COVID Precautions for the extremely vulnerable: Winter 2020

UK government has today announced its strategy to protect UK citizens from COVID-19 infection and to try to reduce virus transmission rates.

Part of these new guidelines refers to the extremely vulnerable eg people who have received the most recent letter or email from UK.gov advising them that they are clinical extremely vulnerable. If you didn’t receive a letter and are still concerned you should contact your doctor.

PROTECTING THE VULNERABLE
75. Under recent national measures, the clinically extremely vulnerable have been advised
to take extra precautions and stay at home as much as possible. Local Authorities
have been working to ensure the right support is available for those that need it.

76. As the national restrictions end, the guidance to the clinically extremely vulnerable
not to go to work or school will also end. The Government will reintroduce the specific
advice for clinically extremely vulnerable people on how they can protect themselves
at each tier. The Government will constantly monitor the latest evidence and the
evolving situation in local areas to keep the advice for clinically extremely vulnerable
people up to date. Support will be available for those who need it, either through
Local Authorities in tier 3 areas or NHS Volunteer Responders. Supermarket priority
delivery slots will also continue for those who have already registered. The
Government has also made free influenza vaccinations available to the household
contacts of those on the Shielded Patients List.

77. A better understanding of the factors contributing to clinical risk has informed the
clinical advice from Medical Officers that most children can be removed from the
Shielded Patient List, following a clinician-parent conversation. It has also led to the
addition of those with Chronic Kidney Disease Stage 5 and of adults with Down’s
Syndrome to the Shielded Patients List, ensuring that they are provided with the best
advice on protecting themselves.

Read the full 2020 COVID-19 Winter Plan here

COVID Update November 5th National Lockdown: Shielding

The UK government have announced that England will go into a period of lockdown whereby those that can stay in their homes should do so except when needing to go out for essential purpose or to work. Full instructions are as follows:

Additional instructions for people living in England who are highly vulnerable have been published. This is the group of people who received a letter from their doctor or UK government during the first wave of infections telling them Shield themselves at home as they are at increased risk of experiencing more severe symptoms if they were to become ill with COVID-19.

This document replaces all earlier documents published on கேடயம், and only applies to England. The advice is different depending on the risk level set in your local area by Gov.uk. (Medium, High or Very High – see link above)

 

For people living in the UK outside of England: The UK government has updated its instructions for people living in England to help prevent infection by COVID-19.

 

Vitamin D and COVID-19

The news media have been extensively covering the publication of research papers over the summer that suggest that vulnerable people should all be taking vitamin D supplements as a precaution against being infected by COVID. If you have been reading these reports you may be wondering what you should do?

Vitamin D is sometimes referred to as the ‘sunshine’ vitamin as we are all able to make it in our skin when the skin surface is lit by the sunlight. Our bodies cannot make it without sunlight so NHS recommendations are for short periods of direct sunlight on our face and arms every day. We can also get vitamin D from our food, principally oily fish, eggs and red meat.

Evidence shows that many of us (20%) in the UK have quite low levels of vitamin D in our bodies, especially during the darker months (October – March) when we don’t get much sunlight shining on our island. There are also people who don’t get much exposure at any time of the year due to their circumstances – for example, they might work at night or they might be unable to get outdoors every day. Sunlight shining through a window is usually insufficient to make vitamin D. People with darker skin pigmentation can also find it difficult to maintain levels of vitamin D.

Foods that contain lots of vitamin D are often not eaten every day, so many people supplement their diet with tablets that contain their daily dose. NHS guidelines are that in general everyone over age 5 should take 10mcg (400UI) Vitamin D per day from October – March. Those people who see very little direct sunlight or who find it difficult to maintain their vitamin D levels should take the supplement all year round. NOTE some people take calcium tablets that are already supplemented with vitamin D, so in that case need no further supplementation.
That said, individuals can be very variable in how much Vitamin D supplement they need so if in doubt see your doctor.

Does vitamin D protect us from COVID-19? So far the answer is maybe but there is not enough evidence to strongly support the suggestion. Studies are ongoing. However as already discussed there is plenty of evidence to suggest that you need to ensure that you get enough vitamin D regardless of COVID-19. Keep your levels up and you will benefit in lots of ways – if we find in the future it is good for prevention of COVID-19 infection, so much the better.

COVID Information for Patients Attending Manchester University NHS Foundation Trust (MFT)

MFT is the Trust that hosts the National Aspergillosis Centre (NAC) in Manchester, UK. MFT is present on 12 sites throughout Greater Manchester including Wythenshawe Hospital which is where NAC is located.

Just like most acute care hospitals in the UK, Wythenshawe and most other sites at MFT have undergone major changes in how they operate outpatient care during the COVID outbreak, and those changes have included how NAC operates so that we can ensure the safety of patients and staff.

For clarity and information MFT have produced a series of webpages that contain all the information you may need if you have an appointment to attend a clinic at any MFT site. The information is updated regularly.

Coronavirus (COVID-19) procedures and precautions for attending MFT as a patient

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 அஸ்பெர்கிலஸ் 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 அஸ்பெர்கிலஸ் 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

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