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.

Extraordinary images of Aspergillus restrictus

In 2017, the Dutch Central Bureau of Fungal Cultures was renamed the Westerdijk Fungal Biodiversity Institute, after Johanna Westerdijk. Westerdijk was the first female professor of The Netherlands and director of the centre from 1907 to 1952. She had a great interest in fungi and, under her leadership, the institute’s collection grew to be the largest in the world. A century on from her appointment as professor, Westerdijk’s accomplishments were celebrated with the centre’s renaming and the unveiling of several extraordinary images of Aspergillus restrictus.

A. restrictus is a mould that can grow in environments with very limited water. The species is often found in indoor air and house dust, and is considered a potential cause of respiratory issues; A. restrictus can also contribute towards cereal and cotton rot. In this project, high resolution images of the species were taken at various magnifications, using both light and electron microscopy. These images, copied below, allow the viewer to zoom in on the structure of the mould at differing levels of detail. This means that we can explore the various stages of fungal growth, from different angles and magnifications. For reference, simplified diagrams of the Aspergillus life cycle and structure are included first.

The life cycle of Aspergillus. [Image copied from: https://aspergillusproject11.wordpress.com/2013/04/18/life-cycle/]

Structure of the conidial head. [Image adapted from: https://mycology.adelaide.edu.au/descriptions/hyphomycetes/aspergillus/]

Images of Aspergillus restrictus:

One of several images of Aspergillus restrictus. An <em>Aspergillus restrictus</em> colony, measuring approximately 1 cm (bar = 1 mm). White aerial hyphae can be seen throughout the colony.

An Aspergillus restrictus colony, measuring approximately 1 cm (bar = 1 mm). White aerial hyphae can be seen throughout the colony.

An image taken closer to the centre of the colony (bar = 0.5 mm). White aerial hyphae and green columnar conidiophores can be seen throughout.

The rim of the colony (bar = 0.5 mm). White aerial hyphae, with the early stages of conidiophore formation, can be seen at the edge of the colony (bottom of the image). Green conidia, organised into rows and columns, are seen more centrally (top of the image).

The rim of the colony (bar = 0.1 mm). Conidial head formation is visible throughout the image. Hyphae can be seen growing into the agar plate and upwards; aerial hyphae also cross above these structures.

Image showing various stages of conidial head formation. Aerial hyphae can be seen in the bottom right corner. Vesicles, found at the end of stipes, are transparent. A row of phialides grow from several vesicles, and conidia organise into rows and columns after these. Rows of conidia often twist clockwise (bar = 0.1 mm).

Image false-coloured to clearly show the various stages of conidial head formation and growth (bar = 0.05mm).

False-coloured image showing ornamentation on the surface of mature conidia (bar = 0.01 mm). These details are not visible on the newly formed conidia.

Conidial heads seen at 3 different developmental stages (bar = 0.01 mm). In the centre, a vesicle has formed at the end of the stipe. On the bottom right, a layer of phialides has grown on the vesicle. In the top of the image, the development of mature, ornamented conidia can be seen.

False-coloured image showing material on the surface of the phialides (brown) and the developing ornamentation of the early conidia (green) (bar = 0.001 mm)

Cell surface and ornamentation of the conidia from various magnifications and angles. Image D shows the formation of a crown at each end of the conidia (bars = 0.001 mm in images A, B and D, and 0.0001 mm in images C and E)

A) Image showing the appearance of material on the surface of the developing phialide tips (bar = 0.001 mm). B) The area where the phialide meets the developing conidia. The structure of the material on the surface of the phialide can be seen; each unit consists of a head and a tail (bar = 0.0001 mm).

 

These images, produced by the Westerdijk Fungal Biodiversity Institute, show the structure and development of Aspergillus restrictus in incredible detail. There are several surprising questions and discoveries that arise from this level of detail. For example, the clockwise twisting of conidial rows has not previously been described, and the chemical composition of the material found on the phialide surfaces is unknown. Therefore, this technology not only provides us with these impressive images, but may also lead to further research and greater understanding of the structure and development of fungi. Greater knowledge of Aspergillus growth and function can assist in the development of drugs which impede its growth.

Read the full paper: Jan Dijksterhuis, Wim van Egmond and Andrew Yarwood (2020), From colony to rodlet: “A six meter long portrait of the xerophilic fungus Aspergillus restrictus decorates the hall of the Westerdijk institute.”

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)

Can I have ABPA without asthma?

Allergic bronchopulmonary aspergillosis (ABPA) generally occurs in patients with asthma or cystic fibrosis. Little is known about ABPA in patients without asthma ⁠— entitled “ABPA sans asthma” ⁠— despite it having first been described in the 1980s. A recent study, performed by Dr Valliappan Muthu and colleagues at the Postgraduate Institute of Medical Education and Research, Chandigarh, India, has looked at the records of ABPA patients with and without asthma, in order to find clinical differences between the two disease subsets.

The study included 530 patients, with 7% of those identified as having ABPA sans asthma. This is the largest known investigation of the disease to date. However, as the research was conducted retrospectively at a specialist centre, and ABPA sans asthma is a difficult condition to diagnose, the true number of those affected is unknown.

Certain similarities were found between the two disease types. There were similar rates of coughing up blood (haemoptysis) and coughing up mucus plugs. Bronchiectasis, a condition where the airways are widened and inflamed, was found more often in those without asthma (97.3% vs 83.2%). However, the extent to which the lung was affected by bronchiectasis was similar in both groups.

Lung function tests (spirometry) were significantly better in those without asthma: normal spirometry was found in 53.1% of those without asthma, in comparison to 27.7% of those with asthma. Furthermore, ABPA sans asthma patients were significantly less likely to experience ABPA exacerbations.

To sum up, this study found that those experiencing ABPA sans asthma were likely to have better lung function and fewer exacerbations than those with ABPA and asthma. However, clinical symptoms, such as mucus pugs and haemoptysis occurred at similar rates and bronchiectasis was more common in ABPA sans asthma patients. This was the largest study to date on this subset of ABPA; however, further research is required to understand the condition better.

Full paper: Muthu et al. (2019), Allergic bronchopulmonary aspergillosis (ABPA) sans asthma: A distinct subset of ABPA with a lesser risk of exacerbation

15th May 2020: Shielding advice to continue until the end of June.

The original shielding letters and advice that have been sent out to people who are highly vulnerable to COVID-19 (coronavirus) infection stated that all recipients of the letter should completely isolate themselves from physical contact, not go outside of their homes for 12 weeks.

This advice was sent to all patients of the National Aspergillosis Centre (NAC) who have chronic pulmonary aspergillosis (CPA).

Patients who have allergic bronchopulmonary aspergillosis (ABPA), severe asthma and forms of aspergillosis other than CPA were informed of their vulnerability status by their local respiratory clinic or GP. Some will have been told to shield, others not but all shielding advice was to remain in place for 12 weeks from the day of receipt of the letter.

That advice for people shielding has now been amended to say that all shielding people should continue shielding until the end of June 2020.

Latest shielding advice (UK).

Latest advice from Welsh government

Latest advice from Scottish government

Latest advice from Northern Ireland

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