The Host, its Microbiome and their Aspergillosis.

Infection

For a very long time, medical science has assumed that infectious diseases are caused by the presence of a pathogen and weakness in the infected person or the host as it is often known, which allows the pathogen to grow and infect. The weakness could be for example a weakened immune system caused by a genetic illness or immune-suppressive treatment such as is used for transplant patients.

We assumed that inside our bodies there was mostly a sterile environment, and one reason we might become ill could be a pathogen getting into one of those sterile areas and then growing uncontrollably. One of those sterile area’s was our lungs – so 30-40 years ago most would have concluded that aspergillosis was caused by an Aspergillus spore getting deep into the lungs of the recipient and then managing to grow.

Microbiome

Around the year 2000 we started to be able to look at our internal spaces in more detail and identify any microbes that might be present, What was found was a surprise, for example, we could find many microbes; bacteria, fungi and virus’ growing in our lungs without causing any harmful symptoms. It is common to find Aspergillus fumigatus (ie the pathogen that we assume causes aspergillosis most of the time) present in the lungs of most of us where it lives without causing aspergillosis. How is that possible and what is the difference between that situation and the allergy & infections caused in the lungs of an aspergillosis patient?

We quickly learned that microbes could establish harmless communities, living in harmony with each other and with our immune system. This community was named the human microbiome and included all microbes who live within and on us. Huge numbers live in our gut, especially in our large intestine which is the last section of our digestive system to receive our food before it is ejected via the rectum.

Our Microbial Friends

It has emerged then that A. fumigatus can be controlled by its microbial neighbours (our microbiome) working in a tightly controlled partnership with our immune system.

The fungal pathogen interacts with the host to calm the host’s response to the pathogen and uses parts of the host’s immune system to do this. In this way the host and pathogen tolerate each other and do little harm, however, it has been demonstrated that if parts of the host’s fungal recognition system are not working then the host will initiate an aggressive inflammatory response. This is not unlike the situation in ABPA where one of the major problems is the host over-responding to the fungus.

We are also given an example of the microbiome controlling the host’s immune response to a fungal pathogen. Resistance to infection can be increased by the microbial population in the gut sensing a signal – presumably in food ingested by the host. This means that environmental factors can influence the rejection of a pathogen by its microbial neighbours – the message we might take from this is to look after our gut microbiome, and it will look after us. This also holds for the microbes in our lungs, where we have seen differences in the types and location of bacteria in the upper and lower airways that seem to be consistent with the microbiome controlling inflammation – the authors speculate that we need to look at what happens when we challenge these lung microbiotas with a highly inflammatory pathogen such as Aspergillus fumigatus.

The microbiome is also self-regulating as long as it is kept healthy. Bacteria can attack fungi, fungi can attack bacteria in an ongoing battle for food. Host pathogens can be eliminated completely from the microbiome by other microbes.

Different microbiomes in a different part of our body can interact and control diseases such as asthma (ie. lung microbiome interacting with gut microbiome) – so what you eat may influence the microbes in your gut microbiome and that can have an impact on your asthma, for example.

 

I must warn you that lots of the observations mentioned above are based on very few experiments so far, and mostly on animal model systems and Candida rather than Aspergillus so we must be cautious in our interpretation with regard to aspergillosis, however there are a few take-home messages worth bearing in mind.

  1. Most healthy people seem to have very healthy, highly diverse microbiomes – so look after yours with a well-balanced diet containing lots of plant material, lots of fibre
  2. Researchers seem to be turning our assumptions of what infection is on its head – they seem to be saying that inflammation causes infection, rather than infection causes inflammation.
  3. What you eat can have a direct impact on the amount of inflammation your body uses in response to what it perceives as a pathogen.

It can’t be that diseases like asthma and ABPA are caused by an unhealthy microbiome can it?

Current research seems to be suggesting that it may play a part, so the value of someone with aspergillosis doing what they can to promote a healthy community of microbes within themselves cannot be overstated.

What should I eat for a healthy microbiome? (BBC website)

Human Microbiome Project

Microbiome-mediated regulation of anti-fungal immunity

July 31st: Update on UK government guidelines for COVID-19 precautions, limited lockdown

Applies to the North West of England: For full details click here

Those people shielding in those areas should consult their local medical services for information in continuing or extending shielding,

An outbreak of coronavirus (COVID-19) has been identified in parts of Greater Manchester, East Lancashire, and West Yorkshire. The government and relevant local authorities are acting together to control the spread of the virus. From 31 July 2020, if you live in these parts of Greater Manchester, East Lancashire and West Yorkshire, you should follow these rules when meeting people who you do not live with. Separate guidance advises on the similar rules imposed in Leicester.

Affected local areas

  • Greater Manchester:
    • City of Manchester
    • Trafford
    • Stockport
    • Oldham
    • Bury
    • Wigan
    • Bolton
    • Tameside
    • Rochdale
    • Salford
  • Lancashire:
    • Blackburn with Darwen
    • Burnley
    • Hyndburn
    • Pendle
    • Rossendale
  • West Yorkshire:
    • Bradford
    • Calderdale
    • Kirklees

Local restrictions

Social contact

If you live in one of the affected areas, in order to help prevent the spread of coronavirus, you should not:

  • meet people you do not live with inside a private home or garden, except where you have formed a support bubble (or for other limited exemptions to be specified in law).
  • visit someone else’s home or garden even if they live outside of the affected areas.
  • socialise with people you do not live with in other indoor public venues – such as pubs, restaurants, cafes, shops, places of worship, community centres, leisure and entertainment venues, or visitor attractions. You may attend these venues with people you live with (or are in a support bubble with), but should avoid interaction with others. If you run such a business, you should take steps to ensure people do not interact with people they do not live with, in line with COVID-19 Secure guidance.

The government will pass new laws to enforce the changes to meeting people in private homes and gardens. The police will be able to take action against those that break these rules, including asking people to disperse and issuing fixed penalty notices (starting at £100 – halving to £50 if paid in the first 14 days – and doubling for subsequent offences).

Business closures

In Blackburn with Darwen and Bradford, the following premises must remain closed by law:

  • indoor gyms
  • indoor fitness and dance studios
  • indoor sports courts and facilities
  • indoor swimming pools, including indoor facilities at water parks

Changes in restrictions

Does my household include close family members?

Your household – as defined in law – is only the people you live with. If you have formed a support bubble (which must include a single adult household i.e. people who live alone or single parents with dependent children aged under 18) these can be treated as if they are members of your household.

What will be illegal?

It will be illegal for people who do not live together to meet in a private home or garden, except for limited exceptions to be set out in law. You should not host or visit people you do not live with, unless they are in your support bubble. If you live in the affected areas, you should not visit someone’s home or garden regardless of whether this is in or outside of the restricted area.

Can I still meet indoors with people in my support bubble?

Yes. Where people from single adult households (people who live alone or single parents with dependent children aged under 18) have formed a support bubble with another household, they can continue to visit each other, stay overnight, and visit other public places as if they were one household.

Can I still meet people outdoors?

In line with the national guidance, you can continue to meet in public outdoor spaces in groups of no more than six people, unless the group includes only people from two households. You cannot meet people you do not live within a private garden.

At all times, you should socially distance from people you do not live with – unless they are in your support bubble.

I live in this area. Can I still meet with my family and friends to celebrate Eid?

Due to higher rates of infection, if you live in this area you should not host or visit friends and family in each other’s homes or gardens. It will shortly be illegal to do so, unless specific exemptions apply. You also should not meet friends and family in other venues – including restaurants or cafes.

Up to two households, or six people from any number of households may meet outdoors (excluding people’s gardens) where there is a lower risk of infection. If you do so, you should still socially distance from those you do not live with, and avoid physical contact.

You may attend a mosque or other place or worship, where Covid-19 Secure guidance applies, but you must socially distance from people outside of your household. This means maintaining a distance of 2 metres, or 1 metre with mitigations (such as wearing face coverings). We recommend at this time that, if possible, prayer/religious services take place outdoors.

Can I still go to work in this area?

Yes. People living inside and outside of this area can continue to travel in and out for work. Workplaces must implement Covid-19 Secure guidance.

I live in this area. Can I still go to cafes, restaurants, the gym and other public places?

Yes. But you should only go with members of your own household – even if you are going outside of the restricted area.

I live in the area. Can people from outside of the lockdown area visit me at my house?

No. This will be illegal.

Do I still have to shield if I live in this area?

Clinically extremely vulnerable people will no longer have to follow the shielding guidance from the 1 August, unless they live in Blackburn with Darwen in the North West and other local affected areas across England where shielding continues.

Can I visit a care home?

You should not visit friends or family in care homes, other than in exceptional circumstances. Care homes should restrict visits to these circumstances.

Can I still have my wedding if it’s in the lockdown area?

Weddings and civil partnership ceremonies in these areas can still go ahead. No more than 30 people should attend a marriage or civil partnership, where this can be safely accommodated with social distancing in a COVID-19 secure venue. Further guidance can be found here.

Large wedding receptions or parties should not currently be taking place and any celebration after the ceremony should follow the broader social distancing guidance of involving no more than two households in any location or, if outdoors, up to six people from different households.

Can I travel outside of the lockdown area to attend a wedding ceremony?

Yes.

Can I travel into the lockdown area to attend a wedding ceremony?

Yes. Weddings should be limited to no more than 30 people and subject to COVID-19 Secure guidelines.

People living outside the lockdown areas may travel into the areas to attend a wedding, but should not go into a private home or garden.

Can I still visit a place of worship in the lockdown area?

Yes, but you must socially distance from people outside of your household. This means maintaining a distance of 2 metres, or 1 metre with mitigations (e.g. face coverings). We recommend at this time that if possible prayer/religious services take place outdoors.

Can funerals still take place in the lockdown areas?

Yes. Funerals should be limited to no more than 30 people and subject to COVID-19 Secure guidelines.

People living outside the lockdown areas may travel into the areas to attend a funeral.

Can I holiday in the lockdown area, or visit shops, leisure facilities, or cafes in it?

Yes. However, you must avoid socialising with people indoors when doing so.

Can I travel in a car with someone I do not live with?

You should try not to share a vehicle with those outside your household or social bubble. If you need to, try to:

  • share the transport with the same people each time
  • keep to small groups of people at any one time
  • open windows for ventilation
  • travel side by side or behind other people, rather than facing them, where seating arrangements allow face away from each other
  • consider seating arrangements to maximise distance between people in the vehicle
  • clean your car between journeys using standard cleaning products – make sure you clean door handles and other areas that people may touch
  • ask the driver and passengers to wear a face covering

The Department for Transport has provided specific guidance on using private vehicles. Please see their guidance on private cars and other vehicles for more information on car sharing and traveling with people outside your household group.

Published 31 July 2020

Update June 23rd: UK government (via Cheshire CCG) guidance for patients in England who are shielding

The UK Government has set out a roadmap for the clinically extremely vulnerable on the future of the shielding programme.

For now, the guidance remains the same – stay at home and only go outside to exercise or to spend time outdoors with a member of your household, or with one other person from another household if you live alone – but the guidance will change on 6 July and again on 1 August, based on clinical evidence.

Shielding and other advice to the clinically extremely vulnerable has been and remains advisory.

What are the changes? 

Recently, the UK Government advised that you can spend time outdoors, if you wish, with your own household, or if you live alone with another household. Following this, and alongside current scientific and medical advice, the UK Government is planning to relax shielding guidance in stages.

From 6 July, the guidance will change so you can meet in groups of up to six people from outside your household – outdoors with social distancing. For example, you might want to enjoy a summer BBQ outside at a friend’s house, but remember it is still important to maintain social distancing and you should not share items such as cups and plates. If you live alone (or are a lone adult with dependent children under 18), you will be able to form a support bubble with another household.

From 1 August, you will no longer need to shield, and the advice will be that you can visit shops and places of worship, but you should continue maintaining rigorous social distancing.

Why is the guidance changing now?

The roadmap has been developed in line with the latest scientific and medical advice and with the safety and welfare of those who are shielding in mind. Current statistics show that the rate of catching coronavirus in the community continues to decrease. On average less than 1 in 1,700 in our communities are estimated to have the virus, down from 1 in 500 four weeks ago.

Unless advised otherwise by your clinician, you are still in the ‘clinically extremely vulnerable’ category and should continue to follow the advice for that category, which can be found here.

We will monitor the virus continuously over coming months and if it spread too much, we may need to advise you to shield again.

If you are in receipt of Government provided food boxes and medicine deliveries, you will continue to receive this support until the end of July.

Local councils and volunteers are also providing support to people who are shielding, to enable them to stay safely in their homes. The government is funding local councils to continue to provide these services to those who need them until the end of July.

What support is available to people who are shielding until the end of July?

Essential supplies

There are a number of ways that those who are shielding can access food and other essentials:

  • Make use of thesupermarket priority delivery slots that are available for this group. When a clinically extremely vulnerable person registers online as needing support with food, their data is shared with supermarkets. This means if they make an online order with a supermarket (as both a new or existing customer), they will be eligible for a priority slot.
  • Use the many commercial options now available for accessing food, including telephone ordering, food box delivery, prepared meal delivery and other non-supermarket food delivery providers. A list has been shared with local authorities and charities.
  • A free, standardised weekly parcel of food and household essentials. If you have registered for this support onlinebefore 17 July you will continue to receive weekly food box deliveries until the end of July.
  • If you need urgent help and have no other means of support, contact your local council to find out what support services are available in their area.
  • For anyone facing financial hardship, the government has made £63 million available to local councils in England to help those who are struggling to afford food and other essentials.

NHS Volunteer Responders

Support will continue to be available through the NHS Volunteer Responder Scheme beyond the end of July.

NHS Volunteer Responders can support you with:

  • Collecting shopping, medication (if your friends and family cannot collect them for you) or other essential supplies;
  • A regular, friendly phone call which can be provided by different volunteers each time or by someone who is also shielding and will stay in contact for several weeks; and
  • Transport to medical appointment.

Please call 0808 196 3646 between 8am and 8pm to arrange support or speak to your health case professional for transport support. A carer or family member can also do this on their behalf. More information is available at www.nhsvolunteerresponders.org.uk

Health care

Any essential carers or visitors who support you with your everyday needs can continue to visit unless they have any of the symptoms of COVID-19 (a new continuous cough, a high temperature, or a loss of, or change in, their normal sense of taste or smell).

People in the clinically extremely vulnerable group should continue to access the NHS services they need during this time. This may be delivered in a different way or in a different place than they are used to, for example via an online consultation, but if they do need to go to hospital or attend another health facility for planned care, extra planning and protection will be put in place.

Mental health support

It is normal during these uncertain and unusual times to feel anxious or feel low.

Follow the advice that works for you in the guidance on how to look after your mental health and wellbeing during coronavirus (COVID-19).

The Every Mind Matters page on anxiety and NHS mental wellbeing audio guides provide further information on how to manage anxiety.

If you feel you need to talk to someone about your mental health or you are looking for more support for someone else, we would urge you to speak to a GP and seek out mental health support delivered by charities or the NHS.

Income and employment support

At this time, people who are shielding are advised not to go to work. This guidance remains advisory.

Those shielding will be eligible for Statutory Sick Pay (SSP) on the basis of their shielding status until the 31 July. SSP eligibility criteria apply

From 1 August, if clinically extremely vulnerable people are unable to work from home but need to work, they can, as long as the business is COVID safe.

The Government is asking employers to work with them to ease the transition back to a more normal way of life for their shielding employees. It is important that this group continues to take careful precautions, and employers should do all they can to enable them to work from home where this is possible, including moving them to another role if required.

Where this is not possible, those who have been shielding should be provided with the safest onsite roles that enable them to maintain social distancing.

If employers cannot provide a safe working environment, they can continue to use the Job Retention Scheme for shielded employees who have already been furloughed.

What support will be available after July? 

From 1 August, clinically extremely vulnerable people will continue to have access to priority supermarket delivery slots if you have registered online before 17 July for a priority delivery slot.

NHS Volunteer Responders will also continue to offer support to those who need it, including collecting and delivering food and medicines.

The NHS Volunteer Responders Scheme has been expanded to offer a new Check in and Chat Plus role. This new role has been designed to provide peer support and companionship to people who are shielding as they adapt to a more normal way of life.

If you are vulnerable or at risk and need help with shopping, medication or other essential supplies, please call 0808 196 3646 (8am to 8pm).

Government is committed to supporting local councils and voluntary sector organisations to respond to those who have specific support needs and requirements during the COVID-19 pandemic. Details of the support and advice available can be found here: https://www.gov.uk/find-coronavirus-support

The updated shielding guidance should not affect any social care or support you were receiving prior to the start of shielding.

Individuals should continue to contact their local council if they have any ongoing social care needs.

May 31st: Shielding Advice Updated by Public Health England

Many people with Chronic Pulmonary Aspergillosis were asked to shield themselves from exposure to the coronavirus COVID-19 in March 2020 as they were thought to be especially vulnerable to the consequences of infection by the respiratory virus.

Back in March 2020 the COVID-19 pandemic was progressing rapidly and there was some doubt about how well we might be able to contain it in the UK using a variety of social spacing measures, consequently, it was appropriate for the most vulnerable to be especially protected. We also knew relatively little about the virus and how it is transmitted, which groups might be more vulnerable to infection and severe symptoms.

More recently, by late May 2020 the pandemic in the UK is currently well under control with the number of cases in the community falling rapidly week on week, estimated at 17% between May 10 and 21st (AskZoe).

There is a real risk that extending shielding will have an overall detrimental impact on health, particularly on the mental health of those shielding, so it is important that we limit the numbers of people to those who absolutely have to, and ease up restrictions on those that have to carry on when it is deemed safe enough to do so.

The overall authority in England is Public Health England (PHE) and they released updated guidelines for people who are shielding here on 31st May 2020. 

What has changed

The government has updated its guidance for people who are shielding taking into account that COVID-19 disease levels are substantially lower now than when shielding was first introduced.

People who are shielding remain vulnerable and should continue to take precautions but can now leave their home if they wish, as long as they are able to maintain strict social distancing. If you choose to spend time outdoors, this can be with members of your own household. If you live alone, you can spend time outdoors with one person from another household. Ideally, this should be the same person each time. If you do go out, you should take extra care to minimise contact with others by keeping 2 metres apart. This guidance will be kept under regular review.

Read further information on schools and the workplace for those living in households where people are shielding. This guidance remains advisory.

 

Advice for Wales (updated but there may be some differences to PHE advice)

Advice for Scotland (not yet changed so are now different to England & Wales)

Advice for Northern Ireland (not yet changed but may change on June 8th)

COVID isolation: Mental well-being while staying at home

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The UK NHS has released a list of helpful resources to assist in safeguarding your mental health during this current COVID isolation period. We have reproduced some of it here for the purpose of allowing indexing of the many sections, hopefully making access a bit quicker and easier.

Taking care of your mind as well as your body is really important while staying at home because of coronavirus (COVID-19).

You may feel bored, frustrated or lonely. You may also be low, worried or anxious, or concerned about your finances, your health or those close to you.

It’s important to remember that it is OK to feel this way and that everyone reacts differently. Remember, this situation is temporary and, for most of us, these feelings will pass. Staying at home may be difficult, but you are helping to protect yourself and others by doing it.

The tips and advice here are things you can do now to help you keep on top of your mental wellbeing and cope with how you may feel while staying at home. Make sure you get further support if you feel you need it.

The government also has wider guidance on staying at home as a result of coronavirus.

To read the complete NHS page ‘Worried about coronavirus’ click here

 

 

For a more complete resource on mental health see the NHS page ‘Every Mind Matters’.

EMM - Coronavirus - Stay at home - Find out about your rights

1. Find out about your employment and benefits rights

You may be worried about work and money while you have to stay home – these issues can have a big effect on your mental health.

If you have not already, talk with your employer about working from home, and learn about your sick pay and benefits rights. Knowing the details about what the coronavirus outbreak means for you (England and Wales only) can reduce worry and help you feel more in control.

GOV.UK: Coronavirus support

2. Plan practical things

Work out how you can get any household supplies you need. You could try asking neighbours or family friends, or find a delivery service.

Continue accessing treatment and support for any existing physical or mental health problems where possible. Let services know you are staying at home, and discuss how to continue receiving support.

If you need regular medicine, you might be able to order repeat prescriptions by phone, or online via a website or app. Contact your GP and ask if they offer this. You can also ask your pharmacy about getting your medicine delivered, or ask someone else to collect it for you.

If you support or care for others, either in your home or by visiting them regularly, think about who can help out while you are staying at home. Let your local authority (England, Scotland and Wales only) know if you provide care or support someone you do not live with. Carers UK has further advice on creating a contingency plan.

Carers UK: Coronavirus

3. Stay connected with others

Maintaining healthy relationships with people you trust is important for your mental wellbeing. Think about how you can stay in touch with friends and family while you are all staying at home – by phone, messaging, video calls or social media – whether it’s people you usually see often, or connecting with old friends.

Lots of people are finding the current situation difficult, so staying in touch could help them too.

4. Talk about your worries

It’s normal to feel a bit worried, scared or helpless about the current situation. Remember: it is OK to share your concerns with others you trust – and doing so may help them too.

If you cannot speak to someone you know or if doing so has not helped, there are plenty of helplines you can try instead.

NHS – recommended helplines

5. Look after your body

Our physical health has a big impact on how we feel. At times like these, it can be easy to fall into unhealthy patterns of behaviour that end up making you feel worse.

Try to eat healthy, well-balanced meals, drink enough water and exercise regularly. Avoid smoking or drugs, and try not to drink too much alcohol.

You can leave your house, alone or with members of your household, for 1 form of exercise a day – like a walk, run or bike ride. But make you keep a safe 2-metre distance from others. Or you could try one of our easy 10-minute home workouts.

Try a 10-minute home workout

6. Stay on top of difficult feelings

Concern about the coronavirus outbreak is perfectly normal. However, some people may experience intense anxiety that can affect their day-to-day life.

Try to focus on the things you can control, such as how you act, who you speak to and where you get information from.

It’s fine to acknowledge that some things are outside of your control, but if constant thoughts about the situation are making you feel anxious or overwhelmed, try some ideas to help manage your anxiety.

7. Do not stay glued to the news

Try to limit the time you spend watching, reading or listening to coverage of the outbreak, including on social media, and think about turning off breaking-news alerts on your phone.

You could set yourself a specific time to read updates or limit yourself to checking a couple of times a day.

Use trustworthy sources – such as GOV.UK or the NHS website – and fact-check information from the news, social media or other people.

GOV.UK: Coronavirus response

8. Carry on doing things you enjoy

If we are feeling worried, anxious, lonely or low, we may stop doing things we usually enjoy.

Make an effort to focus on your favourite hobby if it is something you can still do at home. If not, picking something new to learn at home might help.

There are lots of free tutorials and courses online, and people are coming up with inventive ways to do things, like hosting online pub quizzes and music concerts.

9. Take time to relax

This can help with difficult emotions and worries, and improve our wellbeing. Relaxation techniques can also help deal with feelings of anxiety.

10. Think about your new daily routine

Life is changing for a while and you are likely to see some disruption to your normal routine. Think about how you can adapt and create positive new routines and set yourself goals.

You might find it helpful to write a plan for your day or your week. If you are working from home, try to get up and get ready in the same way as normal, keep to the same hours you would normally work and stick to the same sleeping schedule.

You could set a new time for a daily home workout, and pick a regular time to clean, read, watch a TV programme or film, or cook.

11. Look after your sleep

Good-quality sleep makes a big difference to how we feel, so it’s important to get enough.

Try to maintain your regular sleeping pattern and stick to good sleep practices.

12. Keep your mind active

Read, write, play games, do crosswords, complete sudoku puzzles, finish jigsaws, or try drawing and painting.

Whatever it is, find something that works for you.

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