serve in the frontline in many places, not just in healthcare and nursing home care but also in supermarkets, factories etc. Of course, they should continue to be careful.
With their explicit and informed permission they could be on a register of people willing to be called on for employment and volunteering purposes as required. They would be much in demand and would have a chance to earn income at a time when they may be in hardship. They would be able to turn their disease into an asset for themselves and our society. The Royal College of Physicians of Edinburgh has recorded a video by me on this: (https://learning.rcpe.ac.uk/course/view.php?id=707).
There are a multiplicity of issues to consider, including clinical, public health, legal, ethical and social ones. Research and scholarship is required urgently as well as public debate. This has started with the concept of the immunity passport, debated in Germany (https://www.theguardian.com/world/2020/mar/30/immunity-passports-could-s...), and with research proposed in Sweden (https://www.guaana.com/challenge/qDLtShAhLJtFdPB6S/results/CygwNno9ZRJez...) and under discussion in our institution. The country needs to debate this and other potential exit strategies urgently.
Competing interests: No competing interests
Evidenced based communication is vital to help save the burning building
In Editor’s choice of 19 March Fiona Godlee writes, “With the covid-19 pandemic we have entered extraordinary times, when some things are known but many more are not and where decisions must be made nonetheless.”[1] I strongly agree and how we communicate such decisions based on current evidence is crucial.
Medics are trained in medical school to critically appraise the literature by using evidence based practice. Such practice is typically informed by hard copy or online peer reviewed journals. However, this past week everything changed as a result of Covid 19. Medics are now using WhatsApp groups to share the latest updates, research articles and guidelines from mainstream sources such as the BMJ or other social media such as twitter. New information is coming fast, unfiltered and directly into the palms of their hands. This has its advantages and disadvantages as seen in recent weeks.
The advantages of such communication is that medics on the front line can educate themselves to this new virus. Covid 19 has brought new international and national guidelines for medics on a daily, even hourly basis. Obtaining information via our mobile phone devices is possibly the most optimal way to get the information which will help those most in need. In 2015, Bill Gates highlighted that the greatest killer in our lifetime is more likely to be a virus rather than a war and that information technology is critical in combating future epidemics [2].
While there are undoubhted advantages a significant challenge is the amount of misinformation which is circulating. Much of this information is not grounded in scientific evidence. For example, the recent publication by the BMJ stating that ibuprofen should not be used for managing symptoms led to widespread confusion amongst medics and the public [3]. Information that is not critically appraised or not peer reviewed is now in the public domain and has been publically endorsed by non medical professionals including government representatives. On 14 March, The French Minister, Oliver Veran, tweeted:“Taking anti-inflammatory drugs (ibuprofen, cortisone. . .) could be an aggravating factor for the infection. If you have a fever, take paracetamol,” [4]. This led to widespread panic. On 21 March, President Donald Trump tweeted ‘Hydroxychloroquine & azithromycin, taken together, have a real chance to be one of the biggest game changers in the history of medicine…’[5]. Such tweets undermined and add to the work load of medics. Parallel to coping with this pandemic, medics and scientists have to refute such dangerous misinformation. This further underlines the importance of evidence based medicine to critically appraise such reports and challenge such claims.
A pandemic requires rapid innovation and challenges norms with regard to scientific development. Such is the pace of this virus and the suffering it has brought, that even where question marks remain over the validity of research, the scientific community has no choice but to explore every option. On 13 March, Dr. Michael Ryan, WHO Executive Director of Emergency Programs stated ‘those involved in emergency response, if you need to be right before you move you will never win, perfection is the enemy of good, speed trumps perfection, the problem in society is everyone is afraid of making a mistake, everyone is afraid of the consequential error, the greatest error is not to move, the greatest error is to be paralysed by the fear of failure’[6].
As this pandemic is happening in real time, Information Technology platforms are critical to quickly disseminate potential solutions. Science may get it wrong but if we do not act or if we rely on perfection, the tragedy unfolding before us will be greater then anything we could have imagined. We owe it to humanity to try everything and are fortunate to have communication tools at our disposal to find a solution together.
1. Godlee F. The burning building. Editor’s choice. BMJ 2020;368:m110110.1136. doi: 10.1136/bmj.m1101.
2. Gates, B 2015. We’re Not Ready for the Next Epidemic. We’re not ready for it. But we can get there. Retrieved on 22/03/2020 from https://www.gatesnotes.com/Health/We-Are-Not-Ready-for-the-Next-Epidemic
3. Day M, 2020. Covid-19: ibuprofen should not be used for managing symptoms, say doctors and scientists BMJ 2020; 368 doi: https://doi.org/10.1136/bmj.m1086 (Published 17 March 2020) Cite this as: BMJ 2020;368:m1086
4. France says ibuprofen may aggravate coronavirus. Experts say more evidence is needed: https://edition.cnn.com/2020/03/16/health/coronavirus-ibuprofen-french-h...
5. Trump, D, 2020 tweet: https://twitter.com/realdonaldtrump/status/1241367239900778501?s=12
6. Ryan M, WHO media briefing on COVID 19 live via twitter to 13/03/2020: https://www.pscp.tv/w/1LyxBNlZOAyxN?t=3m39s
Competing interests: No competing interests
In Editor’s choice of 19 March Fiona Godlee writes, “With the covid-19 pandemic we have entered extraordinary times, when some things are known but many more are not and where decisions must be made nonetheless.”[1] We fully agree.
Among the first 15 deaths due to covid-19 in Stockholm County, six were reported, by the Swedish-Somali medical society, to be of Somali origin (March 24). Considering that only 0.84% of the Stockholm County population was born in Somalia (n=8,178 by December 2019) this is an astonishing high rate.
Socio-economic factors, e.g. cramped housing accommodation, high rates of smoking and poor understanding of the Swedish language (which in turn leads to poor understanding of health information on covid-19 provided by the authorities) may explain the situation. Another possible explanation is Ethnic benign neutropenia - the most common form of neutropenia worldwide and very common among East African populations.[2]
A risk factor that we want to highlight, however, is the low vitamin D levels found in the Swedish-Somali population. Vitamin D status is strongly related to low sun exposure and dark skin. In two different studies, the great majority of Swedish women of Somali origin had very low levels of S-25(OH)-D (< 25 nmol/l).[3,4] In Finland, Somali women required more than twice the amount of vitamin D in order to maintain recommended vitamin D status. [5] In addition, vitamin D deficiency was twice as common, regardless of gender, in immigrants from Africa compared with those from the Middle East.[6]
There is evidence that vitamin D is involved in our defence against respiratory tract infections. According to a meta-analysis, vitamin D supplementation (daily-weekly dosage) prevents acute respiratory tract infections, especially in those with 25(OH)-D below 25 nmol/l (NNT = 4).[7] In a randomised trial on individuals with frequent respiratory tract infections, treatment with cholecalciferol 4000 IE/day reduced the need for antibiotic treatment.[8] The mechanism is debated; however, modulation of the renin-angiotensin system has been implicated in animal studies of acute respiratory distress syndrome,[9] and angiotensin-converting enzyme 2 is a well-established receptor for the SARS-CoV virus.[10]
In order to cope with the covid-19 epidemic, preventive measures could be administration of vitamin D to high-risk populations, e.g. dark-skinned adults with low sun-exposure and/or individuals with risk factors for respiratory tract infections. Although it may not always be helpful, it is unlikely to be harmful.
mats.humble@oru.se; susanne.bejerot@oru.se
1. Godlee F. The burning building. Editor’s choice. BMJ 2020;368:m110110.1136. doi: 10.1136/bmj.m1101.
2. Palmblad J, Höglund P. Ethnic benign neutropenia: A phenomenon finds an explanation. Pediatr Blood Cancer 2018;65(12):e27361. doi: 10.1002/pbc.27361.
3. Demeke T, Osmancevic A, Gillstedt M, Krogstad AL, Angesjö E, et al. Comorbidity and health-related quality of life in Somali women living in Sweden. Scand J Prim Health Care 2019;37:174-81. doi: 10.1080/02813432.2019.1608043.
4. Kalliokoski P, Bergqvist Y, Löfvander M. Physical performance and 25-hydroxyvitamin D: a cross-sectional study of pregnant Swedish and Somali immigrant women and new mothers. BMC Pregnancy Childbirth 2013;13:237. doi: 10.1186/1471-2393-13-237.
5. Cashman KD, Ritz C, Adebayo FA, Dowling KG, Itkonen ST, et al. Differences in the dietary requirement for vitamin D among Caucasian and East African women at Northern latitude. Eur J Nutr. 2019; 58:2281-91. doi: 10.1007/s00394-018-1775-1.
6. Granlund L, Ramnemark A, Andersson C, Lindkvist M, Fhärm E, Norberg M. Prevalence of vitamin D deficiency and its association with nutrition, travelling and clothing habits in an immigrant population in Northern Sweden. Eur J Clin
Nutr. 2016;70:373-9. doi: 10.1038/ejcn.2015.176.
7. Martineau AR, Jolliffe DA, Hooper RL, Greenberg L, Aloia JF, et al. Vitamin D supplementation to prevent acute respiratory tract infections: systematic review and meta-analysis of individual participant data. BMJ. 2017;356:i6583. doi: 10.1136/bmj.i6583.
8. Bergman P, Norlin AC, Hansen S, Rekha RS, Agerberth B, et al. Vitamin D3 supplementation in patients with frequent respiratory tract infections: a randomised and double-blind intervention study. BMJ Open. 2012;2(6). pii: e001663. doi: 10.1136/bmjopen-2012-001663.
9. Xu J, Yang J, Chen J, Luo Q, Zhang Q, Zhang H. Vitamin D alleviates lipopolysaccharide‑induced acute lung injury via regulation of the renin‑angiotensin system. Mol Med Rep. 2017;16:7432-8. doi: 10.3892/mmr.2017.7546.
10. Wan Y, Shang J, Graham R, Baric RS, Li F. Receptor recognition by the novel coronavirus from Wuhan: an analysis based on decade-long structural studies of SARS Coronavirus. J Virol. 2020;94(7). doi: 10.1128/JVI.00127-20.
Competing interests: No competing interests
Dear Editor
The World Health Organisation declared COVID-19 a pandemic on 11 March 2020, reflecting the global health impact of over 130,000 confirmed cases and close to 5,000 deaths at that time. Since then, global case counts have more than doubled while deaths have nearly tripled. Aside from direct health impacts, the looming economic consequences of COVID-19 will also be substantial and will require a proactive approach to address.
The general economic impacts of COVID-19 have been well-covered by the media and are the subject of unprecedented government responses in most countries. Disruption to global supply chains and business cash flows, reductions in travel, and cancellations of events are just some examples of the impacts currently being faced. Frantic purchasing of necessities has stretched supermarkets to their limits, while also crowding-out disadvantaged groups such as the elderly and the vulnerable from accessing much needed supplies. Stock markets globally have experienced large declines in value. The Dow Jones Index in the USA declined 10% in a single day on 11 March 2020 and has declined markedly since then; the Index’s worst performance in three decades. Global economic integration means that shocks will reverberate across regions as economic contagion intensifies.[1]
That some individuals will experience severe economic impact due to the ramifications of COVID-19 is inescapable. Around one-quarter of Australia’s workforce is casualised, and around 35% of the casual workforce (or around 860,000 people) are in the badly affected sectors of hospitality and retail.[2] Many individuals in other countries will be similarly disadvantaged. Recent estimates for the UK, for instance, indicate that 1.4 million people are employed in temporary work.[3]
Governments across the world have had varying responses to the unfolding pandemic.[4] The USA and Australian governments have announced economic stimulus packages with financial support for businesses, households, and individuals on welfare schemes or the unemployed. Some governments, including those in the UK, China, Italy, Australia and Norway have imposed extensive quarantine and human control measures to stem virus transmission. Many governments have implemented border control measures, closure of non-essential services such as clubs and dine in facilities, closure of public facilities such as schools and universities, and deployed health measures including specialist COVID-19 clinics.
The loss of livelihoods from the current pandemic presents an immense economic and policy challenge. At the same time, COVID-19 has brought on capacity constraints in the health sector and elsewhere. Shortages of capacity to carry out diagnostic and treatment duties have arisen. An innovative policy solution could consider the redeployment of displaced workers. Options include call centre workers triaging callers to specialist COVID-19 clinics or to a regular general practitioner. Further, increasing the number of cleaners who continuously sanitise necessary public infrastructure, such as public transport and schools, could reduce transmission and minimise disruption of the wider workforce. Additional sanitary workers could also be deployed to critical private infrastructure, such as grocery stores and private health clinics. Public funding could also employ workers to deliver food and other essentials to higher risk people, including the elderly.
Facilitating such workforce redeployments would allocate economic resources to roles and individuals in greatest need. Without intervention, those in precarious employment potentially face destitution and other adverse consequences. Extraordinary times call for extraordinary solutions.
References
1. Ayittey FK, Ayittey MK, Chiwero NB, Kamasah JS, Dzuvor C. Economic impacts of Wuhan 2019‐nCoV on China and the world. J Med Virol. 2020; 1– 3. https://doi.org/10.1002/jmv.25706
2. Gilfillan G. Characteristics and use of casual employees in Australia. Canberra: Parliamentary Library, Research Paper Series 2017-18; 2018 [cited 2020 March 16]. Available from: https://www.aph.gov.au/About_Parliament/Parliamentary_Departments/Parlia...
3. Office for National Statistics. United Kingdom: EMP07: Temporary Employees; 2020 [cited 2020 March 16]. Available from: https://www.ons.gov.uk/employmentandlabourmarket/peopleinwork/employment...
4. McCloskey B, Heymann DL. SARS to novel coronavirus – old lessons and new lessons. Epidemiol Infect. 2020;148, e22, 1–4.
Competing interests: No competing interests
Dear Editor,
There are trillions of bacteria growing on our body surface and billions growing within our tissues. The latter include bacterial pathogens which induce inflammation and cause disease [1, 2]. Viral respiratory tract infections also cause inflammation. Furthermore viral respiratory tract infections can lead to secondary bacterial growth in the oropharynx thereby increasing inflammation. All these processes are in play in the current Covid-19 pandemic. There are three main factors running in parallel.
1. Viral induced respiratory tract inflammation which causes mild to moderate symptoms, depending very much on dose.
2. Secondary bacterial growth in the oropharynx by a range of bacterial pathogens. These include Staphylococcus aureus, which is toxigenic with various strains secreting pyrogenic toxins, such as toxic shock syndrome toxin (TSST) and staphylococcal enterotoxins (SE). The pyrogenic toxins in turn lead to the production of cytokines, such as tumour necrosis factor (TNF), which has an important role in inducing inflammation [3].
3. The at-risk group in Covid-19 is patients with ischaemic heart disease, hypertension, type 2 diabetes mellitus and obesity. They have pre-existing chronic inflammation which is thought to be directly causative for the conditions [4, 5]. The most likely cause of the inflammation is pathogenic bacteria growing within the tissues. Once again this includes S. aureus.
Patients in whom all three factors apply are at high risk of a cytokine storm leading to severe pulmonary inflammation and a fatal outcome. The cytokine storm is induced by the virus and the bacteria acting together.
S. aureus grows between the squamous epithelial cells of the skin and the oropharynx. We all carry this organism and we all have antibodies that recognise the pyrogenic toxins [3]. The toxins are neutralised by the antibodies in the circulation forming immune complexes; but if the antibodies are saturated then free pyrogenic toxin is present and the cytokine cascade is stimulated. Many patients with Covid-19 who are in hospital and on intensive care will have free staphylococcal pyrogenic toxins in the blood.
We cannot directly suppress the viral induced inflammation but we can prevent the development of the bacterial induced inflammation. The agent is natural yoghurt (live, no added sugar). The lactose fermenting bacteria in yoghurt produce lactic acid which will suppress the growth of bacterial pathogens in the oropharynx. If this is consumed on a daily basis for several weeks the carriage of bacterial pathogens is reduced and those who subsequently meet the virus will have a less severe disease.
In the current epidemic the government should first ensure that the dairy industry can maintain the supply of natural yoghurt on the supermarket shelves. They should then exhort everyone in the population to consume a tub of yoghurt every day. It must be seen as a civic duty; because every spoonful of yoghurt consumed will reduce the amount of S. aureus and other bacterial pathogens in circulation. It will probably take up to four weeks to have an effect but then the severity of newly acquired infections should decrease. The number of hospital admissions will fall, as will the number on intensive care and the number of deaths.
If this strategy succeeds we can get back to normal times.
Professor James A Morris
Consultant Pathologist (retired)
Education Centre, Royal Lancaster Infirmary, Lancaster, UK, LA1 4RP
References
1. Morris JA, Harrison LM, Lauder RM, Telford DR, Neary R. Low dose, early mucosal exposure will minimize the risk of microbial disease. Medical Hypotheses 2012; 79: 630 – 634.
2. Morris JA. Re-discovering the germ theory of disease: a major role for proteomics. Journal of Proteomics & Bioinformatics 2016; 9: 84 – 86.
3. Morris JA. Staphylococcus aureus bacteraemia: a hidden factor in the pathogenesis of human disease. JSM Microbiology 2017; 5: 1037.
4. Morris JA. Optimise the microbial flora with milk and yoghurt to prevent disease. Medical Hypotheses 2018; 114: 13 – 17.
5. Morris JA. A cacophony of cytokines explains the biopsychosocial interaction model of mental and physical disease. Archives of Depression and Anxiety 2018; 4: 56 – 64.
Competing interests: No competing interests
Dear Editor,
Thank you for an insightful piece of writing.
What we are seeing at the moment, people ignoring government advice on social distancing and going about their normal day as if all is well, is the result of what is known in the behavioural science literature as ‘Unrealistic Optimism’ (first identified by a US psychologist, Neil Weinstein in the 1980), Unrealistic Optimism or Optimistic Bias is the observation that people are hard- wired to irrationally believe that negative events (ranging from catching a cold, to failing an exam to getting divorced, to falling off your bike) are more likely to happen to the ‘average other person’ than themselves. The phenomenon has been replicated in various populations and with various stimuli.
Experiments have taken place to see how we can correct this irrational thinking in people. We cannot. There is no good evidence that Unrealistic Optimism can be reduced; giving information to people to show that their belief is irrational does not work, nor does giving them information that they may be ‘somewhat wrong’ (although the latter may more effective in providing a slight shift; Jefferson et al., (2017)).
Governments are not going to get people who are in the grips of UO about COVID-19, thinking it will not happen to them, to practice social distancing / isolation, unless governments enforce it. UO is one that we cannot beat simply by asking people to be rational and Government will need to take forceful action, if they wish to curb deaths from COVID-19.
Dr. Koula Asimakopoulou
Chartered Health Psychologist
Chartered Scientist
Weinstein, N.D. Unrealistic optimism about susceptibility to health problems. J Behav Med 5, 441–460 (1982). https://doi.org/10.1007/BF00845372).
Jefferson A, Bortolotti L, Kuzmanovic B. What is unrealistic optimism?. Conscious Cogn. 2017;50:3–11. doi:10.1016/j.concog.2016.10.005
Competing interests: No competing interests
Dear Editor
Indeed, these are extra ordinary times that demand imaginative responses. People who have recovered from COVID-19 and are no longer at risk of passing the infection on are potentially an invaluable asset. We should issue them with a certificate indicating this. These people will almost certainly be largely if not wholly immune to a second infection this year. They could be in the frontline in many places, not just in healthcare and nursing home care but also in supermarkets, factories et cetera. With their explicit and informed permission they could be on a register of people willing to be called on for employment purposes as required. They would be much in demand and would have a chance to earn income at a time when they may be in hardship. They would be able to turn their disease into an asset for themselves and our society.
Competing interests: No competing interests
Dear Editor
Your editorial on 19 March (BMJ 2020;368:m1101) calls attention to the urgent need for increased capacity to test frontline healthcare workers serologically to verify their immunity to the COVID-19 virus. Even more urgent is capacity for viral detection in the whole population. This, together with social distancing and intensive contact tracing, could enable the country to resume fairly normal life with long periods between 3-week lock-downs. Central facilities with the capacity to test the entire UK population simultaneously (say within 6 days at 10 million tests per day) can be available much more quickly than a vaccine, probably within weeks. This would require a crash programme to manufacture the PCR reagents and commission (or commandeer) all existing public and commercial PCR facilities. (For example, the Roche COBAS machines used in the NHS for HPV screening are already FDA-authorised for COVID-19 detection.)
All GP-registered patients would be sent a test kit (a swab for throat and nasal self-sample, and a transport tube labelled with their name, NHS no. and a barcode). The Post Office, Amazon and other companies already have the combined capacity to collect swabs from every household on the same day. All essential workers not in lock-down should be tested at least weekly. At the end of (say) 3 weeks of lock-down all households and care homes would return self-taken swabs taken on that date from all residents. All residents would test negative in most homes, so most people could resume normal life within a month of starting the lock-down. Everyone must carry the card certifying their status (date and result of latest test, and essential/other work status) that would be returned with the test result.
This should be modelled to determine the maximum period between national lock-downs. Weekly or fortnightly universal testing following the first lock-down, together with behavioural changes and efficient contact tracing, would detect most non-trivial new infections and might control the epidemic without further lock-downs until a vaccine is available.
Competing interests: No competing interests
Recruiting recovered Covid-19 patients to the frontline by issuing certificates and offering voluntary registration: update and call for a citizen's jury
Dear Editor,
In my rapid response on 21 March, (1) updated 9 April 2020,(2) on COVID-19 creating extraordinary times demanding imaginative responses,(3) I wrote that people who had recovered from proven infection and were not shedding virus were a potentially invaluable asset. Having recovered, I inferred, they must have at least partial, temporary immunity. I recommended that we issue them with a certificate indicating they would be largely, if not wholly, immune to a second infection this year. I anticipated reliable antibody testing would become available, providing further reassurance on immune status, which is becoming true although it is a controversial matter.(4) Even a test with 99% sensitivity and specificity only has 83.8% predictive power of a positive test when the prevalence of infection is 5%.(5) (A supplementary file provides 12 simple tables of sensitivity, specificity, predictive power of a positive and negative test at population prevalence is of the disease ranging from 1% to 20%.(5)) I proposed that, with care, recovered patients could serve in the frontline, not just in healthcare and nursing home care but also in retailers and factories. With their permission they could be offered registration for employment and volunteering purposes. They might earn a premium income turning their disease into an asset for themselves and society. I identified clinical, public health, legal, ethical and social issues requiring research and scholarship as well as public debate.(1, 2) The Royal College of Physicians of Edinburgh hosted a video on this proposal. (https://learning.rcpe.ac.uk/course/view.php?id=707).
Since then, there has been much scholarly and media-based debate especially about ‘immunity passports’, much of the controversy around antibody testing.(4, 6-10) The phrase immunity passport implies a guarantee that cannot be achieved. WHO cautioned against this on 24 April.(11) I have, however, not changed my mind and think the emphasis on antibody testing is misplaced and is unnecessary, especially as much immunity to respiratory viruses is largely and not humoral. (12) It is a matter of probabilities, as there can never be certainties.
Public involvement has been slow despite media publicity. Chile, to my knowledge, is the first country to formally adopt this proposal. Scientific literature records differing opinions but discusses obstacles and benefits.(6-9) It is time to go beyond opinion but research is just getting underway. The public, scholars and policymakers together need to debate this idea as a component of exit strategies. I believe the public, and especially those who have been sick, may find the idea more attractive than my fellow scholars and researchers. Is it time for a citizen’s jury?
1. Bhopal R. The burning building: recruiting recovered COVID-19 patients to the frontline. BMJ. 2020; https://www.bmj.com/content/368/bmj.m1101/rapid-responses
2. Bhopal R. The burning building: recruiting recovered COVID-19 patients to the front line by issuing certificates and offering registration. BMJ. 2020; https://www.bmj.com/content/368/bmj.m1101/rr-12.
3. Godlee F. The burning building. Editor’s choice. BMJ 2020;368:m1101.
4. Andersson M, Low N, French N, Greenhalgh T, Jeffery K, Brent A, et al. Rapid roll out of SARS-CoV-2 antibody testing—a concern. 2020;369:m2420.
5. Kumleben N, Bhopal R, Czypionka T, Gruer L, Kock R, Stebbing J, et al. Test, test, test for COVID-19 antibodies: the importance of sensitivity, specificity and predictive powers. Public Health. 2020.
6. Phelan AL. COVID-19 immunity passports and vaccination certificates: scientific, equitable, and legal challenges. The Lancet. 2020;395(10237):1595-8.
7. Persad G, Emanuel EJ. The Ethics of COVID-19 Immunity-Based Licenses (“Immunity Passports”). JAMA. 2020;323(22):2241-2.
8. Hall MA, Studdert DM. Privileges and Immunity Certification During the COVID-19 Pandemic. JAMA. 2020;323(22):2243-4.
9. Fraser B. Chile plans controversial COVID-19 certificates. The Lancet. 2020;395(10235):1473.
10. Armstrong S. Why covid-19 antibody tests are not the game changer the UK government claims. 2020;369:m2469.
11. Organisation WH. "Immunity passports" in the context of COVID-19. Scientific brief 24th of April 2020. 2020;https://www.who.int/news-room/commentaries/detail/immunity-passports-in-....
12. Kohlmeier JE, Woodland DL. Immunity to Respiratory Viruses. 2009;27(1):61-82.
Competing interests: No competing interests