Coronavirus Outbreak 2020 ANNOUNCEMENT: A notice for all patients that attend the National Aspergillosis Centre, Manchester, UK, 10th April.
A plea to all NAC patients
As you will be aware the NHS faces unprecedented times due to the Coronavirus pandemic. The National Aspergillosis Centre (NAC) team are extremely busy working on the frontline.
We are currently still trying to offer telephone consultations in place of face to face appointments. However, we are currently overwhelmed with the numbers of calls still required. May we politely request again that you call us to postpone all non-urgent telephone appointments.
Chronic Pulmonary Aspergillosis (CPA) Patients
Many patients have also been in contact with us regarding NHS social shielding letters and support. The National Aspergillosis Centre (NAC) has now sent letters to all NAC registered patients (and their GPs) who have a diagnosis of chronic pulmonary aspergillosis (CPA) advising that they are extremely vulnerable and should follow social shielding advice.
For further details on shielding and protecting highly vulnerable people click here.
All patients living in England will be added to the government’s list of extremely vulnerable people and can register for support at https://www.gov.uk/coronavirus-extremely-vulnerable
NOTE: There is separate advice for patients living in Scotland, Northern Ireland and Wales. For country-specific information regarding social shielding please follow these web links or contact you GP:
- Wales: https://gov.wales/cmo-letter-extremely-vulnerable-people-support-explained
- Scotland: https://www.gov.scot/publications/covid-shielding-contacts/
- Northern Ireland: There does not seem to be any specific advice that has been published as yet, so you should make enquiries with your GP on how to proceed.
Allergic Bronchopulmonary Aspergillosis (ABPA) Patients
Patients with Allergic Bronchopulmonary Aspergillosis (ABPA) and Severe Asthma with Fungal Sensitisation (SAFS) requiring to shield should have been identified by the NHS database searches across the UK. These searches were based on the medication you take to control your asthma. If you have not received a letter and you believe you have severe asthma you should first contact your local respiratory consultant or GP for advice. Please note that the National Institute for Health and Care Excellence (NICE) have defined severe asthma for the purposes of COVID-19 as follows:
“asthma that requires treatment with high-dose inhaled corticosteroids (see inhaled corticosteroid doses for NICE's asthma guideline) plus a second controller and/or systemic corticosteroids to prevent it from becoming 'uncontrolled', or which remains 'uncontrolled' despite this therapy.”
Aspergillus bronchitis and Aspergillus sinusitis Patients
Aspergillus bronchitis and Aspergillus sinusitis have not been identified as risk factors for serious complications from COVID-19. If you have one of these conditions alone, you should not follow shielding advice. Instead, you should follow social distancing guidelines.
For further guidance on social distancing click here
Why is social distancing so important?
There has been much discussion around how the novel coronavirus, SARS-CoV-2, which causes COVID-19, is transmitted from person to person. How does it spread? How can we monitor, isolate and control the spread of COVID-19? Why is social distancing so important?
A recently published paper, provides new evidence which adds to our understanding of transition dynamics.
The study looked at viral loads in upper respiratory tracts of 18 people from Zhuhai in Guangdong, China. 14 of these people had recently returned to Zhuhai from Wuhan and 4 were ‘secondary infections’ i.e. they had not been to Wuhan. Swabs were taken at regular intervals as the infection progressed.
- 13 had signs of pneumonia on CT scans
- 3 required admission to intensive care
- 15 had mild to moderate illness
- 1 had no symptoms
- None had visited the Huanan Seafood Wholesale Market
The paper describes the relationships between the people in the study. For example, one patient worked in Wuhan. He visited his wife, mother and a friend on January 17th. His wife and mother developed symptoms 3 and 5 days later and had virus detected soon after symptoms started. The friend had no symptoms but he too had positive swabs on days 7, 10 and 11 after contact.
The team also looked at viral load in the nose and throat of the patients who had symptoms from the day that their symptoms started. High viral loads were detected very soon after symptom onset, with more in the nose than the throat. There was similarity in the viral load of the symptomatic and asymptomatic patients. This suggests that asymptomatic carries can spread the virus too.
This is different to SARS, which caused a global epidemic in 2002-2003 with over 8000 cases in 25 countries, and suggests that very different case detection and isolation strategies are required to manage and control SARS-CoV-2.
For COVID-19, even people who have mild to moderate symptoms can be highly infectious, and they are very infectious very quickly, perhaps even before symptoms develop or very soon afterwards. This is why social distancing is so important.
Please follow official advice for social distancing, self-isolation or shielding depending on your circumstances.
- Social distancing is something we should all do to reduce social interaction between people in order to reduce the transmission of coronavirus (COVID-19)
- Self-isolation is what people should do if they, or someone they live with, develop symptoms that may be caused by coronavirus.
- Shielding is a measure to protect people who are clinically extremely vulnerable by minimising all interaction between those who are extremely vulnerable and others.
ANNOUNCEMENT for all patients of the National Aspergillosis Centre
The National Aspergillosis Centre(NAC) is situated in the Manchester University NHS Foundation Trust (MFT) at Wythenshawe, Manchester, UK. As the coronavirus SARS-CoV-2 outbreak spreads throughout the UK all hospitals are having to devote most of their activity to help with treating people who have been infected by coronavirus and who are having severe symptoms. Consequently, MFT is shutting down normal outpatient clinics to release staff from their normal duties until at least 1st June 2020. NAC patients are high risk so we have developed our policy to inform and carry on caring for our patents during this time. All patients will get a letter explaining all of this in addition to this note.
NAC Outpatient clinics (26/03/2020)
- MFT has instructed for all out-patient clinics to be cancelled from 26/03/20.
- All new NAC patient appointments will be re-scheduled until after 31/05/20.
- A letter has now been sent to all NAC patients with follow-up appointments from 26/03/20 until 31/05/20 to advise them that their face to face appointment has now been converted to a telephone appointment that will be conducted in the same week as their scheduled appointment.
- In order to significantly reduce the number of consultations patients have been asked in this letter to call our secretarial team to re-arrange their appointment unless it is absolutely necessary.
- Two attempts will be made to telephone each patient; thereafter if no contact can be made their appointment will be re-scheduled by 3 to 6 months.
- If patients are deemed by a consultant to require face to face review following telephone consultation they will be booked into NAC clinic on a Friday morning. No face to face consultations will occur on a Wednesday P.M or Thursday A.M.
- If a patient requiring face to face review has symptoms suggestive of COVID-19 they will be asked to self-isolate for 7 days prior to being reviewed in the hospital.
- Telephone consultations will be held during the same week as the patient scheduled appointment. Due to staffing constraints scheduled appointment times cannot be adhered to. Where blood or sputum sampling is required to inform patient management postal packs will be sent out to patient homes.
- Patients that telephone NAC clinic administrators will be assessed, re-scheduled until after 31/05/20 or passed to a specialist nurse.
- Patients who contact the booking centre should be directed to email idandnacadmin@mft.nhs.uk
- Weekly patient Zoom support meetings are now taking place every day 10am. Register at https://zoom.us/meeting/register/uZQocO-trj8pElzq-0Z9wqj4p-xoVd0CGg
- Monthly patients support meetings at NAC will now take place online at the same address, starting 02/04/2020
Covert infections and the spread of coronavirus
Yesterday, the Prime Minister introduced strict limitations on when and how we can move about and live our lives. He said we should leave our homes only if absolutely necessary. Why is this so important?
The Scientific Journal, Nature, has published an interesting and informative article about the proportion of people with mild or no symptoms of COVID-19 who could be spreading the virus and this information highlights why limiting our movements can help to reduce the spread of coronavirus.
The first important question is how many people are contracting this virus but are experiencing few or no symptoms? It is thought that the number may be quite high because there have been many community acquired infections where the patient has no links to known COVID-19 cases and has not travelled to any area with a large outbreak.
Those people with few or no symptoms may be totally unaware they have the virus and continue to behave as normal. The article calls COVID-19 infections of this sort ‘covert infections’.
Understanding the covert infection rate is crucial if we are to slow the spread of the virus and prevent new outbreaks.
One study that the article reports on looked at 565 Japanese citizens who were all evacuated from Wuhan in February. They were regularly monitored and tested. 13 were infected but 4 (31%) had no symptoms.
The Diamond Princess cruise ship, which was quarantined with 3711 people on board, was another opportunity to study covert infections. There were 700 infections on the ship and 18% of those showed no symptoms. The authors of this study pointed out though that the average age of the people on the cruise ship was relatively high and this could have affected the data because older people tend to experience worse symptoms than younger people.
Finally, there is a suggestion that children may experience mild or no symptoms in 56% of cases.
All of this data show just how important it is to enforce extreme social distancing measures if we are to stop the virus from spreading.
Take a look at the article, it’s available for free on the Nature website.
Do I Have Coronavirus?
What is a dry continuous cough? What if I have a runny nose? How high is a high temperature?
This BBC video answers all these questions and more.
Seasonal Viral Epidemics & COVID-19
Jon Cohen of the Journal Science has briefly reviewed a subject that we will all be interested in before much longer as the coronavirus COVID-19 spreads throughout the world, seasonal epidemics. This is certainly not the first time that a new coronavirus has appeared, apparently from nowhere and spread, killing people along the way. Over many years those viruses have been and gone, some with more publicity than others. Why?
Many of us might remember the SARS (Severe Acute Respiratory Syndrome) outbreak in 2002/3 which arrived in Hong Kong, briefly shocked us and caused 774 deaths.
Since then we have had MERS (Middle East respiratory syndrome) which appeared in 2012 and still occasionally pops up but spreads very slowly.
Where did they go? We didn't develop an effective vaccine, we didn't use a new treatment, they just disappeared. Why?
Cohen looks at these and many more disease outbreaks and the seasons they first appeared and when they disappeared - there are clear correlations.
Clearly many epidemics follow a seasonal pattern. Enveloped viruses like SARS and Influenza seem to favour the winter (SARS appeared in November 2002) but disappear during the summer months for reasons we don't fully understand. There have been many experiments on possible causes including air humidity and sudden changes in air humidity but evidence remains inconclusive. Perhaps part of the reason is that we naturally use greater self-distance in the warmer weather? Perhaps higher temperatures or sunshine contribute? More detail here.
We can't really conclude that SARS was defeated by summertime changes in climate as in the case of SARS there were aggressive attempts to contain it much as we are seeing now for COVID-19, so we might at least partly thank those activities for defeating SARS 2003.
COVID-19 is 80% identical to SARS so there might be a suggestion that it too will fade as summer progresses but at the moment we cannot rely on that hope as we know too little about this new virus. Of four other coronaviruses that we know about three do disappear in the summer, but one doesn't. COVID-19 is a lot less lethal but a much better spreader compared with SARS, and it seems to be spreading regardless of climate, so currently suggests that it will not be affected by differences in humidity or temperature.
As with many aspects of COVID-19, we must try to keep it under control as far as that is possible and wait until it shows us more of its behaviour.
For the full article click here.
Asthma and Covid 19 - research findings
An article published in the European Journal of Allergy and Clinical Immunology has described the symptoms and the allergy status of patients with Covid-19.
The study looked at 140 people in Wuhan who were hospitalised because of Covid-19. They were categorised as non-severe (82) or severe (58) on admission, around 70% of the patients were over 50 years old but the age range was 25-87 years old.
The most commonly experienced symptoms were fever (92%), followed by cough (75%), fatigue (75%), and chest tightness or shortness of breath (37%).
64% of the patients had a co-morbidity. The most common of which were chronic diseases such as hypertension (30%) and diabetes (12%). Only two patients had COPD and two had chronic urticaria (an allergic condition of the skin).
No other allergic conditions were reported, including asthma and allergic rhinitis.
This suggests that asthma, allergic disease and COPD are not likely to be prominent risk factors for COVID‐19.
A more recent report, published on 7th March 2020 in the Journal of Global Antimicrobial Resistance, reviewed the currently available literature published in English of microbiologically confirmed infections. It reviewed 225 available studies and seems to support the suggestion that chronic pulmonary diseases such as COPD, asthma and bronchiectasis are less common co-morbidities in people with Covid-19. Cardiovascular, digestive and endocrine system diseases were more commonly reported.
These are just two studies. We still don't know exactly what the risk factors are. As the scientific community learns more about Covid-19 a more precise picture will emerge. More studies are needed.
In the meantime, government advice is for everyone aged 70 and over, regardless of medical conditions, to follow social distancing measures. Full guidance on the social distancing measures we should all be taking to reduce social interaction between people in order to reduce the transmission of coronavirus is available on gov.uk. This includes information for people with pre-existing health conditions including asthma and COPD. Please read it and follow it.
The full paper in the European Journal of allergy and Clinical Immunology can be read on the Aspergillus Website.
The full report from March 2020, published in the Journal of Global Antimicrobial Resistance can also be read on the Aspergillus Website.
Notice for National Aspergillosis Centre Patients
NOTICE FOR PATIENTS WHO ATTEND THE NATIONAL ASPERGILLOSIS CENTRE (NAC), MANCHESTER.
The NHS in the UK is currently facing an extremely demanding situation in acute and critical care and Wythenshawe Hospital is no different as we run an active A&E department. We need to plan for increasing admissions and demand over the next few weeks, so we are expanding this aspect of our resources as much as possible so as to be ready. Unfortunately this means that staff are having to be taken from other services, and as NAC is part of the Infectious Diseases department our staff are in particular demand.
Consequently for a limited time we are having to reduce the size of our clinics as much as possible. Many people are stable and after discussion with NAC staff can be given a new appointment with no ill effects. Those who feel that they need to be seen, or who we feel need to be seen will be seen after a discussion with one of our specialist nursing team. Essential care remains a priority.
WHAT YOU NEED TO DO
If you have an appointment at NAC on or before the end of April 2020 please phone our dedicated line to either rearrange or speak to a nurse. [wp_call_button btn_text="Call" btn_color="#269041" hide_phone_icon="no"]
Aspergillus fumigatus and azole resistance in the hospital: Surveillance from flower beds to corridors.
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A research team in France have undertaken a screen on indoor air, soil and dust in and around hospitals to look for azole resistant Aspergillus in the environment of the University Hospital of Besançon.
The authors noted that the numbers of azole resistant Aspergillus fumigatus strains that were being isolated from patients, especially cystic fibrosis patients, was increasing. The study was designed to test the air in the hospital to discover if azole resistant A. fumigatus was brought to the hospital from rural environments by prevailing winds. They also wanted to see if plants, trees and flowerbeds around the hospital played a role.
The researchers found 83 azole resistant A. fumigatus isolates.
- 1 from the air of the intensive care unit
- 16 from the main corridors
- 59 from pots of tulips imported from the Netherlands
- 5 from the soil of trees grown in pots.
No samples of azole resistant A. fumigatus were found from an external sensor, suggesting that the resistant strains collected were not carried into the hospital on prevailing winds.
The tulips may be the main source but the authors are careful to note that to confirm this, genetic analysis would be needed to link isolates found in flower beds to isolates found in the hospital or strains isolated from patients.
In the University Hospital of Besançon, the decision has been made to stop planting bulbs. The results demonstrate a need for increasing vigilance on the surveillance of resistant strains.
The full paper is available here.
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Mycobacterium and Aspergillus can be co-isolated but are not often responsible for co-infections.
Aspergillus and Mycobacterium are often seen together in respiratory samples such as sputum. This is known as ‘concomitant isolation’. The relevance of this in terms of infection, disease progression or the effect on other pre-existing conditions such as bronchiectasis, COPD or asthma, is poorly understood at the moment. There’s even debate over whether isolating both organisms from the same sample means that one or both are causing infection or just simply that they are both living in the individual without causing a problem.
A new study from researchers in France has attempted to understand
how often concomitant isolation occurs and to better understand what this means
for patients and their clinical outcomes.
The study looked back at 1384 patients in a hospital near to Paris who has positive cultures for Aspergillus (896) and Mycobacterium (488), over a 3 month period.
50 patients had at least one positive culture for both Mycobacterium and Aspergillus. The most commonly isolated Aspergillus species was Aspergillus fumigatus (33). Seven patients in the study had pulmonary aspergillosis. One third were immunocompromised and 92% had an underlying lung disease such as bronchiectasis.
The authors looked at data from blood samples, microbiology and scans to distinguish colonisation from infection. They concluded that while cases of the two organisms causing infections at the same time was rare, it is very important to perform all available tests and follow ups and discuss cases of co-infection or co-colonisation at multi-disciplinary team meetings to ensure that the best therapeutic decisions are made. This is especially important because development of chronic aspergillosis can worsen outcomes for patients already infected with Mycobacterium. Early diagnosis of CPA for patients with Mycobacterium is crucial.
In addition, the authors note that chronic lung conditions
such as bronchiectasis might increase the likelihood of co-colonisation and so
more work is needed to understand how the two organisms interact with each
other in the lung.
More studies are also needed to see if these results are the same in other health care centres and hospitals and to see what differences, if any, are seen in patients colonised or infected by just one organism as well as both.
Read the full paper over on the Aspergillus website.