this week TIKTOK DOCTORS page 171 • VACCINE NATIONALISM page 172 • VACCINE PRICES page 174 SOPA/SIPA/PA Call to update symptoms for new variant

People infected with the new variant the amount of virus which is shed into Doctors and scientists fear of SARS-CoV-2 discovered in southeast the environment, thereby making it ‘more many people with sore England (known as B.1.1.7 or VUI infectious,’” he said. throats, fatigue, and myalgia 202012/01) are more likely to have a cough, In a letter published in The BMJ , are transmitting infection because they do not recognise sore throat, fatigue, or myalgia than those London GP Alex Sohal said people were them as symptoms of B.1.1.7 infected with other variants, the Offi ce for “mostly unaware of the signifi cance of National Statistics has reported. mild symptoms” that could be covid-19 The ONS report, which looked at cases in and called for the UK to change its case England from 15 November to 16 January, defi nition and testing criteria to include also showed that people with the new such symptoms (BMJ 2021;372:n283). variant are less likely to lose their sense of “Tell the public, especially those who smell or taste. There was no evidence of have to go out to work and their employers, diff erence in gastrointestinal symptoms, that even those with mild symptoms (not shortness of breath, or headaches. only a cough, high temperature, and a These fi ndings have prompted some loss of smell or taste) should not go out, LATEST ONLINE doctors to call for the offi cial symptom list prioritising the fi rst fi ve days of self-isolation to be reviewed and potentially expanded— when they are most likely to be infectious,” Homeless man something that has not happened since she wrote. “Test more of those with should have double last May. The current advice is that people symptoms, identify more infectious cases, leg amputation to be tested if they have a high temperature, a and reduce spread.” save his life, says judge new, continuous cough, or a loss or change A Department of Health and Social Care to their sense of smell or taste. spokesperson said an expert, independent Coroner calls for Richard Tedder, senior research scientifi c group kept the list of symptoms new guidance on umbilical venous investigator in medical virology at Imperial under constant review. They acknowledged catheters after College London, said that the new data on that covid-19 had a much longer list of baby’s death symptoms could explain why B.1.1.7 is symptoms than the ones on the list for BMA calls for more transmissible. “If there is an increased testing but said those symptoms captured urgent review of amount of coughing and perhaps sneezing patients most likely to have covid-19. online exam for associated with a particular variant virus, Elisabeth Mahase , The BMJ medical students these two activities can markedly increase Cite this as: BMJ 2021;372:n288 the bmj | 6 February 2021 169 SEVEN DAYS IN Children’s mental health services are “nowhere near suffi cient” for covid The damage caused to children’s mental health by the pandemic could last for years unless services are improved, the children’s commissioner for England has warned. Anne Longfi eld (left ) said in her annual report that provision of mental health services was “still nowhere near suffi cient to meet children’s needs” and that the government must acknowledge this and “go beyond existing commitments with ambitious new targets to increase access to care.” She also emphasised that some clinical commissioning groups had “consistently deprioritised children’s mental health, ignored the needs of children, and failed to meet the expectations of NHS England” and as such should now “face consequences.” It is estimated that a sixth of children in England have a probable mental health condition, and the number of children being referred for help is increasing. In 2019-20 this rose to 538 564, an increase of 35% from 2018-19 and up 60% from 2017-18. But the number getting treatment is not meeting demand. In 2019-20 only 391 940 children received treatment, just a quarter of those estimated to need it. Of the children who did get access to services only 20% started treatment within four weeks.

PHOTOSHOOT/SHUTTERSTOCK Elisabeth Mahase, The BMJ Cite this as: BMJ 2021;372:n258

Covid-19 vaccination directors of public health during a with a learning disability have new support tool to help hospital Ethnicity data of people local outbreak and will be visited died from covid at over six times doctors improve the care and given vaccines are published as soon as staff are allowed to do the rate of the general population, choices they provide to people Of 6 232 584 doses of the vaccine so, officials said. Vaccination staff yet not all people with a learning at the end of their life. It aims to administered in England up to are also returning to care homes disability who receive care are help doctors identify patients 24 January, 82% were to people to vaccinate any resident who currently on the vaccine priority in their last days or weeks of who identified as white, 8% was unable to have it during the list. The government must life and ensure that patients’ to those from ethnic minority previous visit. urgently give all people with a choices are heard and supported. backgrounds, and 10% to people learning disability priority access It includes guidance on starting whose ethnicity was not known Vaccination does not to the vaccine—it will save lives.” the often difficult conversation or stated, showed figures on require NHS number with patients and their families ethnicity from NHS England The BMA has asked NHS England Palliative care or carers about care at the end published for the first time. to ensure that all staff involved Call for system reform of life, the role of advance care Reports that ethnicity of vaccine in vaccinating know “loudly and as demand accelerates planning and specialist palliative recipients was not being recorded clearly” that healthcare workers, Researchers from the charity care, and advice on clinical led to concerns that this would regardless of where they’re from, Cicely Saunders International management and anticipatory hamper efforts to ensure good have a right to have the vaccine made an urgent call for changes prescribing. uptake in different ethnic groups and “can be protected against to the UK’s palliative care system. and to counter misinformation covid-19 urgently.” NHS England More than half a million people Social care about uptake. confirmed that having an NHS in England and Wales were Delay to reform is number was not a requirement predicted to need palliative or “far from reassuring” All care home residents in for staff or patients to receive a end-of-life care by 2040, but this The chair of the House of Lords England offered vaccine vaccine, after reports that some number was reached in 2020, Economic Affairs Committee migrant workers were denied it the charity said. It added that too rebuked the government’s on this basis. The BMA described many people who had life limiting promise to bring forward the accounts as “extremely illnesses or were approaching proposals “later this year” about disturbing.” death were spending long how to reorganise social care periods in hospital without being in England. A report from the People with learning offered alternatives, when most committee in July 2019 called disabilities “left behind” would prefer to die at home. for an extra £8bn a year to Younger people with a tackle the “national scandal” The SARS-CoV-2 vaccine has learning disability in care New end-of-life care of underfunding in the sector. been offered to 10 000 residents homes or other social care tool is launched Committee chair Michael Forsyth at every eligible care home in settings are being left behind in The Royal College of said a government pledge to bring England for elderly people, the the vaccination programme, the Physicians and forward proposals later this year NHS said this week. A small charity Mencap warned. the Society of “is not really reassuring, given number of care homes have Edel Harris (right), its chief Acute Medicine the urgency and the strength of had their visits deferred by local executive, said, “People launched a feeling shown in this debate.”

170 6 February 2021 | the bmj SIXTY SECONDS MEDICINE ON . . . TIKTOK Workforce Science is a profession DOCTORS Science and medicine most most parents would like respected professions their children to aspire to WE’RE NOT TALKING ABOUT CLOCKS? Science came top of a list of No, we’re talking about the video sharing professions that adults would be platform TikTok. The app has gained huge popularity during the pandemic, with more happy for their child to pursue, people at home and in search of distraction. closely followed by medicine, found a YouGov survey of over DO I NEED TO OFFER APPOINTMENTS 22 000 people in 16 countries. OVER TIKTOK NOW? Among British respondents, four No, you’re safe—for now. Some doctors fifths (82%) backed a career as a are, however, using the platform to provide scientist for their child and 80% health related information to the public, on supported a medical career. both covid-19 and non-covid related matters. observational study published in There are videos on everything from bed Safety at work Lancet Public Health found. Lead ALCOHOL capacity in intensive care units, and hospitals running out of oxygen, to why we sneeze and Ethnic minority doctors author Ruth Watkinson, from A total of 5460 feel unsafe at work how long it takes to become a doctor. Manchester University, said, “We deaths related to Less than a third (28%) of doctors need decisive policy action to SOUNDS TIME C ONSUMING . . . from black, Asian, and other improve equity of socioeconomic alcohol specific It certainly can take time to plan and fi lm ethnic minority backgrounds opportunity and transformation causes were videos, but most of the doctors on the app told a BMA survey they felt of health and local services to registered between provide the content on top of their patient ensure they meet the needs of all January and facing work. The real struggle is not losing a people.” September 2020, whole aft ernoon swiping through it all. IS IT WORTH IT? Bereavement The increasing popularity of the app has One in eight people have 16.4% higher than in the made it susceptible to misinformation, lost a loved one to covid especially concerning covid-19. We know A YouGov survey of 2029 people same period in 2019 that false news travels more rapidly than found that one in eight people in [ONS provisional real news, and we’ve also seen the eff ect of the UK has lost a family member data] conspiracy theories in the form of protests or friends to the virus. More than and people breaking into covid wards. TikTok half (57%) had either tested doctors are trying to combat this by providing fully protected from the risk of positive for covid or knew of a people with a reliable source. SARS-CoV-2 infection in their friend or relative who had, and HAVE ANY DOCTORS HIT THE BIG TIME? workplace, while 72% said they 27% knew someone who had Yes, there are several felt only partly or not protected at become seriously ill. very popular doctors from all. In comparison, 60% of white around the world. In the UK, respondents said they felt fully Infection Nottingham medical student protected. A third (29%) of ethnic Trust pays £7m in baby Ethan Smallwood has gained minority doctors said they had brain damage case 185 500 followers and 3.1 not been risk assessed for the The NHS agreed to pay more than million likes. In his most virus or that assessment needed £7m in an out-of-court settlement popular videos Smallwood updating. Chaand Nagpaul, BMA for failing to properly treat a explains why armpits smell chair of council, said, “We should newborn baby’s eye infection, but also who will get priority access to covid not have a situation where health leaving him with permanent brain vaccines. In the US, ophthalmologist Vicki and social care workers—BAME damage. The baby’s GP Chan has 173 700 followers and 8.5 million

or otherwise—are feeling unsafe had referred him to the likes. She has covered everything from Los or at risk from death or disease in hospital, where a junior Angeles running out of hospital beds to what their workplace.” doctor diagnosed diff erent white coats mean to US doctors. conjunctivitis but failed She even got vaccinated on TikTok. In South Africa, primary healthcare doctor Siyamak Study reveals wide health to take swabs to test Saleh, who has 565 000 followers, has videos disparity in England for infection. The baby on long covid, vaccine ingredients, and Some people from ethnic was given a diagnosis myth busting content like whether eating minorities have much poorer of encephalitis a week pineapple induces labour. health than white people—which later. can be equivalent to being 20 Elisabeth Mahase , The BMJ years older than they are, a large Cite this as: BMJ 2021;372:n301 Cite this as: BMJ 2021;372:n286

the bmj | 6 February 2021 171 COVID-19

AstraZeneca vaccine Variants will follow vaccine approved in EU with nationalism, WHO warns no upper age limit

The European Medicines Agency authorised ffi icials at the World such as health staff and people at risk of Astra Zeneca’s SARS-CoV-2 vaccine for use Health Organization have serious illness, to share them with others, in all adults aged over 18 on 29 January, just voiced concern at “vaccine under the Covax programme. “Health and days after German newspapers suggested the nationalism” that could care workers have been on the frontlines vaccine would be limited to adults aged under Oincrease the risk of the of the covid-19 pandemic but are often 65 because of poor efficacy in older people. coronavirus mutating further, after a underprotected and overexposed. They The EMA said, on the basis of data from week long row over a shortfall in EU need vaccines now,” said Tedros. four clinical trials conducted in the UK, Brazil, supplies of vaccines. and South Africa, that the vaccine was safe Bruce Aylward, senior adviser to WHO’s London and Brussels row and effective at preventing infection. The director general, said, “Anything that On 30 January AstraZeneca tried to diff use two doses can be given between four and restricts the ability to get these products the row between Brussels and London 12 weeks apart. Safety was shown in all out will aff ect our ability to control this over vaccine supplies by promising to four studies, which included around 24 000 disease and prevent variants emerging. increase its deliveries to the EU by nine people, but the efficacy decision was based on The world is going to have to collaborate to million doses by March. This will bring the results from only two of the trials because the get out of this.” total number of vaccine doses from the others had fewer than six cases of covid-19. Vaccines alone were not the solution, company to 40 million, half of what was Also, only data from patients who received however, said WHO technical lead Maria expected by this date. The EU has a deal two standard doses of the vaccine between Van Kerkhove. Test and trace measures, with AstraZeneca for 300 million doses four and 12 weeks apart were included in the social distancing, mask wearing, and altogether. The aim was still to vaccinate final efficacy analysis. This showed a 59.5% personal protective equipment will still be 70% of adults in the EU by the end of reduction in the number of symptomatic covid- essential to control the virus, she said. summer, said EU commissioner Ursula 19 cases in people given the vaccine. Meanwhile, WHO director general von der Leyen. The EMA’s Bruno Sepodes said only 13% Tedros Adhanom Ghebreyesus called on The crisis began as vaccine production of trial participants were aged 65 or above. countries that had vaccines left over after levels fell in the EU. Pfi zer hit problems at “Protection in this population is expected vaccinating their own priority groups, its plant in Belgium, aff ecting supplies in based on their immune response and results in younger participants,” he said. “The exact level Novavax vaccine is effective against of protection cannot be estimated for the UK and South African variants time being.” But he emphasised, “There is The vaccine produced by placebo group and six in with the UK Medicines no reason to expect this the US biotech company the vaccine group. Of the 62 and Healthcare Products would not have some Novavax is 95.6% eff ective cases, only one was severe Regulatory Agency in level of efficacy in that age group.” against the original variant (in the placebo group), and January. The UK has An EMA committee will further assess efficacy of SARS-CoV-2 but also 32 were with the UK variant. secured 60 million doses. as the data emerge. In particular, Sepodes provides protection against A phase II trial is also Meanwhile, Johnson & said, it will evaluate a US trial that includes a the UK variant B.1.1.7 ongoing in South Africa Johnson has reported its “substantial cohort of elderly people.” (85.6%) and the south with 4400 volunteers, in one dose vaccine is 66% Germany will not offer the vaccine to adults Africa variant B.1.351 which 29 cases have been eff ective at preventing over 64 years because of insufficient data, (60%), preliminary trial seen in the placebo group moderate to severe while Italy has authorised it for all age groups data show. and 15 in the vaccine illness 28 days after but recommended other vaccines be used in Interim results have been group. Preliminary data vaccination, a lthough the people over 55. released from a phase III from 27 of these cases announcement lacked key Ingrid Torjesen, London trial carried out in the UK found 93% (25) involved details. The UK has agreed Cite this as: BMJ 2021;372:n295 with more than 15 000 the South Africa variant. a deal for 30 million doses. participants aged between Novavax began the Elisabeth Mahase, The BMJ 18 and 84, including rolling submission process Cite this as: BMJ 2021;372:n296 GERMAN newspapers 27% over the age of 65. The phase III trial, carried out across three continents, claimed the EMA would exclude The trial tested two doses over 65s from the recommended administered three weeks included 43 783 people. A third (34%) of participants authorisation because efficacy was apart and reported 62 were aged over 60, and 41% had comorbidities symptomatic cases of covid, associated with an increased risk of severe covid-19 less than 10% in this group of which 56 were in the

172 6 February 2021 | the bmj Spain, while AstraZeneca, a UK-Swedish confi dential, it would seem to contain a WHERE DID THE EU GO WRONG? company, said it was having problems clause that protects the supply of vaccines meeting planned deliveries from its plants that are pre-ordered under contract for the Vaccine nationalism hit the headlines this week in the Netherlands and Belgium. NHS from being diverted elsewhere. when the EU scrambled to get AstraZeneca to However, AstraZeneca was already AstraZeneca chief executive Pascal deliver the 40 million doses of vaccine it had said producing vaccines from its two UK Soriot said, “The contract with the UK was it would by March. plants to meet its contracted target with signed fi rst and the UK, of course, said ‘you In contrast, the UK was sitting pretty, the UK government. And it was this supply us fi rst,’ and this is fair enough. having acted early to get advance purchase manufacturing supply line that the EU This vaccine was developed with the UK agreements signed to the tune of four doses of various vaccines for every member of wanted its 27 member states to access. government, Oxford, and with us as well. its population. Acting alone, the UK had If not, the EU would permit its member As soon as we have reached a suffi cient a sense of urgency absent in the EU, said states to restrict the supply of any of their number of vaccinations in the UK, we will Sharifah Sekalala, an associate professor in vaccines to the UK. be able to use that site to help Europe.” global health law at Warwick University, on BBC While details of the UK government Lynn Eaton, London Radio 4’s How to Vaccinate the World programme contract with AstraZeneca are Cite this as: BMJ 2021;372:n292 on 1 February. In Oxford, vaccine production sites were being built before planning was approved and manufacturing was scaling up before trial results were available. The UK and the US invested seven times as much in vaccine research and development than the EU, said Rasmus Bech Hansen, chief executive of the data analytics company Airfinity. He said his home country, Denmark, failed to invest in clinical trials and manufacturing and now had less vaccine. “In that way, nationalism is not a bad thing,” he said. But countries acting individually would not deliver the 12 billion doses the world needs. That The world is going to have to The aim is still to vaccinate 70% of will take a global system acting collectively, said Sekalala. collaborate to get out of this aduts in the EU by the end of summer Bruce Aylward, WHO Ursula von der Leyen, EU Zosia Kmietowicz , The BMJ

Surge testing for South Africa What is the purpose of the samples, carried out by surge testing? the Covid-19 Genomics UK variant begins in England Any positive test results consortium in partnership with found in the eight areas will Public Health England, found the What is being deployed? How will it work? be sequenced to identify any cases. Public Health England has The government From Monday 1 February further spread of the South identified 105 cases of the South announced this week it was everyone over 16 living in the Africa variant. The intention is Africa variant since 22 December, rolling out extra surge testing eight postcode areas was being to monitor and suppress the but so far only the 11 could not and sequencing capacity to eight strongly encouraged to take a spread of the virus and to gain a be linked to foreign travel. UK locations where community covid-19 test, even if they did better understanding of the new based infections of the SARS- not have any symptoms. Mobile variant. Are there likely to be CoV-2 variant first identified in testing units will be deployed to further cases? South Africa (known as 501Y. offer PCR swab testing to people How were the 11 cases While the UK is conducting more V2) were found that could not who have to leave their home for identified? genome sequencing (at around be linked back to international work or essential reasons, and Large scale and rapid whole 10% of positive test samples) travel. To date, 11 cases of this additional home test kits will be genome sequencing of virus than any other European kind have been identified. supplied. country except for Denmark, this still leaves ample room for Where are the locations? Who is running it? undetected cases. “There is Surge testing is being Local authorities have been a high probability that further targeted to the postcode areas put in charge of overseeing the local cases are in circulation,” where the 11 cases were found: scheme. People with symptoms said Rowland Kao, professor of EN10 in Hertfordshire; W7, are being told to book a test veterinary epidemiology and N17, and CR4 in London; PR9 in in the usual way, while those data science at the University of Lancashire; ME15 in Kent; GU21 without symptoms are advised to Edinburgh. in Surrey; and WS2 in the West visit their local authority website Gareth Iacobucci , The BMJ

Midlands. for information. ALEX HANNAM/EMPICS/PA Cite this as: BMJ 2021;372:n305 the bmj | 6 February 2021 173 COVID-19

Unequal cost: vaccine prices around the world

string of revelations Other That principle has also been the pandemic phase over and take about vaccine high income applied to the biggest players. The EU profi ts from later sales. prices has focused countries have fi nancially supported the development Vaccine prices are only one factor in attention on a practice a lower price of the BioNTech and Pfi zer vaccine the cost of immunisation campaigns. Aconsidered normal in as they have and has obtained a lower price per Of the £11.7bn the UK expects to the drug industry but often frowned on dose ($14.70) than the US ($19.50). spend on its vaccination programme, invested in elsewhere: charging diff erent prices for Moderna’s vaccine development was £2.9bn buys vaccines, securing the same product. the vaccines’ subsidised by the US government and 267 million doses of fi ve types, South Africa’s government found research and will cost it about $15 a dose, while the according to the National Audit Offi ce. itself on the defensive this week after development EU is paying $18. Even the priciest vaccines repay a senior health offi cial revealed that Anban Pillay, The Oxford-AstraZeneca vaccine their cost many times over in economic 1.5 million doses of the Oxford and South Africa is much cheaper, although neither growth. Affl uent governments could AstraZeneca vaccine just purchased for the UK nor the US can match the EU’s well be tempted to bid higher if use among health workers would cost $2.15 deal: it is thought they will pay supplies tighten. $5.25 (£3.84) a dose, more than twice about $3 and $4, respectively, a dose. Israel, which is on course to what the EU is paying at $2.15. vaccinate all its citizens before The EU fi gure is known because Johnson & Johnson any other country—having denied Belgium’s budget secretary Johnson & Johnson’s single dose responsibility for vaccinating inadvertently revealed the EU’s vaccine, which last week was reported the Palestinians of the Occupied negotiated prices for every major as 66% eff ective, is also much cheaper, Territories—this month acknowledged vaccine on Twitter last month. The costing the EU $8.50, with each dose paying $23.50 a dose on average EU had undertaken to keep the prices going twice as far as the other brands, to Pfi zer and Moderna to obtain confi dential in return for discounts. as it is a single shot vaccine. early shipments. Even at this price, South Africa’s deputy director AstraZeneca and Johnson & Johnson vaccinating the population costs the general of health, Anban Pillay, said have committed to not making a profi t economy only as much as two days of his government had been told that from the pandemic, while Moderna lockdown. Uniquely, Israel agreed to $5.25 was the set price for a country and Pfi zer have not. AstraZeneca give Pfi zer anonymised health data classifi ed by the World Bank as upper reserved the right, however, to declare from its citizens as part of the deal. middle income. “The explanation we For South Africa, more troubling were given for why other, high income than the cost has been an inability to countries have a lower price is that COVAX has set aside 600 secure enough vaccine. It planned to they have invested in the [research and million doses for Africa, enough for a quarter vaccinate 40 million of its 58.5 million development], hence the discount,” people but has only enough vaccine on he added. of the continent’s 1.2 billion people order for 10 million.

NHS will prioritise second doses for ORDER OF PRIORITY four groups most at risk, says Stevens FOR VACCINATION • Care home residents and staff The NHS will prioritise and staff , all over 70s, covid, Simon Stevens the fi rst doses were • Over 80s and frontline second doses of covid- all clinically extremely (below) was asked delivered, we know that health and social care 19 vaccine of the over vulnerable people, and whether he expected the has to be the fi rst call workers 70s, clinically extremely all health staff with a NHS to slow down the on the vaccine available • Over 75s vulnerable people, and fi rst dose by the middle rollout of the fi rst dose in those weeks. As we • Over 70s and clinically frontline health workers of this month and to to other groups (see box) get increasing clarity extremely vulnerable before it moves on to off er all UK adults a from March, when large as to what the available • Over 65s fi rst doses for other vaccine by autumn. numbers of people in supply will be, that • Adults aged 16 to 65 in groups, the chief Giving evidence to the four groups most at will shape the speed at groups at risk executive of NHS MPs on 26 January risk will be due for their which we can advance • Over 60s England has said. at the joint inquiry second dose of vaccine. into those other groups. • Over 55s The government’s by the health and He said, “First and “My expectation • Over 50s target is to science select foremost, those second is that we will do two • Rest of population (order vaccinate all committees doses have got to be things simultaneously to be determined) care home into lessons delivered. So [if] we look as we move into working S o u r c e : Joint Committee on Vaccination and Immunisation residents learnt from 12 weeks on from when age adults. The fi rst

174 6 February 2021 | the bmj FIVE MINUTES WITH . . .

UK Jasmine Ho Oxford- The medical researcher explains AstraZeneca $3 how her PPE charity wants to promote the use of reusables Europe • Oxford-AstraZeneca edSuppyDrive UK $2.15 started last year. There • Pfi zer $14.70 Israel was unused PPE in our US • Moderna $18 Pfi zer and Moderna labs, and I thought • Oxford-AstraZeneca $4 • Johnson & Johnson $23.50 $8.50 “M we could redirect it to • Pfi zer $19.50 the front line. We began by writing to labs and • Moderna $15 businesses—the donations came flooding in and South Africa we had 100 volunteers within a week. To date Oxford-AstraZeneca Covax, the World Health A study $5.25 we’ve circulated around 380 000 items of PPE. Organization’s vaccine distribution commissioned by “More recently we started thinking about programme, has set aside 600 million the International something more sustainable. In the US, they have doses for Africa, enough to vaccinate Chamber of guidelines for reusables and for decontamination. a quarter of the continent’s 1.2 billion Commerce Research Why don’t we have guidance here? population. But South Africa’s status as Foundation “The government says there are not enough an upper middle income nation makes it concluded that rich FFP3 masks to go around. Our solution? Look at ineligible for Covax assistance. nations would reap huge economic reusables. Anyone who’s facing covid positive benefi ts if they paid the roughly $27bn patients more than six hours a day should be Surplus doses needed to fully fund Covax. Failure thinking about reusables. Intensive care units are At a 26 January virtual meeting of the to vaccinate the nations included in very well facilitated, but the forgotten few are staff World Economic Forum, South Africa’s the WHO programme would cost the in theatres and those in emergency departments, president, Cyril Ramaphosa, called on global economy up to $9.2 trillion, covid-19 positive wards, and acute medicine rich nations to give up surplus doses. the report found, with half of that cost wards that see admissions. On 28 January the African Union of falling on wealthy nations. “As a charity, our fundamental mission is to 55 countries announced it had secured WHO’s secretary general, Tedros protect workers. We’re hoping we can get the 400 million extra doses of the Oxford- Adhanom Ghebreyesus, said, “I backing of the medical AstraZeneca vaccine, bringing its total believe the world faces a catastrophic bodies and unions. We’re order to 670 million. South Africa is moral failure in equal access to grateful to be working closely likely to be a key benefi ciary. Africa now the tools to combat the pandemic. with the Doctors’ Association has enough vaccine ordered to vaccinate This research shows a potentially UK. Changing culture and half its population. The UK has ordered catastrophic economic failure.” normalising reusables are enough to theoretically vaccinate about Owen Dyer , Montreal the main things we want to three times its population. Cite this as: BMJ 2021;372:n281 do. There is almost a stigma associated with their use. We’re also working with THERE IS ALMOST is that, when we’ve got delivery, after recent olds and above, the high manufacturers to see if we A STIGMA a lot more supply, we advice from offi cials risk patients, and their can innovate and help them ASSOCIATED WITH THE USE will be able to make to redirect available staff that fi rst vaccine make their masks—which OF REUSABLES vaccines available in supply to areas that still [dose], which is why, have been geared to the many diff erent outlets. At had large numbers of for the time being, we’re construction industry—more appealing to the the same time, the larger patients in the highest on this so called ‘push’ healthcare industry. vaccination centres that priority cohorts awaiting model for fairness. “We’re hoping trusts will pick this up so we we’ve established will be fi rst doses. “But, for the second can trial getting people trained up and fit tested going all guns blazing doses, we will be partly for reusables, and then have regular auditing for increasing numbers Fair distribution moving on to a so called feedback from users on how we can improve of people. But right now, He told MPs, “We’re ‘pull’ model where the compliance, on decontamination matters, and supply is constrained.” wanting to do it in a fair local services will be on how we can streamline. Having a centralised Stevens was also way so that each part of saying, ‘I need this many stamp of approval is what everyone is looking for, asked how the NHS the country has enough vaccines next week for my so the legal concerns everyone has will hopefully would be handling vaccine to have been able second vaccinations,’ and disappear. The main inertia is that no one is willing regional variation in to off er all of their 70 year then the vaccination team to put their stamp on it to say, ‘This could work.’” will make those vaccines Jasmine Ho is a clinical research training fellow in tissue engineering Increasing clarity as to the available supply available to them.” and regenerative medicine at University College London will shape the speed at which we can Gareth Iacobucci, The BMJ Gareth Iacobucci , The BMJ advance into the other groups Simon Stevens Cite this as: BMJ 2021;372:n252 Cite this as: BMJ 2021;372:n270 the bmj | 6 February 2021 175 THE BIG PICTURE China races to contain covid outbreak

Aft er a new outbreak of covid-19 last arisen from a determination to contain the month, China is constructing a quarantine outbreak before this month’s Lunar New camp to house around 4000 people. Year celebrations, during which hundreds The quarantine centre in Shijiazhuang, of millions of people are expected to travel a city 300 km south of Beijing, is designed to visit family members. to house close contacts of people with On 1 February health authorities in confi rmed covid-19. China’s state China reported 33 new locally transmitted television reported that each of the site’s cases, one of which was in Hebei, the 4156 furnished rooms will contain an lowest level in more than three weeks. en suite bathroom, wifi , and a television. Since covid-19 emerged the country has Construction of the camp in the capital reported 89 000 cases, while the offi cial of Hebei province began on 13 January, death toll is under 5000. and the fi rst section was ready for use a Alison Shepherd , The BMJ week later. The speed is reported to have Cite this as: BMJ 2021;372:n307

176 6 February 2021 | the bmj the bmj | 6 February 2021 177

YANG SHIYAO/XINHUA NEWS AGENCY/PA EDITORIAL Averting market failure in care homes We need public and political consensus about long term options

ur population is not sustainable and even generate super Without reform A tipping point is approaching.12 ageing well. The profi ts. Local authority payments and direction, To avoid care home shortages, proportion of older alone are insuffi cient to maintain good care quality local authorities need to pay higher 4 people aff ected by care homes in good condition. will continue to fees. This will necessitate public medium to high Sustainability is subject to two and political consensus about long O 5 deteriorate disability in England is increasing, further threats. In homes with mixed term options: market management, but social care cannot meet their funding, self-funders pay more than franchise development, or alternative needs and seems curiously separate local authority funded residents, models of care. Buying out care homes from the NHS. It took a global eff ectively subsidising them.6 If (nationalisation) might stabilise some pandemic for data on care home self-funders realise this, they may but would be expensive—the market is capacity to be collected weekly and seek fee reductions. Because capital worth £17bn. shared with England’s regulators and and savings can shrink quickly, commissioners.1 some care home residents drop NHS franchise If we assume that half of older out of self-funding to become local The NHS could enter the care home people with medium to high disability authority funded (payer shift). Local market, perhaps by promoting a are cared for in their own homes, by authorities, such as Worcestershire, franchise like that underpinning 2025 an additional 71 000 care home are already modelling the eff ect of general practice and off er care homes places could be needed.2 Some 5500 payer shift on their budgets.7 support for training and infrastructure. organisations operate care homes3 ; This matters to the NHS—some General practice and care homes are 90% of these are private providers, of the loudest calls for social care diff erent entities but are community including some charities. The fi ve reform come from the health service.8 based and focused on local needs. largest chains in England provide Inequalities in access to social care Alternatively, investment in home care, only 15% of places. Around 70% of are increasing, with an estimated 1.5 provision of hospital at home, and providers have three or fewer care million older people having an unmet greater support for family carers might homes.4 Most care homes are small care need.9 Limited availability lessen reliance on care homes. enterprises run by owner managers. of social care aff ects hospitals by The recent government spending fostering delayed transfers. 10 Lack of review promised to issue proposals Threats to sustainability social care produces excess disability Jill Manthorpe, for reform in 2021, adding to the 17 director , Policy About 3700 care home places (of a and distress that often presents in policy documents on social care that Institute, King’s total of around 400 000) have been primary care. The public is surprised have been published since the turn College London lost over the past decade. Many care that a fragmented system exists. 11 of the century.13 In January 2021 the Steve Iliffe, emeritus homes are not accepting residents While some see the “catastrophic” professor of primary government published a mental health funded by local authorities because costs of paying for their own (or care for older people, white paper and seems confi dent 4 fees cannot cover costs. Those parents’) care as deeply unfair, Royal Free Campus, that it can get it into legislation in the taking only self-funders are mostly in most are willing to make some London current parliament. But social care affl uent areas and are likely to remain contribution. 11 [email protected] seems stuck on the money questions at a time when connections between care homes and the NHS have never been so important and when there may be more goodwill about sharing budgets than ever before. Ironically, it may be covid-19 that makes the diff erence, since it will become increasingly evident that without reform and direction, care quality will continue to deteriorate. Care homes are in the news, and the government should not postpone rational changes to the funding of long term care. Cite this as: BMJ 2021;372:n118

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PA http://dx.doi.org/10.1136/bmj.n118

178 6 February 2021 | the bmj EDITORIAL Increasing recruitment into covid-19 trials An urgent priority for the NHS

ince March 2020, now allows patients to participate UK researchers have remotely regardless of the location of established over 70 urgent their registered general practitioner. public health studies Although we acknowledge the S to investigate potential extreme pressure currently felt treatments, vaccines, and diagnostic throughout the NHS, all hospitals, tests for covid-19. NHS hospitals clinics, and general practices have had a vital role in delivering should do all they can to make trial these studies and the results are now recruitment a priority, advancing informing practice worldwide. eff orts to improve survival and In June 2020, the Recovery trial recovery from covid-19. found that dexamethasone improved All eligible patients should be survival among covid-19 patients off ered the opportunity to take part on ventilation by 36%.1 The NHS in a clinical trial, whenever feasible, immediately made it the standard of and research should become part of care, and it is estimated to have averted the clinical pathway for patients with

12 000 deaths in the UK up to the end SHUTTERSTOCK covid-19 in the NHS. of 2020 and 650 000 worldwide.2 This crisis others have recruited less than 5% of Individual trusts and university Trials save lives. They cannot do provides an admissions, and some less than 2%. partners could support recruitment in so, however, without the participants opportunity Recovery continues to evaluate several ways. These include online and on which they depend. Recruitment to embed convalescent plasma, monoclonal text messaging of trial requirements of patients with covid-19 to UK large scale neutralising antibodies (REGN-COV2), and locations to patients, clear clinical trials must now be prioritised. aspirin, and colchicine. In the case of signposting to further information, randomised Although vaccines are a cause for convalescent plasma and REGN-COV2, access to trial recruitment advice for optimism, the pandemic remains a trials at the it is important not to miss benefi ts that clinicians and patients, and local national and international emergency. heart of might be confi ned to patients with clinical and research champions who It is imperative eff orts continue to fi nd NHS care early disease or those unable to mount could coordinate participation. new, safe, and eff ective treatments to a good antibody response themselves. lessen its severity and impact, in the Doubling the rate of recruitment Transform evaluation UK and globally. would halve the time taken to get clear This crisis provides an opportunity answers to important questions about to embed large scale randomised Variable recruitment these treatments. trials at the heart of NHS care. Such Enrolment into Recovery, which The Remap-Cap trial,4 based in an approach could transform the passed 20 000 patients in December, intensive care units and designed way the NHS evaluates and deploys has varied between 7% and 10% of to evaluate treatments for the treatments for common chronic hospital admissions for covid-19. sickest patients, has shown that diseases and emergencies, including Recruitment rates vary substantially the corticosteroid hydrocortisone heart disease, diabetes, degenerative across the NHS, however, leaving has similar eff ects on mortality to musculoskeletal disorders, cancers, plenty of opportunity to improve dexamethasone. The trial recruits and seasonal infl uenza. participation. While some hospitals around 20% of all patients in ntensive The Recovery trial has shown that (such as trusts in Leicester and care units but also has variation such approaches can be tailored Hartlepool) have recruited 25-50% among hospitals and therefore scope to existing drugs (dexamethasone, of patients admitted with covid-19, for further improvement. hydroxychloroquine) as well as novel The largest community based treatments (REGN-COV2). Delivering Ara Darzi, co-director, Institute of Global Health Innovation covid-19 trial in the UK, Principle,5 6 similar trials across the country [email protected] evaluates treatments to prevent would increase participation of both Andrew Goddard, president, Royal College of Physicians hospital admission or transmission, patients and NHS staff , and improve Katherine Henderson, president, Royal College of Emergency including doxycycline and inhaled the robustness and generalisability of Medicine budesonide. Recruitment has been the results. Engagement from all NHS Ravi Mahajan, president, Royal College of Anaesthetists slow because of the disruption of hospitals is vital in achieving this goal. Clare Marx, chair, General Medical Council primary care during the fi rst wave, Cite this as: BMJ 2021;372:n235 Neil Mortensen, president, Royal College of Surgeons of England reaching 2000 participants in Find the full version with references at Alison Pittard, dean, Faculty of Intensive Care Medicine December. To aid recruitment Principle http://dx.doi.org/10.1136/bmj.n235 the bmj | 6 February 2021 179 WELLBEING get into endless minutiae but not emotions: “I think what is diffi cult for this type of couple is the emotional The perils of pillow talk with connection. Doctors, through their training, learn not to get overly the other doctor in your life emotional and deal with the problem in front of them. How do you make sure your emotions are in check one Being in a relationship with another medic has its perks—but also its minute and the next be emotionally pitfalls. Jessica Powell explores how to successfully navigate them connected to your partner? It’s not easy to make that switch.” This resonates with Baillie: “You do t’s tempting, isn’t it? If you’re It is important doctors, they are completely steeped get hardened by some things at work— a couple of doctors, it’s hard to behave as in medicine and so it becomes really when you tell people awful news, you to resist getting home from a couple, not important to be able to distinguish can’t be in tears. But maybe that does a shift and talking non-stop as colleagues between work life and home life,” he mean that even with your partner you I shop: “Do you think I got that says. That is: to behave as a couple, don’t talk about things—it feels easier diagnosis right? What do you think not as colleagues. to try and be professional. Without of the latest from Hancock?” And as “From a psychology point of view, some persuasion from my husband, I social distancing has dragged on and it’s about making unconscious habits can fi nd it hard to talk about diffi cult you’ve seen fewer friends and family conscious and having a disciplined work things, like when I’ve had who don’t know their NICU from their approach to pulling back from them. patients that have been in upsetting NSAID to dilute or distract, you might For example, there might be an situations.” Yet she feels it’s benefi cial have found medic chat has dominated agreement that when you’re preparing to be open: “If you’re not, things on more than ever. dinner you’re not talking about work,” your mind probably infl uence your But consultant psychologist Hekster says. ability to relax and move on. And Marc Hekster at the Summit Clinic Putting a buff er between work and sometimes you don’t realise it, but in London says that doctor couples home time can also help—something those things are having an impact on (and, of course, doctors in a that surgical registrar Caroline Baillie your mood and how grumpy you are couple with other healthcare has found useful. “I have quite a long with your partner.” professionals) should be wary drive home from work, so I use that Kaff el recommends checking in of letting work talk take over. time to wind down. I often talk to my with each other every day, “In doctor “When you have two sister or listen to podcasts,” she says. couples there’s often the assumption All of this means that, by the time she that ‘we know’ what each other is THREE WAYS TO gets home to her GP husband, she going through. But this can often lead CONNECT QUICKLY doesn’t feel the same need to offl oad to them feeling their partner takes about every detail of her day. them for granted. Plus, there can be One of the biggest challenges facing doctor Anaesthetic registrar Mark Parson some sort of expectation that doctors couples will be getting quality time together when both says that having diff erent interests should be able to cope, so they can are doing demanding jobs, often with antisocial hours. Try these shortcut s from his wife, Felicity Pilkington, feel shame if they don’t feel they can.” also an anaesthetic registrar, outside Explicitly asking how each other is • PLAN A 15-MINUTE DATE of work might also be an advantage: feeling is crucial, she says. “Actively schedule time with each other to reconnect, “She’s a big social person, and I’m She recognises that this comes with uninterrupted, even if it is just for 15 minutes. probably less social, but I have lots an additional challenge for many Sometimes just taking a moment together, in the epicentre of the storm, can be enough,” says consultant of mini projects on the go at any one doctors: “You’re having so many psychologist Marc Hekster. time, so it means that other things relationships with other people— fi lter in beyond medical stuff .” maybe seeing 20 patients a day—that • BE EXPLICIT Pilkington thinks that having non- when you come home you’re tired of It’s usually little things tha t people want to feel connected medic friends is a massive bonus, as talking to people.” to their partner, like a kiss in the morning or a text it jumpstarts them into talking about This also rings true with Baillie: during the day, says couples therapist Dawn Kaffel. She encourages couples to be clear in asking for what they diff erent things, too. “Sometimes when you’ve had all day want: “It’s about getting more comfortable sharing what in a clinic where you’ve been talking to you need from your partner.” It’s still good to talk patients, listening to their problems, • REFRAME IT Of course, sharing how your day’s and trying to solve them I guess . . . it gone—your worries and successes— sounds really bad . . . but you’re less Is the little time you have pointless or precious? It might with your partner is important. inclined to want to chat about your just depend on what you tell yourself. Surgical registrar Caroline Baillie says that having limited time with her GP But Dawn Kaff el, couples therapist partner’s day. So I actively remind husband can make them really appreciate the moments at Coupleworks, says that, in her myself that that’s really important.” they do have. “We make the most of the time we have.” experience of working with doctor But Hekster, who’s a spokesperson couples, she fi nds they sometimes for the British Psychological Society,

180 6 February 2021 | the bmj It becomes notes that what a partner needs really from you is diff erent from a patient: important to “Doctors are all about fi xing and step out of repairing and making everything doctor mode all right. But sometimes with their partner it’s about just listening. and just listen Marc Hekster Sometimes their partner just needs to splurge for a few minutes. It becomes really important to step out of doctor mode and just listen.”

Make the heart grow fonder One of the biggest challenges facing doctor couples is getting quality time together when both are doing demanding jobs, often with antisocial hours. “Spending time together is a huge challenge at the moment,” says Pilkington. “Because of juggling our diff erent rotas and childcare for our toddler, we basically have to take a lot of our days off when the other person is working. Plus, we each work two weekends in every four, so it’s hard.” Kaff el’s answer to this is again about explicitly asking what each other needs to get through. “I WILLET MALCOLM spend quite a lot of time working appreciate the moments you do have. it’s quite a structured career path. with couples thinking about what “If I have a weekend on call, we’re So as long as you keep the lines they would like their partner to do often like, ‘OK next weekend shall we of communication open, you can to make them feel there is more of do something nice.’ So I feel like we try discuss how it’s going to be one an emotional connection. And it’s to make the most of the time we have.” person’s turn this year, and the usually just little everyday things other’s the next, for example.” like, ‘I just need you to kiss me good Healthy competition Pilkington admits she can feel a morning’ or ‘send me a text during Another peril of being in the same twinge of jealousy when her husband the day.’ It’s about helping clients to profession is that it’s almost inevitable has a success that she hasn’t. “You feel more comfortable with sharing that one of you will progress further have to recognise that’s a human what they need from their partner in a or faster than the other. Parson notes feeling and it doesn’t mean you’re warm, loving way.” that, despite starting out on the same not happy for them. We talk very Hekster is a fan of the 15 minute career trajectory, his wife has raced openly about that—acknowledging date: “Actively schedule time ahead of him—passing exams faster it makes it seem like less of a big with each other to reconnect, than him. But he says that he’s been deal.” This is exactly what Hekster uninterrupted, even if it is just for able to square this in his mind by recommends couples should do to 15 minutes. Sometimes just taking a recognising that they’re very diff erent stop tensions mounting. moment together, in the epicentre of people with diff erent journeys. And the good news, as Kaff el notes, the storm, can be enough.” “I’ve never been someone who just is that there are massive perks to Baillie notes that an unexpected saunters through exams, so it wasn’t being in a double doctor couple: “I advantage of having limited time unexpected. It helps that we don’t see think the constant thread is that their together is that it can make you really it as a race. Not putting pressure on relationship is stronger because you’re yourself is probably a key thing. It’s with a partner who knows there’s long KEEP IT CONFIDENTIAL like that phrase: life’s a journey, not hours, there’s sleepless nights, there’s While an after work rant to your other half can feel good, a destination.” Pilkington agrees that shift work, you’re dealing with critical it’s important to keep patient confidentiality in mind. A seeing the big picture helps them— patients, with death, loss. spokesperson for the GMC says: “Patient confidentiality she got ahead by passing exams faster “It helps to have somebody there lies at the heart of the doctor-patient relationship. When than her husband, but he’s now going who understands what you’ve speaking about a particular case, doctors know they have to catch up with her because she’s been through because they’ve been a duty of confidentiality, and we trust doctors to use their been on maternity leave. through it themselves.” professional judgment.” Kaff el thinks this is a healthy Jessica Powell journalist , Devon The GMC guidance Confidentiality: Good Practice in Handling Patient Information is at gmc-uk.org. approach. “Usually in the medical [email protected] profession there is time to plan, as Cite this as: BMJ 2021;372:m4970 the bmj | 6 February 2021 181 ENVIRONMENT The rise of the green GP practice

Jessica Powell meets the doctors and their staff who are practising what they preach when it comes environmental initiatives to protect the planet—and their patients

f you think of a climate practices throughout the UK were More than 750 an increase in heatwaves (which crusader you might picture working to decarbonise. In 2014 the practices have killed nearly 900 people in England someone chained to a tree or Green Impact for Health Toolkit was signed up to alone last year) and greater spread

touting a placard. But there’s a launched by Kemple and colleagues, the Green of infectious diseases, to name just I new activist in town: the local giving GPs practical steps for going Impact for a couple. GP. With the NHS having committed greener, and over 750 practices have “In the UK, 40 000 people are Health Toolkit to reaching a net zero carbon signed up so far. dying from air pollution each footprint by 2040, many general Then in 2017 Aarti Bansal, a year,” says Matthew Sawyer, a GP practices around the UK are already Sheffi eld based GP, founded the and director of SEE Sustainability using their position at the heart of Greener Practice group: a network ( seesustainability.co.uk ), which communities, and their huge reach, of GPs, medical students, and others off ers carbon footprinting of to lead the charge. aiming to help general practices general practices and “carbon Last year the Royal College take action to benefi t people and the literacy” training. “We’ve had of General Practitioners (RCGP) planet. (See box below) about 40 000 deaths from covid- declared a climate emergency and For GPs engaged in the green 19 so far [at the time of interview]. highlighted “the catastrophic eff ect mission, the health eff ects of an We had that from air pollution last on human health of not acting unhealthy planet are obvious: year, but did we have a lockdown? decisively and urgently on climate Did we have billions of pounds change.” THREE WAYS TO GROW A GREENER PRACTICE being spent? No, we just accepted Terry Kemple, RCGP representative • Check out the Green Impact for Health Toolkit (greenimpact. it—and to me that’s criminal.” for sustainability, climate change, org.uk/GIforHealth). It lists actions that general practices can and green issues, says, “We’re not take, from using a renewable energy supplier to fitting valves Impact on practices talking about if there will be climate on taps to save water—all with the opportunity to be awarded But what have environmental issues change—we’re talking about how bad for your work got to do with GPs, beyond them it’s going to be. If we’re concerned • Visit openprescribing.net to see how your practice’s tackling the health fallout? You may with the health of our patients, it’s prescription data compare with others, to help assess think it’s down to governments and not something any rational person opportunities to deprescribe or make lower carbon industry to clean up the climate can ignore.” medicine swaps mess. Honey Smith, GP and chair of And a growing number of GPs • Head to greenerpractice.co.uk and sign up to the mailing list Greener Practice, notes that it can be don’t need convincing. Well before to join this community of green GPs. The site can also connect hard for GPs to make the connection you with like minded practices in your area the RCGP declaration, general between the climate and ecological

182 6 February 2021 | the bmj crisis and their clinical work. She Vasumathy Sivarajasingam, If we’re concerned says, “They may see that climate GP partner at Hillview Surgery in with the health change is going to have a massive London, was shocked by the impact of our patients, impact on health but question, ‘How of inhalers. She says, “I read that climate change does that change my practice?’” the amount of emissions from a is not something That’s where groups such as particular MDI inhaler we use in Greener Practice come in—to show practice could be equivalent to any rational person GPs how they contribute to, or driving 175 miles, say from London can ignore could help to combat, the climate to Sheffi eld.” Terry Kemple catastrophe. Smith adds, “All of the patients Take, for example, medicines. I’ve spoken to about the carbon 40 000 people NHS England’s Delivering a “Net footprint of their inhaler said they’d are dying from air Zero” National Health Service report be delighted to change. After all, pollution each year has found that they account for air pollution causes enormous and we just accept it. 25% of emissions within the NHS problems for asthma patients, so and are the greatest contributor they understand the importance of To me that’s criminal Matthew Sawyer within primary care. As such, looking after the environment.” groups including Greener Practice And that’s the thing: it’s not advocate deprescribing where about weighing up planet versus clinically appropriate: reviewing patients. “Reducing prescribing, for whether patients’ prescriptions are example, is good for patients, as it Reducing problematic appropriate, determining whether reduces the risks of side eff ects and polypharmacy and they actually take them, and it’s good for the planet. So, it’s win- medicines wastage exploring low carbon alternatives. win,” says Smith. Smith explains, “If we have Where MDIs are still needed, many is also a major strand patients with, say, borderline raised practices are working on establishing of our work blood pressure, we can either “green disposal” schemes for Honey Smith reach for our prescription pad or patients to recycle them in an we can look at things other than environmentally friendly way. medicines such as using social prescribing, health trainers, and Practise what you preach ‘green prescribing’—prescribing Another major contributor to a The amount of nature based activities, as nature is general practice’s carbon footprint emissions from a known to have additional benefi ts for is travel. Sawyer explains, “From particular MDI inhaler mental and physical wellbeing. the work I’ve done I know that, if we use in practice “Reducing problematic you add up the distance travelled by could be equivalent to polypharmacy and medicines patients and staff in a large practice, driving 175 miles wastage is also a major strand of it’s about 100 000 miles a year. And Vasumathy this work.” in [carbon footprint expert] Mike Sivarajasingam Berners-Lee’s latest book, How Bad Breathe easy are Bananas? The Carbon Footprint Crucially, Delivering a “Net Zero” of Everything, there’s a chart which Realising that the National Health Service notes that a shows that 3.5 minutes of life is lost healthcare you’re small number of medicines account by a surrounding urban community providing causes for a large portion of emissions—one per mile you drive through it in a harm is galling such group being inhalers. As such, petrol car. So, for that large practice, Munro Stewart there’s a drive by climate conscious it works out as nearly 250 days of life GPs to move away from prescribing being lost.” metered dose inhalers (MDIs), where “Realising that the healthcare clinically appropriate, towards you’re providing causes dry powder inhalers (DPIs), harm is galling,” says which have a smaller carbon Munro Stewart, a GP Patients working on footprint. our practice allotment see the value in the natural world, as something important to save Maria Read

the bmj | 6 February 2021 183 IN ONE YEAR Frome Medical Practice in Somerset saved

£10 000 just from reducing its photocopying and printing.

plan. This can also help you dodge red herrings, he says—recycling being a common one. “When I’ve assessed the carbon footprint of practices, only about 0.1% of the footprint is waste,” he explains. “We cannot recycle our way out of the climate crisis.” Once you get started, “virtuous circles” often develop, says Maria Read, a GP at Dovercourt Surgery in Sheffi eld. She set up an allotment at the practice to provide her patients, in a deprived area, with fresh fruit JOHN BIRDSALL /SPL and veg. But she’s seen numerous and representative for the RCGP opportunity. “I feel there’s a real other benefi ts for patient volunteers. on climate change and health in window here while systems are She says, “Being out in the open, Tayside. But it can galvanise change. changing,” he explains. “There have being productive, has meant that The tactics GP surgeries are been some positives, like getting people in a community who feel employing to tackle the impact of GPs rapidly skilled at telephone disempowered begin to feel good travel include installing charging and video consultations.” These, about themselves. And they see points for electric vehicles, bike he believes, could be built on where the value in the natural world, as racks, and promoting active travel— appropriate, to shrink practices’ something important to save.” be it cycling, walking, or running. carbon footprints. Sawyer, who cycles to home Do no harm visits, says, “It’s about being a good Saving money Some nervousness exists about role model.” Of course, time and money are two this responsibility being dumped The fact that GPs are seen as pillars inevitable barriers for practices, on GPs’ shoulders, but Smith of the community is one reason and organisations such as Greener If doctors, believes that it’s about staging a why many consider themselves well Practice are calling for funding who are multipronged attack. She says, “If placed to lead the climate charge. to support their work and that of considered enough health professionals commit “Patients believe in us,” argues individual practices. In the long the most to decarbonising, and to making Sivarajasingam. “As GPs we are run it will pay off , says Kemple. their voices heard about the climate educators. Every day we’re educating “The whole point of sustainability trustworthy and ecological crisis as an urgent about exercise, or blood pressure, is that you use less, you waste professionals, health issue, it may become more or depression. So, we’re in a perfect less, and actually that saves you talk health, and more diffi cult for governments place to educate about climate money,” he says. environment not to listen.” She encourages GPs change too.” Karen Creffi eld is practice people are to get involved with their clinical Indeed, in a recent survey doctors manager at Frome Medical Practice likely to listen commissioning groups, local were considered to be the most in Somerset, which is held up as medical committees, and RCGP trustworthy professionals, so if they a shining example of what can be faculties—anywhere that they can talk about the connection between done, having taken 85 green actions lobby for change. the environment and health, people listed on its website and winning “Doctors sign up to a Hippocratic are likely to listen. The beauty of a 2018 Green Impact Award. She principle of doing no harm,” she the mission is that it becomes a notes that the practice saved £10 000 notes, adding, “We also sign up to whole team eff ort: Sivarajasingam in one year just from reducing its GMC duties to protect and promote says, “It brings everyone in the photocopying and printing. the public health—and if we’re not practice—clinical staff , admin staff , And it’s not about having to do taking that seriously, what kind of receptionists—together.” everything at once, says Sawyer. He doctors are we?” For all the devastation covid has recommends that practices work Jessica Powell, freelance journalist, Devon, UK brought, Stewart believes that the out their carbon footprint and then [email protected] pandemic could provide a golden chip away at it with, say, a 10 year Cite this as: BMJ 2021;372:m4827

184 6 February 2021 | the bmj BMJ OPINION Christina Pagel How to break the cycle of covid-19 lockdowns As the UK waits out its third national lockdown, these are the steps countries need to exit the loop

n 4 January, just as the Vaccines will certainly help us to get new vaccines seemed there but alone they will not suffi ce. QUOTE to off er hope, England We don’t yet know to what extent GOES entered its third national vaccines prevent transmission of the HERE O lockdown, following the virus but even if they were as eff ective ??????? likes of France, Germany, and Spain at preventing transmission as they are back into a familiar cycle of restrictions at preventing symptomatic illness, we and perseverance. cannot vaccinate our way to no cases. Countries all over the world are Herd immunity will not prevent grappling with the same dilemma. local outbreaks in communities with Until populations at large are lower uptake for years to come. And in vaccinated, people are not safe from the face of more transmissible strains, covid-19, and, though we know a herd immunity would likely require lot more about the virus than a year at least 80% of the population to be ago, the many questions that remain protected from infection. Even with SOPA/SIPA/PA mean the blunt tool of lockdowns a very optimistic real world effi cacy stamp down on new outbreaks in and other social restrictions are the (as opposed to trial effi cacy) of 90%, the months and years to come. This main weapon used, in Europe at least, that would require vaccinating over includes easily accessible tests, against a virus that has infected more 90% of people. In the face of vaccine testing of all close contacts, and than 100 million people and claimed hesitancy, particularly among fi nancial and practical support to over two million lives so far. minority groups; less interest in isolate. Investment in quicker, easier As millions are vaccinated, at what vaccination among the young; and no tests (such as saliva tests, provided point is it safe to lift UK restrictions? current licensed vaccine for children, accuracy was reasonable) would be we will not reach that threshold. enormously useful in supporting this The dangers to consider eff ort, as would other tools such as The dominance of new, more So, what should the UK do? monitoring waste water for traces of transmissible variants means that a There are four steps to a new normal. the virus. policy of trying to “live with” the virus First, we need to continue Fourth, we need strong border will fail, certainly in the UK where to vaccinate the entire adult control with negative tests before the B.1.1.7 variant is now the most population as quickly as possible to and after travel and 14 day managed common. I know of no country that is prevent long covid, severe illness, isolation on entry for everyone successfully living with the virus while hospitalisations, and deaths. It (including returning citizens). As we Christina Pagel, avoiding lockdown and restriction is likely that this will also greatly director, Clinical reach zero community transmission, cycles, a high death toll, or—as in the reduce transmission, although we do Operational any new community transmission UK—both. not yet know by how much. Research Unit, that cannot be traced must be We need to set our sights instead on Second, we need to have strong University College contained with local, short term, where we want to be and then work restrictions in place until we have London tight restrictions, as in Australia. out how to get there. The role models driven cases back down to levels [email protected] On the other hand, travel corridors we have are Vietnam (35 deaths, last seen in the summer. Enhancing with other zero internal transmission 98 million population), Thailand restrictions with a concerted eff ort countries could be explored. (73 deaths, 70 million population), to make workplaces safer and I don’t know, however, if any South Korea (1371 deaths, 51 million supporting self-isolation will greatly single country can realistically exit population), and New Zealand reduce the length of time needed. the pandemic unless all countries (25 deaths, 5 million population) Third, we need to rebuild local do. Without global suppression, where people have been living much contact tracing capability to a vaccine resistant strain is likely more normal lives for months. aggressively drive cases down to emerge and covid will spread Following their example, the way further as restrictions are again. That’s why the ultimate out is for the UK to pursue a national eased and to spot and solution is for the UK to work suppression strategy—zero tolerance internationally to ensure rapid for any community transmission— The way out is to vaccination and a robust strategy which comes with the added benefi t of pursue a national for monitoring transmission, protection from homegrown vaccine suppression strategy identifying new variants, and resistant variants. Christina Pagel coordinated border control.

the bmj | 6 February 2021 185 BRIEFING Covid-19: how the UK is using lateral flow tests in the pandemic

Rapid result tests are pivotal to the government’s strategy to reduce the spread of the virus by identifying asymptomatic people. But, with doubts over their accuracy, Ingrid Torjesen asks if they are being used appropriately

s many as 384 million The World Health Organization especially among regular users such kits have been ordered points out that the accuracy of LFTs as people testing themselves several by the government at depends on several factors, including times a week before going to work, a cost of more than time from onset of infection, the says Iain Buchan, professor of public A £1.3bn, with the lion’s concentration of virus, the quality health and clinical informatics at share spent on a test made by the US and processing of the specimen, Liverpool University. fi rm Innova Group. And an additional and the precise formulation of the WHO says that LFTs are more £900m worth of contracts have just reagents in the test kits. likely to pick up positive cases when closed. Lateral fl ow tests (LFTs) have Quality and processing are viral loads are highest and patients become a lucrative business. determined to a large extent by who are most infectious—typically, Laboratory based polymerase carries out the tests. PHE’s evaluation one to three days before the onset chain reaction (PCR) tests are often of the Innova test showed that its of symptoms and during the fi rst treated as the “gold standard” for sensitivity was 79.2% when used by fi ve to seven days after the onset of identifying clinical cases of infection. trained laboratory scientists, 73% symptoms. But they take time, are relatively by trained healthcare staff , but only A recent evaluation of data from expensive per sample, and are not 57.5% by Boots employed track-and- a quarter of million people in the very portable, because of the need for trace centre staff . But performance NHS Test and Trace programme, laboratory processing. They are also should improve with experience, available as a preprint, supports this. not perfect—and detect viral shedding The evaluation, by the University of long after the infectious period, with WHAT’S THE DIFFERENCE BETWEEN Oxford and PHE, found that only six people continuing to test positive LATERAL FLOW TESTS AND PCR TESTS? in 100 contacts of infected cases went for a mean of 17 days. This means Lateral flow tests on to get infected themselves, and, that people who are not infectious These simple test kits detect viral using modelling, LFTs detected most are unnecessarily quarantined (see proteins (antigens) from the SARS- of the people who would otherwise Analysis, p 197). CoV-2 virus in respiratory samples, go on to infect someone else. The As the pandemic stretches on, such as from a nose or throat swab. modelling indicated that LFTs would countries around the world are looking If the target antigen is present in detect up to 90% of the infections at rapid diagnostic tests, such as LFTs, enough quantity it will bind to specific that individuals passed on. antibodies fixed to a paper strip as a way to test themselves out of the enclosed in a plastic casing and cycle of lockdowns and restrictions What about asymptomatic people? generate a visual signal, usually within and reopen their economies. 30 minutes. These tests are not to be All the studies from PHE and Oxford confused with rapid antibody tests, University have focused on patients How accurate are LFTs? which use blood to detect antibodies with symptoms. Lack of a central registration process generated in response to infection. “Asymptomatic people have a and of comparative data means PCR tests viral load peak that looks to be, on that Public Health England’s (PHE) Polymerase chain average, lower than the viral load Porton Down laboratory and Oxford reaction tests detect the peak of people with symptoms, and it University have been tasked with virus’s RNA in a sample. stays at that peak for less long,” says evaluating LFTs. Only three of 40 kits The test amplifies small Mike Gill, former regional director of made it through fi rst assessments . bits of genetic material public health for the South East of And only one of these has been to enable detection. So England. evaluated in fi eld studies; it is still a test can give a positive In other words, if you don’t show result long after a person unknown how the others work in the symptoms, you shed virus or clear stops being infectious. real world. virus more quickly, he says, which

186 6 February 2021 | the bmj REGULATION GREY ZONE Lateral flow tests occupy a deregulated grey zone. Most such “in vitro diagnostic tests” can be declared as conforming to the UK Medical Device Regulations 2002. A UK approved body approves tests for higher risk infections, such as HIV, or if it is a self-testing kit. The list of high risk infections is outdated and doesn’t include hygiene messages such as “hands, SARS-CoV-2. So, manufacturers can self-declare covid tests for professional use. face, space.” The only stipulation is that they must be carried out by trained staff: The DHSC is piloting the tests for they cannot be simply rolled out as part of a self-testing programme. some other uses, including testing That said, they can be used for research purposes. Innova’s test hospital patients to more quickly was piloted for community testing in Liverpool last year. And the identify those with infection so that MHRA has issued an exemption for the Innova test so that, even they can be isolated. though it is approved only for use by professionals, it can be sent out for self-testing under the NHS testing programme. This has What should LFTs not be used for? highlighted the need to reform the regulations, at least in the UK. At present, LFTs are not authorised The claims of diagnostics companies have been “without any serious for “serial testing” of school scrutiny” for years, says Jon Deeks, of University of Birmingham’s Institute of Applied Health Research. “They tend to be based on selected pupils who have been exposed results, published with minimal detail, and their performance claims are to a confi rmed positive case of rarely ever replicated. It is possible for the government to use tests for purposes for covid-19 to enable them to attend which there is absolutely no evidence or approval,” he says. school (pupils who are exposed to infected cases have to isolate). The means that any test with a relatively example, in the US the Food and government had hoped that serial low level of sensitivity (as with LFTs, in Drug Administration authorised testing would enable them to reopen comparison with PCR) could struggle its fi rst home test in December. schools but such plans are on hold. to pick up asymptomatic infections on Germany plans to make self-testing LFTs also cannot be used to an “intolerable” number of occasions. kits available from pharmacies this shorten the length of quarantine of Where the tests have been used month at a cost of €10-15. travellers arriving in the UK, under among asymptomatic people in All in all, self-testing using the government’s Test to Release real world settings, the reported LFTs leaves a lot of possibility for scheme. That can be done only with performance has indeed been lower. misinterpretation of results. LFTs give a negative PCR test result. In a pilot study conducted in Liverpool people hope Jon Deeks, who leads the 60% of infected asymptomatic people What should LFTs be used for? by enabling Biostatistics, Evidence Synthesis went undetected, including 33% In a nutshell, the tests must be used them to do and Test Evaluation Research Group of those with high viral loads. Up to within strictly defi ned parameters. something for at the University of Birmingham’s 21 January nearly 560 000 LFTs had The Innova test is being used as a themselves Institute of Applied Health been done in the city on more than self-test in asymptomatic individuals Iain Buchan Research, says the DHSC’s “red 200 000 residents, identifying 4421 as a part of the UK’s Test to Find light” interpretation of a positive people who may not have otherwise strategy. A positive result is a “red result is a good use of LFTs. But a known they were likely to be light,” says the Department of Health “green light” negative result should infectious. Among students tested by and Social Care for England, requiring not be taken as a sign that all is LFT at the University of Birmingham the most infectious individuals and well, he says, and particularly not in December, only 3% of those who their contacts to rapidly isolate to to do anything you would not have would have tested positive on PCR protect other people from infection. done otherwise. The WHO Essential were detected. This is why WHO The tests are for people who Diagnostics Test states that recommends repeat testing using cannot work from home, including negative results should never be lateral fl ow devices. NHS and care home staff , teachers, used as a basis of decision making. “We already knew that lateral university students, and employees Asymptomatic That’s hard for authorities to fl ow tests do appear more accurate of companies that have signed up people have control, particularly in a population with patients who have more virus to the government testing scheme. a viral load that’s spent close on a year enduring present,” says Alexander Edwards, Self-tests are usually conducted twice peak that lockdowns and social distancing. associate professor in biomedical weekly before users leave home. looks to be, A lack of consistent messaging technology at the Reading School of The tests are also being distributed on average, across the UK is exacerbating the Pharmacy. “It follows that they may to local councils to off er community lower than situation. People who receive a be better suited to spotting ‘spreaders’ testing. This has been very well the peak of negative result in Lewisham are told than identifying everyone infected.” received in Liverpool, says Buchan, people with it’s “great news,” while in Blackpool The question is how to manage one of the senior clinicians involved they are told that “you were not symptoms false negative results, he says. Are in analysing the pilot data. It enabled Mike Gill infectious when the test was done.” people who receive a negative test people to get tested before doing They are encouraged to keep getting result “safe” or “safer” than they something that would put them tested “regularly” in Lewisham, were before they were tested? in contact with others, such as which translates to “once a week” That’s a worry, particularly as over shopping. Buchan says it engages in Bradford and “twice a week” in the counter LFTs become common. communities and gives people hope Havering. In other countries the tests are by enabling them to do something Ingrid Torjesen, freelance journalist , London available to buy whether or not for themselves, while allowing the Cite this as: BMJ 2021;372:n287 customers have symptoms. For public health team to reinforce  ANALYSIS, p 197 the bmj | 6 February 2021 187 COVID-19 Imperial College London, told The BMJ . As covid-19 vaccination might become routine, much like fl u vaccination, the NHS is Why aren’t vaccines being to look at future logistics. On 12 January, Kate Bingham, former head of the government’s distributed in prefilled vaccine taskforce, told the Public Accounts Committee that distribution of the vaccine needs to be simplifi ed if, as expected, it turns syringes? out that people will need further doses. She told MPs that this would be “ideally oral or Pre-fi lled syringes intranasal or even a patch where you could just get it sent in the post.” A patch has are the safe standard long been touted as an alternative to the fl u for modern vaccinations. vaccine without a solution emerging. Jane Feinmann asks why Bingham failed to mention prefi lled syringes, covid-19 vaccines rely widely tried and tested, easy to use, and almost entirely safe. “Given the importance to life and on glass vials instead the national economy, it’s surprising that with nearly a year to prepare, a superior and available technology like [prefi lled syringes] does not appear to have been considered,” says Whitaker.

y 24 January more than of multidose vials ignores this guidance. Increased production 5.8 million people in the “The method is unchanged from Jonas In November the US International Development UK had been given their Salk’s polio vaccinations over 70 years Finance Corporation approved a $590m fi rst dose of a covid-19 ago,” says Whitaker. “It’s as if people are (£430m) loan to Apiject, a North Carolina B vaccine. The achievement is being made to use fountain pens and company, to build a facility to produce up all the more remarkable given the time bottles of ink instead of Biros.” to three billion single dose prefi lled plastic consuming safety precautions that must injectors a year. It’s not clear whether prefi lled be taken. For the Oxford/AstraZeneca Emergency approvals syringes will be produced at the UK’s Vaccines injection, healthcare professionals, The anomaly is partly explained by Manufacturing Innovation Centre—being built working alone or in pairs, take “full the unpredictability around emergent in Oxfordshire and set to “make 70 million responsibility” for following a lengthy, vaccine approval over the past doses within a four to fi ve month period,” says, itemised standard operating procedure, few months followed by the “near Matthew Duchars, the centre’s chief executive. which was published by the Specialist instantaneous clamour across the world The success so far of Britain’s vaccination Pharmacy Service on 7 January. to stock up on vaccines and the ancillary programme could be an argument to stick with As well as guidance on preparing the products required for their delivery,” said vials. “It’s clear from the huge numbers being workstation and removing vaccines from Simone Blayer, who oversees vaccine vaccinated that healthcare professionals are the refrigerator, the checklist involves a process development at PATH, It’s like having managing well with multidose vials, 12 step guide to fi lling up to 10 syringes a non-profi t global health to use fountain which are also the cheapest way to from each vaccine vial. This involves organisation in August 2020. pens and deliver them,” says Kis. “Cost will carefully cleansing the vial “bung” “Across the world, we were always be a factor in vaccination before puncturing it in 10 places to looking at up to four billion bottles of ink programmes, especially globally.” withdraw each dose into a single use doses to be deployed in the instead of biros But Apiject rejects the idea that syringe. This procedure is far removed fi rst quarter after a vaccine David Whittaker vials are cheaper. As well as avoiding from normal vaccination practice. is approved for manufacture,” he said. contamination and insurance payouts, Apiject In high income countries, prefi lled “Many plants can fi ll tens of thousands claims that in the long run, prefi lled syringes syringes are now the norm for infl uenza of vaccine doses per hour, but when the are cheaper than multidose vials, “where vaccines, as well as heparin and millions immediate need is for billions of doses, wastage of up to 50% is routinely factored in.” of other injectable medicines. This is even the fastest robotic fi lling arm can be Whitaker argues that prefi lled syringes are in line with the Royal Pharmaceutical too slow.” the most up-to-date, safe, and effi cient format. Society’s guidance to “minimise the Reports of a global shortage of medical “At this stage in this continuing emergency, manipulation of medicines outside of glass, said to be a key factor in slowing it’s important that crucial decisions are made pharmacy,” said William Harrop-Griffi ths, down the bottling at vaccines plants by people who understand what it’s like to of the Royal College of Anaesthetists, at across the world, have raised concerns. deliver vaccinations at speed and with the need the guide’s launch in 2018. These, however, seem to be unfounded. for constant vigilance to ensure every dose is David Whitaker, a retired anaesthetist “We’ve been hearing these rumours, but delivered safely.” and chair of the patient safety it’s not causing a problem, at least in the Jane Feinmann, freelance journalist, London committee of the European Board of UK,” Zoltan Kis, research associate at the [email protected] Anaesthesiology, is concerned the use Future Vaccine Manufacturing Hub at Cite this as: BMJ 2021;372:n263

188 6 February 2021 | the bmj