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The government has set out steps to relax shielding guidance. Watch this video to find out how these changes will affect you, and when. Stay up to date with the latest government advice: https://bit.ly/3fSiJcm #StayAlert

Posted by NHS Cheshire Clinical Commissioning Group - CCG on Tuesday, 23 June 2020
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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

Coronavirus (COVID-19) Social distancing introduced

24th March: Social distancing measures extended

The government last night asked us all to stay at home to protect each other and reduce pressure on the NHS. 

Full information on staying at home and away from others is available from the government website

People with CPA are classed as extremely vulnerable. Stay at home at all times and avoid any face-to-face contact for at least 12 weeks. More guidance on shielding and protecting people defined on medical grounds as extremely vulnerable is available from Public Health England.

17th March: Social distancing measures introduced

The government has issued guidance is for everyone advising on social distancing measures we should all be taking to reduce social interaction between people in order to reduce the transmission of coronavirus (COVID-19). It is intended for use in situations where people are living in their own homes, with or without additional support from friends, family and carers. If you live in a residential care setting guidance is available.

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.

GOVERNMENT ADVICE ON SOCIAL DISTANCING

 

12th March: Precautionary increase in protective measures advised

COVID-19 is starting to spread in an unconstrained manner in the UK with over 460 cases identified. This makes it a little more likely that the virus will spread through the community, increasing the number of cases. UK government measures are slowing this spread down so the total number is still relatively small, with only a handful of cases in each area so the chances any one person will be infected are still really small, but if you are a chronic respiratory disease patient with a disease such as aspergillosis you are at slightly higher risk of infection. Consequently we are recommending that you use additional protective measures.
In addition to frequent handwashing, no touching of your face and limiting direct contact with other people the suggestion is that you start social distancing so that any infectious person will find it very difficult to pass on the virus. The link explains everything in detail but essentially you avoid groups, people with symptoms, close contact ie less than 2 metres away from someone for more than 15mins. Also minimise use of public transport.

 

9th March : YOUR QUESTIONS ANSWERED BY A RESPIRATORY EXPERT

A useful series of questions specifically aimed at bronchiectasis, COPD, asthma, cystic fibrosis and more. Written by European Respiratory Society (ERS) expert Professor James Chalmers. 

Answers to common questions about COVID-19 from the NHS

Public health Advice

British Thoracic Society guidance – UK region specific

BBC information resources on COVID-19

What do I need to know about the coronavirus?

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.

Fungal spore and air quality forecasts

Good air quality is important for everyone’s health. However, those with lung conditions, such as aspergillosis and asthma, may be more vulnerable to the effects of poor air than others. Airborne pollutants and allergens are found both indoors and outdoors, and can irritate our lungs and exacerbate existing conditions. It can be useful, therefore, to know when and where these irritants are at their most harmful concentrations ⁠— this can allow us to understand, avoid and prevent any harmful air conditions that may be affecting our health. Here we have compiled a selection of air quality forecasts and information:

Fungal Spores

Fungal spores are microscopic particles responsible for the reproduction of fungi. We inhale huge numbers of these particles in each breath ⁠— for most people, this doesn’t affect their health. However, some individuals, including aspergillosis patients, are more susceptible to allergic reactions and infections from mould spores. It can therefore be useful to know when mould spores are at their highest concentrations, in order to reduce exposure to them. We are currently entering peak spore season for most moulds (June – August). Peak spore season coincides with hayfever season, and allergies to pollen and spores carry similar symptoms (runny nose, sore eyes, rashes). Therefore, it is often difficult to distinguish between these conditions, and medical tests may be necessary.

The National Pollen and Aerobiology Research Unit at the University of Worcester has produced a number of helpful calendars, showing the monthly spore count averages over a period of 5 years. They have also compiled useful information on the allergenicity of each spore type and where each mould prefers to grow. This allows those at risk to avoid areas where the spore concentration is potentially very high. The information for Aspergillus/Penicillium spp. is copied below:

 

The year starts with a high risk for these types with a total monthly average of 1,333 (per m3) spores in January and 1,215 in February. Spores continue to be airborne during Spring and early Summer but possibly below the levels needed to trigger symptoms. From mid-August the risk starts to rise again and people often report symptoms during warm, humid conditions in late August, September and October, with the peak reaching an average of 1,950 spores in October. Although the spore levels continue to be high during November and December, few people report symptoms, so it is likely that the types occurring during these months are less allergenic.

Habitat / Substrates:


microscopic view of fungal spores in small round particles

There are many species of Aspergillus and Penicillium, which live on a wide range of substrates. The spores can be very prevalent during the peak periods, triggering a range of respiratory problems. The spores are particularly prevalent in wooded areas, compost heaps, rotting wood chips and bark mulch. Some species rot down pine needles, so conifer plantations should be avoided during Autumn. Penicillium chrysogenum is found widely in nature, occurs on indoor substrates and is the type used to produce the antibiotic penicillin. N.B. Houseplants can be sources of spores, particularly Aspergillus/Penicillium types.  If you’re keen to have houseplants, only have cacti, which require dry conditions, and ensure the soil surface is covered in grit.

Season: 

Aspergillus and Penicillium spores are present in the air throughout the year but the main peak periods are late August to October and January to February.

Allergenicity: 

High for some types, particularly A. fumigatus and P. chrysogenum. A. fumigatus is a major cause of aspergillosis (farmer’s lung).

For spore forecasts and information about other species:

For regular updates on pollen and spore counts:

Indoor air

 

Those self-isolating due to COVID-19 are spending almost all of their time at home. Therefore, indoor air quality is more of a concern than ever. Over the past ~50 years, our homes have become far more insulated. While this stops drafts and keeps our homes warmer, it also means than our living spaces are generally damper and less ventilated. This can provide ideal conditions for mould to grow and thrive. There are a number of small things that we can do to prevent mould and damp: these include drying laundry outside (if possible), fixing leaks and using lids when cooking. It is also important to identify and remove any mould in your living space, in order to prevent it from spreading. A selection of articles on indoor air quality and instructions for how to safely remove mould are listed below.

For more information:

Pollution

pollution causes poor air quality

Air pollution is a significant health concern, especially for those living with existing lung conditions. This is a particular issue in urban areas, where the sources of pollutants are concentrated. Weather also influences levels of pollution, with stiller conditions often worsening the issue. It can therefore be useful to access pollution forecasts, so that high levels can be avoided, where possible.

Regularly-updated pollution forecasts for the UK and worldwide:

 

For further information on air quality:

Living with hyper-IgE syndrome and aspergillosis: patient video

The following content is reproduced from ERS

 

In the above video, Sandra Hicks summarises her experience with hyper-IgE syndrome (HIES), a primary immunodeficiency syndrome, and how living with this rare genetic condition and associated lung infections impacts her life. As a direct consequence of HIES and its effect on the immune cascade, Sandra concurrently manages chronic Aspergillus infection (aspergillosis), nontuberculous mycobacterial infection (Mycobacterium avium-intracellulare), bronchiectasis colonised with Pseudomonas and asthma. She discusses the effect this rare disease and infection burden have on her daily life, including the influence of other factors such as temperature, humidity and antimicrobial resistance.

Sandra conveys her hopes for clinicians treating others with similar disease profiles, including the impact of immunoglobulin treatment; early, accurate diagnosis of primary immunodeficiencies and fungal infections; and awareness of potential interactions between antifungals and other medication (https://antifungalinteractions.org). She also discusses the importance of comprehensive, timely communication within and between multidisciplinary teams. Finally, Sandra emphasises the value of support from allied healthcare professionals for people with chronic lung conditions.

Sandra has since returned to pulmonary rehabilitation classes. These provide great benefit, not just for people with COPD but also for those living with other lung conditions. Making this service widely accessible would improve management of chronic lung conditions and could even reduce associated healthcare costs.

Sandra Hicks is a co-founder of the Aspergillosis Trust, a patient-led group that aims to raise awareness of aspergillosis. Click here to visit the group’s website and find out more about their work. 

The New York Times on the dangers of mould

Those living with aspergillosis know all too well the risks associated with mould exposure. It can be difficult, however, to sort fact from horror story on the internet sometimes. Damp and mould in the home can be a serious issue, both for those with and without pre-existing illnesses — it is therefore very important to understand the risks and take measures to identify and prevent any sources of mould growth. The New York Times has written a very useful article, quoting Professor David Denning of the National Aspergillosis Centre, on the known health consequences of mouldy homes and the importance, and difficulty, of removing the fungus.

Read the article here:

Mold Can Make Your Family Sick. Here’s How to Get Rid of It.

cartoon of family living with mould in their home

For more advice:

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.”

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