Covid-19: NHS bosses told to assess risk to ethnic minority staff who may be at greater risk
BMJ 2020; 369 doi: https://doi.org/10.1136/bmj.m1820 (Published 04 May 2020) Cite this as: BMJ 2020;369:m1820Read our latest coverage of the coronavirus pandemic
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Dear Editor
I recently received a letter from the acting chief executive officer of the hospital where I work. The letter was sent to all black and ethnic minority (BAME) workers. It was intended to provide some degree of re-assurance to staff and acknowledge our concerns of the potential and disproportionate effect of COVID-19 on BAME workers. I am aware of the many reasons, which have been cited in articles, studies and opinion pieces of why this might be the case. Many of these factors are socioeconomic, such as a high proportion of BAME workers in the NHS; another includes living in multi-generational households. 1,2 There are also physiological reasons such as a higher incidence of co-morbidities among BAME groups.3 Many of these potential links however, are not immediately reversible or treatable in the short term. The link with vitamin –D deficiency however, is in my opinion, an exception to this. There have been numerous reports from epidemiological studies looking at the strong link between Vitamin D deficiency and the severity of COVID-19 related symptoms. 4, 5,6
I am aware that the Government and Public Health England (PHE) are planning to undertake a review of the evidence of the impact COVID-19 has had on BAME groups. 7 However, as a BAME NHS doctor working in anaesthetics and ICU, it would be more reassuring to me if hospital trusts in the UK consider adding this relatively inexpensive test to the admissions bloods of at risk groups, especially when a low cost treatment exists.8 It has been previously reported in the BMJ that Vitamin D supplementation has no serious side effects and supplementation should be considered in vulnerable groups in the community, in an attempt to protect these groups further.9 Subsequently if more vitamin D testing were to occur in COVID-19 patients, the data could be used in prospective studies which could conclude one way or the other if this link really does impact on the severity of symptoms in these groups rather than extrapolating data from epidemiological studies alone. 4,5 I have searched the literature for UK prospective studies undertaking vitamin D testing in COVID-19 patients in the UK, but could find none. In real terms if this possible link exists and is not being acted on it, it could represent a missed opportunity at a low cost treatment to save lives. 8,9
References
1. https://www.ethnicity-facts-figures.service.gov.uk/workforce-and-busines...
2. https://www.ethnicity-facts-figures.service.gov.uk/uk-population-by-ethn...
3. https://www.kingsfund.org.uk/blog/2020/04/ethnic-minority-deaths-covid-19
4. http://imj.ie/irish-medical-journal-may-2020-vol-113-no-5/
5. https://www.sciencedaily.com/releases/2020/05/200507121353.htm
6. https://www.bmj.com/company/newsroom/vitamin-d-supplements-acute-respira...
7. https://www.england.nhs.uk/blog/note-for-all-bame-colleagues-working-in-...
8. https://www.nice.org.uk/guidance/ph56
9. https://www.bmj.com/content/366/bmj.l4673
Competing interests: No competing interests
Dear Editor
Risk assessment not just for health staff
The BMA has called for a national risk assessment framework to help with the safe deployment of staff in the NHS so those at higher personal risk from infection can have extra safeguards [1]. This will also be important for those other occupations which carry extra risks [2]. The public at large as well as their employers would like to understand when the consequences of personal infection with covid-19 are more likely to be grave.
Currently UK policy appears to have only 3 risk groups, ie the standard, the extra care (based around those offered a routine winter flu immunisation), and those with very significant risks who have to be shielded. Emerging evidence, such as that becoming available from large UK-based studies, should allow greater differentiation [3,4]. Broad risk groupings could take account of the basic demographics (age, sex, ethnicity) as well as significant morbidities [5]. If there are enough categories, then the fit over 70s could be distinguished not only from those with relevant comorbidities, but also equally fit but younger adults. Most patients will know enough to do their own assessment using an on-line tool, depending on the degree of detail required (eg HbA1c for diabetics and medication being taken for asthma). A positive test of covid-19 antibodies could allow a shift to the lowest risk group, assuming this means some immunity to infection.
Categorisation based on the emerging risk shown to date could reassure some, but demonstrate to others the importance of extra care. The level of personal risk is a key question for everyone as we emerge from lockdown, so better have an ‘official version’ updated frequently on the evidence rather than self-made assessments or risk groups defined weeks ago mostly based on first principles. It would make more explicit some of the existing difficult policy questions arising from the associations with deprivation and demographics. The degree of social interaction to be permitted for which risk category would be among the many difficult questions on how best to resume normal life while freeing NHS hospitals from those ill with covid-19.
It would be double-edged, of course, since it would bring home to most of the young that their personal risks of severe illness are very low and yet they will still be required to social distance and hand wash to prevent spreading to others.
Hilary Pickles, Director of Public Health (retired)
Hilary.pickles@doctors.org.uk
1. Health staff to be risk assessed BMJ 2020;369:m1820
2. https://www.ons.gov.uk/employmentandlabourmarket/peopleinwork/employment...
3. AB Docherty et al Features of 16,749 hospitalised UK patients with COVID-19 using the ISARIC WHO Clinical Characterisation Protocol https://doi.org/10.1101/2020.04.23.20076042doi
4. OpenSAFELY: factors associated with COVID-19-related hospital death in the linked electronic health records of 17 million adult NHS patients https://doi.org/10.1101/2020.05.06.20092999doi
5. A Banerjee et al. Estimating excess 1-year mortality associated with the COVID-19 pandemic according to underlying conditions and age: a population-based cohort study DOI:https://doi.org/10.1016/S0140-6736(20)30854-0
Competing interests: No competing interests
Dear Editor,
As already commented in a response on 20.4.2020 (1), I think one of the possible reasons for more Covid-19 victims among patients and medical staff with ancestors from malaria countries could be the widespread use of chloroquine (cq) and hydroxychloroquine (hcq) for therapy and for prophylactic indications with patients with a G6PD-deficiency. Most frequently high doses up to 800 mg daily are recommended.
Although it is long known that patients with a G6PD-deficiency should not get cq or hcq, it seems to be almost forgotten with new programs and studies against covid-19. In a rapid scan of 1830 "all COVID-19 trials from the ICTRP database" (2), hydroxychloroquine or chloroquine were mentioned in 1163 of them, but "G6PD" or "Glucose-6", or "glucose-6-phosphate dehydrogenase" was only mentioned less than 100 times.
In Sub-Saharan Africa e.g. the prevalence of G6PD-deficiency (3) has been found to be 20-30% of the population. But even in Mediterranean countries the prevalence is said to be something between 2 and 20%.
Mostly men with this enzyme constellation get serous hemolysis, which is dose dependent. The symptoms would be breathlessness, microthrombosis and multi-organ failure, something that has been reported with covid-19 but was misleadingly (4) explained as a direct effect of the SARS CoV-2. In addition to this, there is a massive ramping up of hcq (5) production in Africa and India to be used off label (compassionate use).
So, if someone wants to assess the risk to ethnic minority staff, who may be at greater risk, he should have in mind, that there is a common risk in staff and patients that have ancestors from malaria regions, which has to be added to the risk of cardiac complications. The risk to assess is the use of hcq or cq in staff or patients with G6PD-deficiency.
1. https://www.bmj.com/content/369/bmj.m1432/rapid-responses
2. https://www.who.int/ictrp/COVID19-web.csv
3. https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1...
4. https://chemrxiv.org/articles/Flawed_methods_in_COVID-19_Attacks_the_1-B...
5. https://www.voanews.com/science-health/coronavirus-outbreak/cameroon-beg...
Competing interests: No competing interests
Dear Editor,
NHS leaders in England have been advised to “risk-assess” and make “appropriate arrangements” to protect ethnic minority staff who may be at a greater risk of covid-19, as more than half of all deaths of healthcare workers were from an ethnic minority background. A national risk assessment framework would probably take into account ethnicity, age, sex, and other medical conditions, as well as nature of work, risk of exposure, and other factors. The steps to support BAME [black, Asian, and minority ethnic] staff would be developed (1). In our opinion, measuring vitamin D levels in individuals could be an important risk-assessment tool, and vitamin D supplementation might be a useful measure to reduce the risks in covid-19 pandemic.
It is well known that vitamin D reduces the risk of respiratory tract infections through several mechanisms. Those mechanisms include inducing cathelicidins and defensins that can lower viral replication rates and reducing concentrations of pro-inflammatory cytokines that produce the inflammation that injures the lining of the lungs, leading to pneumonia, as well as increasing concentrations of anti-inflammatory cytokines. Several observational studies and clinical trials reported that vitamin D supplementation reduced the risk of influenza. Evidence supporting the role of vitamin D in reducing risk of covid-19 includes that the outbreak occurred in winter, a time when vitamin D (25(OH)D) concentrations are lowest; that the number of cases in the Southern Hemisphere near the end of summer are low; that vitamin D deficiency has been found to contribute to acute respiratory distress syndrome; and that case-fatality rates increase with age and with chronic disease comorbidity, both of which are associated with lower 25(OH)D concentration (2).
It is estimated that in overall, 13% of population across Europe has vitamin D deficiency (25(OH)D concentration <30 nmol/L) on average in the year, with differences in geographical regions and subpopulations (3). Recent statistical analysis of data obtained from hospitals and clinics across the world evaluated whether a link exists between severe cases of covid-19 that feature cytokine storm and vitamin D deficiency. Age-specific case fatality ratio (CFR) in Italy, Spain, and France (70 yrs ≤ age < 80 yrs) was substantially higher (>1.9 times) than in other countries (Germany, South Korea, China); for the elderly (age ≥70 yrs), Italy and Spain present the highest CFR (>1.7 times that of other countries). As more severe deficiency of vitamin D is reported in Italy and Spain compared to other countries the researchers conclude that elimination of severe vitamin D deficiency could reduce the risk of high CRP levels (4). Recent retrospective multicentre study of 212 cases with laboratory-confirmed infection with SARS-CoV-2 and known serum 25(OH)D levels revealed that serum 25(OH)D level was lowest in critical cases, but highest in mild cases. Vitamin D status was significantly associated with clinical outcomes: higher serum 25(OH)D level in the body could either improve clinical outcomes or mitigate worst (severe to critical) outcomes, while lower serum 25(OH)D level could worsen clinical outcomes of covid-19 patients. In conclusion, vitamin D supplementation could possibly improve clinical outcomes of patients with covid-19 (5).
In addition to regional differences European data have confirmed, there are differences in vitamin D deficiency also regarding the ethnicity and race, as studies show that the prevalence of deficiency risk among Kurdish and Somali adults living in Finland is quite higher, 50.4% and 28.0% (3). The population survey in the United Kingdom found the prevalence of vitamin D deficiency was 20.0% in white, 40.0% in black and 63.8% in Asian participants(6). It can be assumed that skin colour (increased skin pigmentation inhibits cutaneous synthesis of cholecalciferol, the metabolic precursor of vitamin D), in addition to environmental and cultural factors in BAME subpopulation contribute to elevated risk for vitamin D deficiency, which could be related to higher covid-19 morbidity and mortality in BAME healthcare workers.
In Slovenia we have low covid-19 mortality rate, 47 per million population, compared to UK with 433 per million population.7 More than half of all deaths in Slovenia were from fragile elderly in nursing homes. One month ago, in spite of the fact that there are still no clear clinical data on the relation between vitamin D and covid-19, Slovenian medical community managed to agree to advice all medical doctors to supplement vitamin D in fragile patients in nursing homes, covid-19 patients in hospitals and healthcare workers, especially in covid-19 units. We believe that common sense approach in Slovenia regarding vitamin D supplementation was an important measure for low covid-19 morbidity and mortality in addition to other measures, e.g. social distancing and mandatory use of face masks in the community.
1. Iacobucci G. Covid-19: NHS bosses told to assess risk to ethnic minority staff who may be at greater risk BMJ 2020;369:m1820. doi: https://doi.org/10.1136/bmj.m1820
2. Grant WB, Lahore H, McDonnell SL, et a. Evidence that Vitamin D Supplementation Could Reduce Risk of Influenza and COVID-19 Infections and Deaths. Nutrients 2020;12:988. doi:10.3390/nu12040988
3. Cashman KD, Dowling KG, Skrabakova Z, et al. Vitamin D deficiency in Europe: pandemic? Am J Clin Nutr 2016;103(4):1033–44.
4. Daneshkhah A, Agrawal V, Eshein A, Subramanian H, Roy HK, Backman V. The Possible Role of Vitamin D in Suppressing Cytokine Storm and Associated Mortality in COVID-19 Patients. medRxiv 2020.04.08.20058578; doi: https://doi.org/10.1101/2020.04.08.20058578
5. Alipio M. Vitamin D supplementation could possibly improve clinical outcomes of patients infected with Coronavirus-2019 (Covid-2019) (April 9, 2020). https://ssrn.com/abstract=3571484 or http://dx.doi.org/10.2139/ssrn.3571484
6. O’Neill CM, Kazantzidis A, Kiely M, et al. A predictive model of serum 25-hydroxyvitamin D in UK white as well as black and Asian minority ethnic population groups for application in food fortification strategy development towards vitamin D deficiency prevention. J Steroid Biochem Mol Biol 2017;173:245–52.
7. Worldmeter. COVID-19 Coronavirus Pandemic. 5 May 2020. https://www.worldometers.info/coronavirus/
Competing interests: No competing interests
Re: Covid-19: NHS bosses told to assess risk to ethnic minority staff who may be at greater risk
Dear Editor
It is high time to mitigate the risk for NHS health care workers, we must learn from the Public health England’s report on COVID-19 deaths.
It was now more than a month since this article was published. Following the reports of staff deaths and disproportionate effects on ethnic groups NHS England issued guidance to NHS bosses on 29th April 2020 to risk assess all current and returning staff [1]. Public Health England has now published a two part report on analysis of all COVID-19 deaths including root cause analysis of [2]. Since the publication of this article over 40,000 deaths have taken place in England including 200 healthcare workers. The PHE report and mortality statistics from other professional bodies clearly show risk groups who are disproportionately affected by this virus. As already now known, The Institute of Fiscal Sciences (IFS) report found that the death rate for people of Black African descent was 3.5 times higher than for white British people, while for those of the Black Caribbean and Pakistani descent, the death rate was 1.7 times and 2.7 times higher, respectively [3]. It is known that people from BAME (Black, Asian and minority ethnic) groups account for 44% of NHS medical staff and 20% of nursing and support staff in the NHS [4]. It has already been reported that two-thirds of UK healthcare workers who have died from COVID- 19 were from ethnic minority backgrounds, including 18 of the 19 doctors (94%), 35 (75%) nurses, and 27 (56%) support workers [5]. The majority of the healthcare workers who died were working in direct patient-facing roles. Of importance, there was no death reported among anaesthetists or intensivists, raising concerns for the adequacy of personnel protective equipment (PPE) provided to staff in non-intensive care settings. Staff surveys conducted by the BMA and UK Royal Colleges showed apprehension of BAME healthcare workers to work in the current climate [6] [7].
NHS employer’s guidance was issued for extremely vulnerable categories, emphasising to ensure the safety of both staff and patient and the systematic application of a risk reduction framework to guide and protect its employees [8]. Chief coroner of the UK now recommends that the death of a healthcare worker due to COVID-19 be reported for investigation [9]. Health and safety legislation 1974 and PPE at work regulation 1992 emphasises employers have a legal duty to provide a safe working environment [10]. With the ease in lockdown, the government's Scientific Advisory Group for Emergencies (SAGE) has warned of a second wave of infections and calls for protecting those at high risk, including older and ethnic minority people [11]. This is also worrying since prediction models from Imperial College research suggest only 05% populations is exposed to this virus till date, raising concern for vulnerable groups in post lockdown period [12].
An expert group of clinicians commissioned by NHSE have already provided a risk reduction framework NHS staff at risk of COVID-19 infection [13]
Since the original Public Health England (PHE) guidance, which included only three risk factors (age >70, comorbidities, and pregnancy), new variables, particularly BAME ethnicity, have been associated with increased mortality. These now include comorbidities like hypertension, diabetes, cardiovascular diseases, obesity and their sex (male) and ethnicity. Of importance, these comorbidities are more common in people from the BAME workforce, further increasing their risk. Before any individual assessments are made it is important to emphasise that all preventative measures are taken, including safe hygiene, avoiding unnecessary exposure and following the latest PHE recommendations. Employers must ensure that appropriate workplace adjustments are made, such as redeploying high-risk staff in non-COVID-19 areas or providing a high level of protection in all areas. Each individual must be assessed, in consultation with occupational health, sensitively and confidentially.
After learning from recent events, together with the current PHE guidance on the assessment of individual risk factors, employees will arbitrarily fall into the following risk groups. Ultra-high risk (age >70y, underlying serious health issues like active cancer or immunosuppression), moderate risk (male, Caucasian age >60y, BAME >55y, diabetes mellitus, hypertension, cardiovascular disease, chronic kidney disease, COPD, obesity, pregnancy >28 weeks) and low-risk categories (all others). Both the expert group and the PHE guidance emphasises to completely shield the ultra-high-risk group from work (working from home). Consideration should be given for the moderate risk group to be either shielded or redeployed to non-patient facing areas. An appropriate algorithm should be published to make it easy for assessors and self-assessment for employees.
We now have the evidence, PHE analysis and expert group guidance. It is the time for action. It is also a good time in this epidemic to see the preliminary results of UK RECOVERY trial [14] showing impressive survival with dexamethasone in critically ill COVID-19 patients, but knowing that two thirds of patients will still die, it is important that we don’t become complacent and implement the risk assessment tool universally to protect healthcare staff.
References
1. NHS England. Coronavirus: second phase of NHS response to COVID-19. 29 Apr 2020. https://www.england.nhs.uk/coronavirus/publication/second-phase-of-nhs-r....
2. Public Health England. Disparities in the risk and outcomes of covid-19. Jun 2020. https://assets.publishing.service.gov.uk/government/uploads/system/uploa...
3. https://www.ifs.org.uk/inequality/chapter/are-some-ethnic-groups-more-vu...
4. GOV.UK, Ethnicity facts and figures: NHS Workforce. . Available at
https://www.ethnicity-facts-figures.service.gov.uk/workforce-and-busines... NHS-workforce/latest#by-ethnicity. Accessed on 29th April 2020, 2020.
5.Rimmer A Covid-19: Two thirds of healthcare workers who have died were from ethnic minorities. BMJ2020; 369:m1621. doi:10.1136/bmj.m1621 pmid: 32327412
6.BAME doctors hit worse by lack of PPE by Keith Cooper Doctors with BAME (black, Asian and minority ethnic) backgrounds have been disproportionately affected by the chronic shortages of PPE (personal protective equipment) across the NHS. Location: UK, Published: Friday 24 April 2020
7. UK Doctors finding it harder to get PPE kit to treat COVID-19 patients, research reveals.
Dennis Campbell, Guardian 27 April 2020.
8. NHS Employers, COVID-19 guidance for NHS workforce leaders. Available at
https://www.nhsemployers.org/covid19. Accessed on 1st May 2020
9. CHIEF CORONER’S GUIDANCE N0 37: COVID-19 DEATHS AND POSSIBLE EXPOSURE IN THE WORKPLACE https://www.judiciary.uk/related-offices-and- bodies/office-chief coroner/guidance-law-sheets/coroners-guidance/
10. http://www.legislation.gov.uk/uksi/1999/3242/contents/made
11. NHS leaders in England have been told to “risk-assess” and make “appropriate arrangements” to protect ethnic minority staff that may be at a greater risk of covid-19. BMJ 2020; 369 doi: https://doi.org/10.1136/bmj.m1820
12.Flaxman S, Mishra S, Gandy A, et al., Imperial College COVID-19 Response Team. Estimating the effects of non-pharmaceutical interventions on COVID-19 in Europe. Nature2020 ;( Jun). Doi: 10.1038/s41586-020-2405-7. Pmid: 32512579
13. Expert consensus statement on risk reduction for NHS staff at risk of COVID-19 infection
https://www.fom.ac.uk/wp-content/uploads/Risk-Reduction-Framework-for-NH...
14. Covid-19: Low dose steroid cuts death in ventilated patients by one third, trial finds
BMJ 2020; 369 doi: https://doi.org/10.1136/bmj.m2422 (Published 16 June 2020)
About the authors
Dr Farooq A Wandroo is a consultant Haematologist and President of British Kashmiri Medical Association (a minority Ethnic group)
Dr Mudasir Firdosi is a Consultant Psychiatrist in NHS and Vice Chair of British Kashmiri Medical Association (BKMA)
Ifrah Farooq, is a 2nd year Medical student at UCL medical School, and a student member of BKMA
Competing interests: No competing interests