this week NAMING STRAINS page 129 • VACCINE INTERVAL page 130 • NON-COVID CARE page 132 MATTHEW HORWOOD / ALAMY / HORWOOD MATTHEW Public not warned of rapid test’s limits

EXCLUSIVE Only a third of the local public health experts are concerned about Experts fear people who have authorities off ering lateral fl ow tests false reassurance from mass testing. tested negative will continue have made the test’s limitations clear Studies show that, while false positive to work on site believing they to the public—including that people results are rare with the commonly used are not carrying the virus testing negative could still be infected, an Innova lateral fl ow test, false negatives are investigation by The BMJ has found. much more common. Results from Public A search of the websites of the 114 local Health England showed the test’s overall authorities in England off ering the tests sensitivity to be 76.8%, meaning that found that 81 provided test information 23.2% were false negatives. Sensitivity to the public. Of these, nearly half (47%; dropped to just 57.5% when carried out by 38) did not explain the test’s limitations or self-trained staff at a track and trace centre. make it clear that people had to continue Margaret McCartney, a GP in Glasgow, following lockdown restrictions and social said, “It’s a rule-in, not rule-out test. False distancing whatever their test result. positives low, false negatives high. We can Although 53% (43) did advise people to argue about fi ne print, but people need LATEST ONLINE continue to follow current measures after clarity about what the results mean. It’s a negative result, only 32% (26) were clear important that the risk of false negatives One dose of Pfi zer about the test’s limitations or its potential is spelled out.” She added that local vaccine could be for false negatives. The advice the websites authorities should be better supported in less eff ective than expected, reports gave about a negative test result ranged their communication with the public. from Israel indicate from “A single negative test is not a passport A spokesperson for the Department of Mental Health Act: to carrying on your daily life ‘virus-free’ . . . Health said the government had been clear doctors should don’t let a negative covid-19 test give you a that a negative lateral fl ow test result did not use video false sense of security” to “It is good news not rule out infection and that everyone assessments to that you don’t have the coronavirus.” should continue to follow restrictions. The detain patients On 10 January England’s health spokesperson added that the government during pandemic secretary, , launched the drive was working to support local authorities to BMJ appeal raises for local authorities to test asymptomatic communicate such public health messages. over £53 000 for Elisabeth Mahase , The BMJ people who cannot work from home, to try food aid charity to halt the spread of the virus. But many Cite this as: BMJ 2021;372:n238 the bmj | 30 January 2021 127 SEVEN DAYS IN Consultant is struck off after pressuring patients to remove poor online reviews A consultant who worked as an ear, nose, and throat surgeon in the NHS has been struck off the medical register for a “pattern of failures” in private cosmetic rhinoplasty work he performed on six patients more than four years ago and for pressuring two of them to remove unfavourable online reviews of his work. A medical practitioners tribunal found that Mohammed Tahery misled some patients about the rate of revision surgery needed aft er his operations, claiming it was rare when the true rate was 20-25%. In one case Tahery’s surgical work was found to be below par. The charges against him focused less on the standard of his surgery and more on his statements about risks and his responses to dissatisfi ed patients. One patient, whose consent form had understated the rate of revision surgery, left an unfavourable review on the website Realself. Using his secretary’s email, Tahery wrote to this patient, “Due to the recent multiple untrue allegations posted on the website . . . you are now in total breach of the doctor-patient contract.” He conceded at the tribunal that there was no such contract and he should not have used the term. The erasure will take eff ect aft er 28 days unless he appeals.

Clare Dyer, The BMJ Cite this as: BMJ 2021;372:n187

Covid-19 the digital era, said the panel, last year were highlighted by for patients with serious mental Some occupations have along with a “political step experts appearing before the illness. The parts of the QOF to higher covid death rate change in the willingness of House of Lords Public Services be implemented from April will Nearly two thirds of 7961 countries to hold themselves Committee. By 31 July more depend on the covid situation. deaths of adults (aged 20 to 64) accountable for taking all than 8600 contracts related to involving covid-19 from 9 March necessary actions as soon as the pandemic—worth £18bn— Research news to 28 December in England and an alert is given.” A full report is had been awarded, including Air pollution may Wales were among men (5128 expected in May. those for personal protective raise risk of AMD deaths), showed Office for equipment, which accounted National Statistics data, and the Rules are too flexible, for 80% of these contracts. But age standardised mortality rate says Independent SAGE standards were rarely met: the was significantly higher in men The government must stop National Audit Office found that (31.4 deaths in 100 000) than in blaming the public for high from January to July 2020 only women (16.8 deaths in 100 000). infection rates and instead focus around 55% of the contracts Working in social care was linked on tightening lockdown rules, agreed had been published in the to higher death rates in men Independent SAGE warned. As required 90 day timeframe. and women than in the general the home secretary, Priti Patel Air pollution was linked to population, but working in (below), announced £800 fines GP contract a higher risk of age related healthcare showed a link only in for people who breach lockdown Now is not the time for macular degeneration (AMD) men. Nurses, nursing auxiliaries, rules, the group said too flexible big changes, say leaders in an observational study and assistants also had higher rules and not house parties The BMA and NHS England published in the British Journal death rates, but teachers did not. were the problem. It called for a agreed that only minor changes of Ophthalmology that reviewed narrower definition of key workers would be made to the GP data from 115 954 UK Biobank WHO and China “acted to cut workplace transmission, contract in England from April. participants. During the six too slowly” in early days more financial support for people NHS England reconfirmed more year follow-up 1286 of the The World Health Organization who can’t work, safer schools, funding for practices to hire extra participants (just over 1%) had was slow to act when SARS- and allowing tradespeople to do staff and minimal changes to the AMD diagnosed. Higher exposure CoV-2 emerged and should have only essential work in homes. quality and outcomes framework to fine particulate matter declared a pandemic sooner to (QOF). Minor changes to (PM2.5) was associated with an ensure countries understood Government failed account for the pandemic increased risk (by 8%) of AMD, the gravity of the situation, procurement standards will be made to modules and all other pollutants except concluded the Independent Poor transparency, on early cancer diagnosis coarse particulate matter were Panel for Pandemic Preparedness incomplete documentation, and improving care for associated with changes in retinal and Response. It said the global and questionable patients with learning structure. If the findings were pandemic alert system was processes for disabilities, and replicated “this would support “not fit for purpose” and “slow, government further funding will the view that air pollution is an cumbersome, and indecisive.” procurement during support physical important modifiable risk factor The system needs updating for the pandemic health checks for AMD,” said the authors.

128 30 January 2021 | the bmj SIXTY SECONDS MEDICINE ON . . . NAMING US news STRAINS Biden launches covid plan to be based on science WHAT’S IN A NAME? President Biden offered a General bewilderment, it turns out, when we’re talking about SARS-CoV-2 variants. 200 page national plan to combat Biden has ordered that More potentially worrying variants are being the spread of SARS-CoV-2 and masks must be worn on identifi ed, but there’s no agreed way of to rebuild the US’s public health all interstate transport naming them. A report in this month infrastructure, after warning that said researchers were in a world of confusion. the US death toll from covid-19 Even terms like “variant,” “lineage,” and could reach 500 000 in February. “strain” don’t have unambiguous defi nitions. He said, “The national strategy will be driven by scientists NAMING STRAINS IS A STRAIN? and public health experts free Exactly. “All of us are becoming very confused from political interference.” Staff could not proactively by the diff erent variant names,” said Maria Masks will now be required on monitor the risks to all patients on EXCESS Van Kerkhove, covid-19 technical lead for the airlines, ships, railroads, and the list, many of whom were very World Health Organization. Or, as Tulio de interstate buses; for people in vulnerable, said the CQC. Some Oliveira, a bioinformatician at the University DEATHS of KwaZulu-Natal in Durban, put it, “The federal properties and offices; staff said that “they felt unable nomenclature is a bloody mess.” and for federal employees and to raise concerns without fear of From last March to contractors. The US was rejoining retribution,” inspectors reported. October 297 500 HAVEN’T WE BEEN HERE BEFORE? WHO and the Paris climate more people died With covid-19? Yes, we did all have to get agreement, Biden added. Psychiatry on average in the used to a couple of names for the virus and College calls for the disease. Before last February the SARS- Trump pardons doctor unconscious bias training EU—24.9% CoV-2 virus was known as nCoV2019 or 2019- who defrauded Medicare nCoV, and the covid-19 disease was referred The Royal College of Psychiatrists more deaths being An ophthalmologist was released called for all mental health staff to as 2019-nCoV acute respiratory disease. registered—than from prison after the outgoing to undergo mandatory training WHAT ABOUT THE CA TCHY “B.1.1.7”? US president, Donald Trump, on unconscious bias, as it found the monthly That’s just one name for that particular commuted his 17 year sentence that six in 10 psychiatrists from average from 2016 variant—the one formerly known as “variant for defrauding the government. ethnic minority backgrounds had to 2019. Poland had under investigation 202012/01.” It has also Salomon Melgen, experienced racism the highest excess been known as 20I/501Y.V1, and the media 66, was Medicare’s at work. Of the 136 mortality (97.2%) have called it “the UK variant” and even “the highest billing doctor doctors in its survey Kent variant.” for several years. A court who had faced overt and Denmark the lowest (5.5%) WHAT’S WRONG WITH “UK VARIANT”? found in 2018 he had or covert racism at Scientists try to avoid geographical names— falsely diagnosed AMD work, just 40 (29%) [ Eurostat ] variants spread rapidly and can emerge in in patients and then reported the incident. one country but be identifi ed in another. fraudulently billed for Over a quarter said Also, a fear of stigmatising nations could over $73m (£53.4m) in tests and the experience had affected their discourage some from reporting variants. treatments. The commutation health, and four in 10 said it had is a “slap in the face to patients had an impact on patients. NAMING AND SHAMING? who are getting needles stuck That’s what we want to avoid. Donald Trump repeatedly labelled SARS- in their eyes and lasers blasting Regulation CoV-2 the “China virus” as part of a their retinas for treatments they GMC will maintain PR campaign that coincided with a did not even need,” said his lead flexibility during pandemic rise in harassment of Asian American prosecutor, Roger H Stefin. The GMC said it will continue to medical staff in the US. progress open investigations on Gender dysphoria fitness to practise where possible IS SOMEONE SORTING THIS OUT? Waiting list of 4600 and will pause new cases unless They’re trying to. A WHO working prompts concern the accused is already aware or group was set up on 12 January to develop a England’s only gender identity where patient safety is an issue. consensus naming system. development service has been ID checks will be suspended as HOW ABOUT A PUBLIC VOTE? rated inadequate by the CQC, in the first wave, and doctors Maybe not—we could end up with “Strainy which has imposed conditions on who meet all other criteria will McStrain Face.” the Tavistock and Portman Trust’s continue to be registered. registration, to try to reduce a Tom Moberly, The BMJ waiting list of 4600 young people. Cite this as: BMJ 2021;372:n222 Cite this as: BMJ 2021;372:n218

the bmj | 30 January 2021 129 COVID-19

Moderna trials a booster New UK variant may be dose to counter B1.351 linked to rising death The US drug company Moderna has announced it is developing two approaches to emerging variants of SARS-CoV-2 after studies showed its vaccine has a rate, early data indicate reduced level of neutralising titres to the South African variant, suggesting immunity might wane. he new UK variant studies analysed cases of the new and Although the studies showed that Moderna’s current of SARS-CoV-2 may old variant by linking community vaccine, known as mRNA-1273, was effective against be associated with testing data with death data. both the UK and South African variants, a sixfold an increased risk of At a Downing Street press reduction was seen in neutralising titre levels to the T death, emerging data briefi ng led by the prime minister, South African variant, named B1.351. are suggesting. , on 22 January, the Moderna said that “out of an abundance of caution” In a briefi ng paper published on government’s chief scientifi c adviser, it was starting a clinical programme of two booster 22 January the government’s New , said the preliminary approaches to increase immunity to the new variants. and Emerging Respiratory Virus analyses suggested that in every 1000 Its chief executive officer, Stéphane Bancel, said, “We Threats Advisory Group (NERVTAG) men aged 60 years who were infected believe it is imperative highlighted several preliminary with the new variant 13 or 14 might be to be proactive as the analyses showing a possible increase expected to die, compared with 10 in virus evolves.” in the severity of disease associated 1000 infected with the original virus. In the first approach with the new Moderna said it would (VOC) B.1.1.7, which fi rst emerged in Hospital admissions see whether a third Kent in September. NERVTAG said that further analysis “booster dose” of Two unpublished papers, one was needed because the data involved mRNA-1273 would from the London School of Hygiene a relatively small number of people further increase neutralising titres against the emerging and Tropical Medicine and one from (around 8% of the total deaths variants. In a second approach it said it had developed Imperial College London, reported an occurring during the study period) a booster vaccine candidate called mRNA-1273.351 increased case fatality rate in people and did not include data on hospital against the emerging South African variant and was with s-gene target failure (SGTF, admissions. beginning phase I studies in the US to see whether this a proxy for variant B.1.1.7). Both At a Science Media Centre briefi ng would increase the immunological effect. on 25 January Peter Horby, professor of In an interview with The BMJ earlier this month The death rate emerging infectious diseases at Oxford Andrew Pollard, a leader of the Oxford-AstraZeneca when linked University and chair of NERVTAG, said, vaccine trials, explained that modifying the vaccine “What the analysis so far shows is was not difficult. “For the RNA vaccines and the viral to community that the rate of death when you link vectors it’s relatively straightforward, because you just testing is higher community testing to death is higher have to synthesise a new bit of DNA in our case—or RNA in those with in those with the B.1.1.7 variant than in [the Pfizer and Moderna] cases—and then insert that B.1.1.7 variant matched people with the other virus into the new vaccine. Then there’s a bit of work to do Peter Horby variant. to manufacture the new vaccine, which is a reasonably heavy lift. But the same processes would be used.” Experts split over vaccine interval, Trial groups Moderna’s new approach may be ready by the as WHO recommends six weeks autumn, and authorisation by the US Food and Drug Administration may be quicker than the long phase I, II, Medical professionals the interval to the World a 21 day gap. At the and III trials required for a new vaccine. seem to be divided over Health Organization’s time, concerns were Bancel told the Financial Times that a few thousand the UK’s decision to recommended six raised over the lack of trial participants for the new approaches would be delay the second dose weeks. evidence for the interval divided into two groups. One would receive a booster of the Pfi zer-BioNTech and the potential third dose of the original two dose vaccine, while a vaccine from three to Resistant variants for vaccine resistant second group would receive mRNA-1273.351. 12 weeks after the fi rst, The UK government variants to develop. The UK variant has eight mutations in the spike so as to administer announced at the But the four UK chief protein it uses to attach to human cells, and the South more fi rst doses to end of December that medical offi cers said the African variant has 10. Both are more infectious and vulnerable people. the interval between move would “protect cause a higher viral burden. Another variant, found in Most other countries vaccine doses would be the greatest number Brazil, shares many of the South African mutations. are either vaccinating at extended to 12 weeks, of at-risk people in the Janice Hopkins Tanne, New York the intended three week despite clinical trials shortest possible time,” Cite this as: BMJ 2021;372:n232 interval or extending of the vaccine using while reducing the

130 30 January 2021 | the bmj The baseline risks go up steeply with age, so for those in their 80s the new variant would take the average mortality risk from 8% to around 10% and for those in their 90s from around 20% to 27%—a massive impact

The baseline “But what we have not been able NERVTAG also cited a subsequent data from one NHS trust from the risk for people to detect yet is an increased rate of independent case-control analysis Covid-19 Clinical Information in their 20s hospitalisation, or once in hospital, of community testing data linked Network did not fi nd an increased goes only from an increased rate of dying with this to death data by Exeter University, risk of death associated with VOC 1 in 3000 to 1.3 variant versus another variant, so which found that the mortality among people admitted to hospital. David that’s where the uncertainty lies . . . hazard ratio for VOC infected But NERVTAG said more work was and that’s where the work is needed.” people, versus non-VOC, was 1.91 needed to understand the eff ect of Spiegelhalter LSHTM’s analysis was based on (1.35 to 2.71). variant on risk. 2583 deaths among 1.2 million tested All the analyses were adjusted The government advisers noted individuals; 384 deaths were among for age, location, time, and other that the absolute risk of death per people with SGTF. The relative hazard variables. infection “remains low.” of death within 28 days of a test for Commenting on the data, David VOC infected people in comparison Matched cohort analysis Spiegelhalter, chair of the Winton with people with the original variant And an updated matched cohort Centre for Risk and Evidence was 1.35 (95% confi dence interval analysis of 14 939 SGTF cases and Communication at the University 1.08 to 1.68). 15 555 comparators from Public of Cambridge, said, “The baseline Imperial’s study found the mean Health England identifi ed 65 deaths risks go up steeply with age, so for ratio of case fatality rate in VOC among non-SGTF cases (0.1%) those in their 80s the new variant versus non-VOC people was 1.36 and 104 deaths among SGTF cases would take the average mortality (1.18 to 1.56), when calculated in a (0.2%), giving a death risk ratio for risk from 8% to around 10% and case-control weighting method, and VOC infected people versus non-VOC for those in their 90s from around 1.29 (1.07 to 1.54) in a standardised of 1.65 (1.21 to 2.25). 20% to 27%—a massive impact. But case fatality rate method. A separate rapid analysis of for those in their 40s it goes from around 1 in 500 to 1.3 in 500, and for those in their 20s from 1 in 3000 LSHTM’s analysis was based on 2583 deaths among 1.2 million to 1.3 in 3000, a trivial increase.” Gareth Iacobucci , The BMJ tested individuals; 384 deaths were among people with SGTF Cite this as: BMJ 2021;372:n230 strain on the NHS. of supplies, there may list should suff er slower doses to “allow for a However, the BMA not be any guarantees access to their fi rst dose higher initial coverage.” has since written to that second doses of the so that someone who’s But it said that there England’s chief medical Pfi zer vaccine will be already had one dose, were no data on effi cacy offi cer, Chris Whitty, available in 12 weeks’ and therefore most of beyond 42 days, as the asking him to bring time.” the protection, can get interval between doses the interval down to a second? Everyone in trials ranged from 19 the six week (42 day) Medical officer opinion on the priority list is to 42 days. maximum suggested by In an opinion piece in at risk from this virus, After WHO’s WHO. the Telegraph , however, and vaccines just can’t recommendation some A BMA spokesperson England’s deputy be produced at an EU countries, including told The BMJ that the chief medical offi cer unlimited rate.” Who on the at-risk list Denmark, France, and letter refl ected growing Jonathan Van-Tam said WHO has should suffer slower access Germany, decided to concern in the medical that, while some people acknowledged that to their first dose? administer the second profession regarding were questioning the some countries were Jonathan Van-Tam Pfi zer dose three to six the delay of the second UK’s policy, what “none facing “exceptional weeks after the fi rst. dose and that, “given of these . . . will tell me circumstances” and may Elisabeth Mahase, The BMJ the unpredictability is: who on the at-risk want to delay second Cite this as: BMJ 2021;372:n226 the bmj | 30 January 2021 131 care units are fi lling up with covid patients, and it’s also being able to fi nd space within the hospital, because once you have a ward with covid patients, you can’t put your planned care patients on that same ward,” Donald said. Last April the NHS stopped doing P. MARAZZI / SPL / MARAZZI P. most planned surgery for several NEWS ANALYSIS months to help it deal with the covid- 19 pandemic. In the second wave of the pandemic, How is the pandemic affecting Johannsson, who is a council member at the Royal College of Anaesthetists, provision of non-covid care? said huge eff orts were made to avoid this. “We’ve got this enormous As NHS hospitals struggle to fi nd enough beds for patients with covid-19, mountain to climb to get back on top of Gareth Iacobucci examines the strain this is placing on other services the elective waiting list,” he said. “We are trying to get through as many of the routine operations as we can, because ne of the operating But there is evident nervousness Everybody we know we cannot aff ord to shut suites that across the country. After cancellations tried very everything down. It’s actually been normally does of cancer surgery in London and in hard to keep harder work [than in the fi rst wave] routine surgery has the East of England, NHS England everything from that angle.” “O been converted reportedly wrote to all regional health going. But And as Neil Mortensen, president into a 12 bed intensive care unit. We’re bosses earlier this month instructing that meant of the Royal College of Surgeons of doing very little routine work, and them to ensure that urgent cancer care England, highlights, this has created a we’re struggling to try to get some of was given the same priority as covid- hospitals didn’t catch 22 situation. “This time around, the cancer work done. On a day to day 19, the Health Service Journal reported. have enough everybody tried very hard to keep basis, we very rarely get intensive care space for the everything going. But that meant beds at the moment.” Restrictions on planned care incoming tide of the hospitals were all rammed and Like many doctors, consultant With covid-19 rife across the country, covid patients they didn’t have enough space for the anaesthetist Helgi Johannsson (below, Donald said all trusts were being Neil Mortensen incoming tide of covid patients.” right) was moved from planned restricted in their ability to provide surgery to the intensive care unit planned care. Daily prioritisation meetings because of the high volume of covid “It’s partly because there’s staff Some hospitals have been able to keep admissions. And he expects to remain sickness—so that restricts the number more services running by separating there for several months. “Although of people that we’ve got in operating patients without covid, those with [covid cases are] fl attening off a little theatres. It’s partly because intensive suspected covid, and those with bit, it certainly hasn’t reached the stage defi nite covid. where we’re emptying intensive care THE IMPACT ON CARE But Mortensen said that the sheer beds,” he told The BMJ . Elective care At the end of November, 192 169 number of patients in intensive care patients had been waiting more than 52 weeks units has meant that almost every trust Postponement of cancer surgery for planned surgery, whereas in the same month has had to prioritise care because of The picture Johannsson paints will in 2019 the number was just 1398. Around the limited number of beds. be familiar to most hospital doctors 4.46 million patients are now waiting for NHS He said that most trusts were still in the UK. Earlier this month it was treatment to start. doing priority 2 procedures but that reported that one London trust was so Emergency care In December, 3745 patients for the time being they have stopped overstretched that it had to postpone waited 12 hours or more in emergency all priority 4 cases (elective treatments all “priority 2” surgery, such as cancers departments before being admitted, the highest that can be deferred for longer than and urgent cardiac surgery, which are number on record who waited this long and an three months) and most priority 3 deemed medically necessary to be increase of 60% on December 2019. cases (electives that need to be done done within 28 days. Cancer Between April and October around within three months). Fiona Donald, vice president of 3500 fewer patients than expected were given a Local clinical networks were the Royal College of Anaesthetists, diagnosis of bowel cancer in England. meeting every day to assess capacity told The BMJ, “London appears to Heart disease The number of heart operations and identify critical care beds be having the biggest pressure at the such as coronary bypass and heart valve surgery available, he added. moment. Some of the priority 2 surgery was around 25 000 between January and “If there is a bed, then they is having to be cancelled. In other November 2020, a decrease from 37 000 in the carefully weigh the demands of all the areas, that’s defi nitely not the case.” same period in 2019. cases on the book and say, ‘This one

132 30 January 2021 | the bmj Q&A How to feel safe working in a pandemic gets the green light and must go,’” Covid has presented doctors with legal and ethical challenges in Mortensen said. “It’s really tough, because it is like the judgment of treating patients. Clare Dyer examines some of the key questions Solomon sometimes, trying to decide between one and another. But on the If resources are Can I be required to work Childs and Stewart Duffy, whole, [staff ] have been very grown insufficient, who decides in a different specialty? partners in the law firm up about it and have been working on on patient priority, and how will NHS employers have been RadcliffesLeBrasseur, write getting those patients done.” the decision be taken? advised that implied terms that manslaughter charges In the short term, he said, some Many trusts have guidelines in an employee’s contract, could, in principle, be brought hospitals were being forced to or protocols to help such including the obligation for alleged failure to provide adapt treatment schedules for some decisions. Guidance is also to follow reasonable or continue treatment. But cancer patients while they await available from the BMA’s management instructions, they hope police will be a bed for surgery. For example, he ethics committee, NICE, can be relied on in a national mindful that, “in the heat of said oesophageal cancer now had and the Royal College of crisis to “encourage people to the most extraordinary public a schedule that includes upfront Physicians. The basic principle move into other roles where health emergency in living chemoradiotherapy before the is to use the resources these moves are necessary memory,” doctors will often operation. available to try to ensure the to reduce/remove the spread find themselves “in an almost greatest medical benefit for the of and treat covid-19.” The impossible position.” Use of the private sector greatest number of patients. law firm Capsticks advises Last April the NHS took the Decisions should not be that the availability of other Could I face GMC unprecedented step of block booking based purely on a patient’s staffing resources should misconduct charges over most private hospital capacity age, disability, or medical be considered in deciding my treatment decisions? in England so that cancelled or condition, says the BMA whether an instruction was The GMC’s guidance says postponed NHS treatment could guidance, although these reasonable, along with the it will take account of the continue. This gave the NHS breathing factors may be relevant if any individual’s current role, skills, current extremely challenging space, but the Treasury subsequently of them mean that the patient and expertise. circumstances. It will also raised concerns that it did not deliver is significantly less likely to The BMA advises that consider any guidelines value for money because capacity went survive the treatment. doctors and students should unused in some areas. work only within their area This time there is no national Could my trust face a of competence and should deal, although NHS trusts in some clinical negligence claim receive adequate training and areas—London, Nottingham, and if a resource is denied to one supervision. If pressured to Oxford, for example—have continued patient so it could be given to work outside their competence to seek help from the private sector another deemed to have a they are advised to contact the or protocols in place, the for services such as cancer treatment, better chance of survival? BMA for support. They should resources available, the Mortensen said. Doctors will not be found also tell their medical defence problems of working in He acknowledged that the private negligent if their actions meet organisation if they are unfamiliar areas of practice, sector had been a “safety valve for the standard of a responsible working in a different field. stress, and tiredness. Lock cancer” during the pandemic but said body of medical opinion. writes, “I cannot see any that in the longer term the government In one court case the judge Do doctors risk a gross legal basis for a doctor being needed to make a sustained accepted that doctors in negligence manslaughter held to be unfit by applying investment in NHS capacity to deal emergency departments investigation as a result of a the terms of a lawful NHS with the huge backlog in elective care, must make quick judgments decision to deny treatment? rationing policy.” with 4.5 million people currently on without being able to consult This fear was a major factor the waiting list. others. He confirmed that in prompting doctors’ I’m feeling anxious and “We have to have a plan for it,” he “the standard of care owed by organisations to write to overwhelmed. Where can said. “Business as usual is not going to an [accident and emergency] England’s health and social I get support? be enough.” doctor must be calibrated in a care secretary, Matt Hancock, A list of support organisations manner reflecting reality.” asking for new emergency is available on NHS Gareth Iacobucci , The BMJ Cite this as: BMJ 2021;372:n215 In a legal opinion this month laws to protect them from Resolution’s website David Lock QC argued that it “inappropriate” legal action. (bit.ly/39iipTL). Samaritans would be “exceptionally Hancock has said he doesn’t is operating a confidential difficult to establish that believe that this is necessary support line for NHS staff in doctors have acted negligently “at this point.” England and Wales on 0800 06 during this pandemic.” Lock, a Lock sees “no reasonable 96 222, from 7 am to 11 pm, member of the BMA ethics prospect” that a doctor would seven days a week, or by committee, added, “Only be prosecuted for medical texting FRONTLINE to 85258 at when blatant and egregious manslaughter for following any time. errors have occurred should an NHS organisation’s clear Clare Dyer, The BMJ doctors be concerned.” prioritisation policy. William Cite this as: BMJ 2021;372:n179 the bmj | 30 January 2021 133 THE BIG PICTURE “We must learn the lessons of this dark death toll”

This week the number of people in the UK who have died with covid- 19 passed 100 000. To mark the awful milestone the BMA projected a message of condolence and commemoration onto its building in Tavistock Square, London. As the message was displayed, Chaand Nagpaul, the BMA’s chair of council, said, “We must not and will not forget this day. Among those who have died are many health and care workers who lost their lives in the course of doing their jobs. We know that some of those staff were not properly protected from the virus and yet felt under pressure to continue to work and do their duty by their patients. “As the fi rst nation in Europe to have reached this dark death toll, we must learn the lessons of this tragedy. “Now is the time to express our immense sadness at these deaths, to remember the lives they led and the good they did, and to redouble our commitment to reducing the spread of infection, vaccinating the population, and protecting one another from this deadly disease.” Alison Shepherd, The BMJ Cite this as: BMJ 2021;372:n237

134 30 January 2021 | the bmj the bmj

| 30 January 2021 135

BMA EDITORIAL therefore, the goal is to identify evidence of possible problems with brain health and act to reduce their Sport associated dementia consequences. Prevention remains the only cure Knowledge regarding the mid-life onset of neurodegenerative disease has been accumulating over the ecent media reports past decade14 through programmes of high profi le former such as Prevent Dementia15 and the soccer and rugby European Prevention of Alzheimer’s players with diagnoses Dementia programme.16 Specialist Rof neurodegenerative brain health clinics provide detailed disease have raised concerns about risk profi ling, detect early disease, the dangers of contact sports and and develop personalised prevention led to threats of litigation against plans.18 19 This approach provides an sports organisations over perceived ideal pathway for former athletes to failures in duty of care.1 2 But are obtain independent specialist review concerns that brain health is aff ected and advice. by participation in contact sports Consensus criteria for diagnosis of justifi ed and, if so, what might be chronic traumatic encephalopathy done to mitigate risk? are yet to be established. Traumatic brain injury is a leading While eff orts to recognise chronic risk factor for neurodegenerative traumatic encephalopathy better are disease, contributing to 3-15% welcome, other neurodegenerative of cases of dementia in the diagnoses associated with contact community.3 4 A link between sport participation, including traumatic brain injury in contact Alzheimer’s disease and motor sport and neurodegenerative disease neuron disease, must not be was fi rst proposed almost a century overlooked in former athletes. ago with descriptions of punch drunk syndrome among boxers,5 Risk profile and the associated pathology The goals in later life are to was later defi ned as dementia recognise that sport may be pugilistica.6 In the past 20 years, implicated in an individual’s however, the pathology of dementia a clear understanding of the Every effort risk profi le, to record all cases of pugilistica—now termed chronic consequences of traumatic brain should be neurodegenerative disease in former traumatic encephalopathy—has injury for brain health, which made to reduce athletes for surveillance purposes, been increasingly recognised in might be considered in three exposure to and to engage patients and their athletes playing other contact broad life periods: early life (while families in research towards head impacts sports, including football,7 rugby, 8 participating in sport and exposed to understanding the infl uence of sport and American football,9 and among injury); mid-life (retired from sport during early life on lifelong brain health, including others with traumatic brain injury and no longer exposed to injury); autopsy studies. unrelated to sport. 10 and late life (when symptoms might Current evidence supports an Chronic traumatic emerge). association between elite level encephalopathy is now widely To date, traumatic brain injury participation in contact sports and acknowledged to be associated remains the only known risk factor increased risk of neurodegenerative with a history of traumatic brain for neurodegenerative disease disease, which, on balance of injury or exposure to repetitive head associated with contact sports. probabilities, is a consequence of impacts. 10 11 Furthermore, mortality Therefore, adopting a precautionary exposure to repeated head impacts. from neurodegenerative disease principle, every eff ort should be In the coming years, whether sports is higher than expected among made to reduce exposure to head organisations acted appropriately former professional footballers impacts during early life, and William Stewart, to protect athletes’ brain health and American football players. 12 13 to better identify and manage consultant will be tested in the courts. In the neuropathologist , Autopsy studies on former athletes traumatic brain injury in all sports. meantime, the question for them to Institute of with dementia showed most had consider in 2021 is whether current Neuroscience neurodegenerative pathology Cumulative injury and Psychology, policies are good enough to reduce typical of chronic traumatic Retired athletes have already been University of risk of harm for today’s athletes. 7-9 encephalopathy. exposed to the cumulative eff ects Glasgow Cite this as: BMJ 2021;372:n168 Addressing neurodegenerative of traumatic brain injury and william.stewart@ Find the full version with references at disease linked to sport requires repetitive head impacts. In mid-life, glasgow.ac.uk http://dx.doi.org/10.1136/bmj.n168

136 30 January 2021 | the bmj EDITORIAL Covid-19: Supporting se lf-isolation is critical Government action needed now to reduce infections and death

ocioeconomically Lost wages are person households to be infected.5 support. A test-and-care model disadvantaged and the primary Furthermore, crowded households in San Francisco, US, addressed many ethnic minority reason for are often multigenerational family many of the logistical and fi nancial groups have been not following groups, including people in barriers to self-isolation faced by disproportionately high exposure occupations and socioeconomically vulnerable S isolation 5 8 13 aff ected by covid-19, with increased vulnerable older people. populations through provision risk of infection, hospital admission, guidelines The highest covid-19 mortality of information about community and death.5 - 8 has been observed in facility based resources, home deliveries of material Despite the vaccine rollout, outbreaks, including in long term goods (groceries, personal protective many younger people, particularly care facilities, retirement homes, equipment, and cleaning supplies), those working in high exposure and homeless shelters.1 14 15 Staff and clinical and social support for occupations, living in overcrowded in long term care and similar people with positive results. 17 housing, or without a home will occupations are low paid, often on A similar scheme in New York City remain subject to an ongoing burden zero hours contracts, and typically off ers people with positive results a of quarantine orders, along with a share the prevalence patterns of the menu of supportive services to help disproportionate risk of infection communities at greatest risk of covid.15 them quarantine either at home or in 18 and onward transmission for the Muge Cevik, clinical Since the landmark principles of a free hotel accommodation. Vermont foreseeable future.1 5 9 An equitable lecturer, University population screening test were fi rst set designed a response with the needs and eff ective public health response of St Andrews, out by Wilson and Jungner in 1968, it of high risk groups in mind and has requires the integration of supportive St Andrews has been accepted that the usefulness generally had low community spread services to decrease their contact rates mc349@ of screening tests is determined by the compared with other US states. Its and subsequently risk of infection.9 st-andrews.ac.uk eff ectiveness of the intervention they community and public health led Most countries have used testing as Stefan D Baral, trigger.16 What interventions can justify scheme includes protection from a tool to interrupt transmission chains associate professor, covid-19 screening tests, given the eviction, state supported housing for Johns Hopkins by encouraging isolation of contacts. barriers to self-isolation faced by those homeless people, hazard pay, meal School of Public However, the ability to quarantine at highest risk of a positive result? deliveries, and free pop-up testing Health, Baltimore until test results are available, and to in high risk communities.19 These Alex Crozier, isolate if positive, depends on people research scientist, Successful models interventions have led to high rates having the space and resources to do University College Several well described models have of test uptake, number of contacts 10 so. Survey data from the UK suggest London been shown to enhance compliance identifi ed, and adherence to self- that less than one in fi ve people are Jackie A Cassell, with quarantine and isolation. isolation, contributing to reducing 11 able to adhere to isolation protocols. professor, Brighton Fundamental components include total household and community Notably, lower rates of adherence have and Sussex Medical ensuring fi nancial security and transmission.10 been reported among men, younger School, Brighton compensation as well as practical As vaccines are rolled out, even people, key workers, those living small improvements in people’s with dependent children, and those ability to quarantine and isolate can in lower socioeconomic groups. 11 have an important eff ect on slowing Although willingness to self-isolate transmission, hospital admission, was high across all respondents, and death, especially among those the self-reported ability to isolate most at risk of covid-19.10 20 was three times lower among those Ultimately, people need to be able earning less than £20 000 a year or to isolate without fear of substantial who had less than £100 saved.12 Lost damage to their work, income, family, wages are the primary reason for not or caring responsibilities. We can’t following isolation guidelines.10 wait for vaccine mediated decreases in The risk of household transmission morbidity and mortality to manifest. within crowded and otherwise Integrating equitable support services inadequate housing intersects with for those most at risk for covid-19 is a fi nancial barriers to isolation and national emergency and governments inability to work from home. Offi ce should act accordingly. for National Statistics data show Cite this as: BMJ 2021;372:n224 those living in six person households Find the full version with references at were three times more likely than two http://dx.doi.org/10.1136/bmj. n224 the bmj | 30 January 2021 137 CORONAVIRUS IN THE UK Being a doctor in the House during covid MPs with medical training have been in a unique position to shape health policy over the past year. Five tell Tom Moberly how the pandemic has infl uenced their discussions with constituents and colleagues

Doctors in or the 10 members of the to wind down she received a lot his medical background. “I’ve had parliament current UK parliament of “distressed” messages from parliamentary colleagues come to have been with medical training, people being made redundant. She me and ask what I think about tier 3 deciphering knowing what life is like continues to face daily queries about restrictions being imposed on their press F in hospitals and surgeries the latest guidance. constituency, for instance, and I do briefings, during the pandemic, as well as Luke Evans, Conservative MP for my best to give a balanced opinion. explaining the policy landscape that’s key to Bosworth and a GP, says he gets a lot “But opinions are only as good as helping it, has been eye opening and of emails about lockdown—whether the data and evidence on which they restrictions, exhausting. it should be tighter, or in place at are based—and, because it is such a and digging “Because I’m a doctor, often all—“and they’re in equal measure rapidly changing picture, and there into the people will come to me,” says on either side” he says. are new data every day, it is not evidence Philippa Whitford, Scottish National “People will quote statistics and always easy,” he says. Party MP for Central Ayrshire and conspiracy theories,” says James “I’ve had to do a lot of digging, a breast surgeon. Even though Davies, Conservative MP for Vale using my scientifi c background, to health is devolved to the Scottish of Clwyd and a GP. “The number try to get to the bottom of what’s parliament, constituents still direct of conspiracy theories is vast. It’s going on. For instance, when there’s queries to her. Her team saw a sharp pretty wearing. If you want to be been a rise in the number of cases, rise from around 150 emails a day to thorough and try to get the scientifi c what is the underlying reason for 500 at the start of the pandemic. perspective across, it can be very that, what settings are involved, and Many are from constituents frustrating.” so forth.” wanting her to explain aspects of Rosena Allin-Khan, Labour MP for the pandemic and the response. Helping to follow the science Tooting and an emergency medicine The initial surge became more The feeling that you have to doctor, says she’s been asked a lot manageable after the fi rst lockdown “respond in a scientifi c way, about immunity, particularly at the started “when everyone knew in a way that other colleagues beginning of the pandemic. “I would the rules and knew what was aren’t perhaps able to do,” and also often be asked to decipher happening,” says Whitford. But to a population polarised on the some of the things that were spoken once the furlough scheme started response to the pandemic, has put about at the press briefi ngs, as well the MPs who have had medical as receiving various thoughts and training in a privileged, if diffi cult, opinions on the vaccines,” she says. ONE MP saw a rise from around position, says Davies. “There was a lot of discussion 150 500 And it’s not just constituents. about at one point— emails a day to Davies says he has also been questions about what I’d seen, at the start of the pandemic approached by fellow MPs aware of what I thought. I’ve had a lot of

The initial surge became more I’ve done enough statistics to It does help to have people in manageable when everyone ask experts—the Whittys and the Commons who are able to knew the rules and knew what Van Tams—to go through more make the case about what the was happening than they might normally clinical reality is Dan Poulter, Tory Philippa Whitford, SNP and surgeon Luke Evans, Tory and GP and mental health doctor

138 30 January 2021 | the bmj questions about vitamin D, too, and ensuring that restrictions are are practical things that will make obviously some of the conspiracy suffi cient to control the virus—but a diff erence. I know that, if my theories.” also that they’re legitimate and political career ended tomorrow, Evans says that being able to not overzealous,” he says. “That I’ve achieved X, Y, and Z, and that’s “speak the language” has also requires the right questioning to really fulfi lling,” he says. allowed him to seek more detailed determine why certain measures He cites syringe drivers in care answers for himself. “I’m by no have been selected and whether homes as one matter he has been means a statistician, but I’ve done they’re based on valid evidence.” able to fl ag. “I was worried that enough statistics to be able to everyone was talking about getting understand confi dence intervals Value of expertise ventilators, but not many were and the validity of data, and For Dan Poulter, Conservative MP thinking about the care sector and sensitivity and specifi city, and for Central Suff olk and North people whose ceiling of treatment where we’re likely to go,” he says. Ipswich and a mental health doctor, means they were never going “It allows you to ask the experts— the pandemic has underscored into hospital. The government the Whittys and Van Tams of this the value of having people with responded and did a review and we world—to go through more than they clinical experience in parliament. got the law temporarily changed might normally be asked about.” “When you see things that the on morphine prescribing. Davies sees digging into the data government are doing, some of “It’s a bit like in general as an important part of his role as which are positive and some where practice when you get a patient one of the doctors in parliament. there have been mistakes, it does who understands that their “I feel a duty as someone who has help to have people in the House cholesterol is high and they are a medical background to question of Commons who are able to make borderline diabetic, and they what’s being done in terms of the case about what the clinical take all the dietary advice, go reality is.” to the gym, and come back and Allin-Khan says she has their risk factors have dropped frequently been asked whether signifi cantly,” he says. her clinical experience refl ects “You get that reward of knowing what they have been hearing from that someone’s listened to what you elsewhere about matters such as said and taken it on board and that personal protective equipment, they’re going to benefi t.” the mental health of NHS and care Tom Moberly, UK editor, The BMJ workers, and the disproportionate Cite this as: BMJ 2021;372:n185 eff ect of the pandemic on ethnic minority communities. There was a lot of discussion about Evans believes that covid-19 long covid at one point—questions The number of conspiracy has made the role of doctors in theories is vast. It’s pretty parliament particularly important, about what I’d seen, what I wearing to try to get the as they have been able to bring thought. I’ve had a lot of questions scientific perspective across their experience to bear in the about vitamin D Rosena Allin-Khan, James Davies, Tory and GP response to the pandemic. “There Labour and A&E doctor the bmj | 30 January 2021 139 ESSAY mindset helps explain the platforms’ tepid responses to health misinformation. Before covid-19 social media companies Too little, too late: the real had taken a hands-off approach, at least until 2016 when the Brexit referendum, along with threat of failing to tackle elections in the Philippines and US, woke them up to political disinformation. And until recently they had done next to nothing to vaccine misinformation combat health misinformation. To experts, this oversight was especially worrying. As the world looks to covid-19 vaccines with hope, there are major This approach changed in 2018 when a fears about how anti-vaxx posts on social media will aff ect uptake. series of measles outbreaks in the US seemed to be fuelled by vaccine misinformation. Claire Wardle and Eric Singerman ask what platforms need to do This was certainly not the fi rst time that misinformation potentially aff ected a public anuary 2021 will be remembered else had this happen after there [sic] 6 week health crisis, but because this took place in for the “great deplatforming”, vaccinations?” Should this post be removed America, home of Facebook, Google, Twitter, when many technology companies or labelled as potentially misleading? Should and others, it got their attention. took actions against the then US it have a link to a vaccine information centre? For the most part, their fi rst steps were J president and those who took Should it be demoted so fewer people see it? limited. Relying on counter speech, Facebook part in or supported the insurrection. In These questions grow more urgent. Global and Twitter added educational pop-ups contrast, as misinformation proliferates immunisation levels against diseases such as for users searching for vaccine content. around the rollout of the covid-19 vaccines, measles remain high, but an increasing, loud And focusing on content that might cause there is loud criticism that the major social minority of people are more reluctant to take “real world harm,” they changed their media platforms are not doing enough to vaccines and less willing to listen to scientifi c recommendation algorithms to suppress false deal with vaccine misinformation. institutions. It’s hard to pin down the causal statements. Some went further—Pinterest Notably, in late autumn the platforms links between misinformation, vaccines, limited the results of any search for “vaccines” stated they would take more action against and trust but the eff ects to offi cial sources such false and misleading information about the of misinformation should as the World Health vaccine. But the problem has certainly not not be dismissed. Organization. But social gone away because these policy updates do media remained breeding not cover many types of speech that have Definitions grounds for health the potential to lead to vaccine hesitancy. Disinformation and misinformation as the Take a mother’s recent post on a public misinformation are not world entered a pandemic. Facebook Group where people share the same. Deliberately It’s only now, as personal experiences of vaccinations, “Prior creating or sharing false or misleading pressure on the companies from governments, to her 6 week vaccinations, my daughter content, with the intent to cause harm, is scientists, doctors, and the public hits was perfectly fi ne,” but, she lamented, “she disinformation. To do so unwittingly with breaking point, that policies changed. was having major seizures...has anyone no harmful intent, is misinformation. They Facebook, Twitter, and YouTube all took a both include outright lies and imposter more assertive and expansive view of “harm.” BIOGRAPHIES news outlets, but also more benign content Facebook, for example, targets “false claims Claire Wardle is a leading expert on user like misleading headlines or even satire. about the safety, effi cacy, ingredients, or side generated content, verification, and People spread disinformation for all kinds eff ects of vaccines.” Previously these types of misinformation. She is co-founder and US of reasons: fi nancial gain, power, or just for claims would have been fl agged and demoted director of First Draft, the world’s foremost fun. They spread misinformation to connect in newsfeeds. Now, they are being removed. non-profit organisation focused on research with communities, to test out ideas, and to The new policies also target misleading and practice to tackle misinformation showcase their beliefs and identities online. claims and those designed to spread and disinformation. Previously, she was a The fact that virtually all of this is legal confusion, by adding labels and demoting research fellow at the Shorenstein Center compounds the problem. Most discussions them. Repeat off enders could have their for Media, Politics, and Public Policy and research director at the Tow Center for about misinformation and disinformation, accounts disabled, sometimes permanently. Digital Journalism at Columbia Journalism not to mention company policies, start with School. She has worked with newsrooms freedom of speech. Aside from terrorist Consensus and responsibility and humanitarian organisations around the and child abuse content, this approach is Despite this stronger stance, the networks are world, providing training and consultancy founded on the idea that counter speech, still uncomfortable accepting responsibility. on digital transformation. She earned a PhD not censorship, is the best way to deal They are not, they claim, “arbiters of truth,” in communications and an MA in political with falsehoods. It avoids penalising but merely providers of a platform. They fall science from the University of Pennsylvania. harmful speech until its harms are clear back on health organisations to determine Eric Singerman is a research assistant and and imminent. And it struggles to realise what counts as false, misleading, or confusing, policy adviser at First Draft. He is currently a that not all legal speech deserves the same whether it’s international bodies such as WHO law student at the University of Chicago. “freedom of reach” on the internet. This or national bodies such as the NHS.

140 30 January 2021 | the bmj vaccination, or one blogpost claiming that to undermine the institutions, companies, vaccines cause autism would have limited and people managing the rollout. They impact individually. But together, they form will be posting vaccine injury stories and a deeper story that erodes trust and pushes providing fi rst person videos detailing side people to question the safety of vaccines. eff ects that are diffi cult to factcheck. And, Unfortunately, you can’t just factcheck, when well meaning local radio stations ask People spread disinformation label, or remove a narrative. They shape and on Facebook, “Will you be getting the covid for all kinds of reasons: financial sometimes dangerously warp how we make vaccine?” the comments will be fl ooded gain, power, or just for fun sense of the world. No matter how companies with conspiracy ideas and suggestions. react, their policies will come up short. On The question for the companies is The decision to rely on expert the one hand, even the most clearly written whether they’re prepared to tackle this, organisations makes sense in principle, policies have fl aws. Bad actors spreading even if such posts don’t break current but in practice matters aren’t so simple. For disinformation will fi nd loopholes, like those guidelines. This will sit uneasily with one, scientifi c consensus struggles to keep who posted websites that had been removed, people who recognise that changing pace with misinformation. Last summer, by using new, seemingly harmless, links policies during a public health emergency while health agencies fl ip fl opped on from the Internet Archive. And benign, well could lead to a slippery slope that ends guidance concerning masks and airborne intentioned posts will get up curtailing freedom of transmission misinformation was allowed caught in the net, like the speech. What’s required to fester. It became increasingly clear that iconic “napalm girl” photos is more innovative, agile health and political misinformation are hard from the Vietnam war that responses that go beyond to tease apart. Anti-quarantine and anti- were removed for violating a the simple questions of mask groups on Facebook used political ban on nudity. whether to remove, demote, arguments to evade the censure of expert On the other hand, more or label. We need responses agreement on science. Making matters malleable policies are that acknowledge the worse, disinformation campaigns targeted criticised for putting too complexity of defi ning long trusted scientifi c institutions. much discretion in the hands misinformation, of relying Like scientifi c consensus, it’s hard to fi nd of the companies. When on scientifi c consensus, and consensus on what counts as misinformation. they instituted a ban on “hate speech,” for of acknowledging the power of narratives. Consider a recent article in the Spectator , with example, critics were left wondering what, Unfortunately, we don’t have time to design the headline “Landmark Danish study fi nds exactly, had been banned. The history of them. So while we implore the platforms to no signifi cant eff ect for facemask wearers.” content moderation is one of grappling with take a more active role, it is us, those who To much fanfare, the article was labelled policies that are either clear but infl exible or use social media, who need to start taking misinformation and removed from Facebook. adaptable but too vague and discretionary. responsibility for our posting and sharing. As Kamran Abbasi, The BMJ’s executive Let’s hope that by the next pandemic, editor, pointed out, the study in question It’s up to all of us these challenges will have been tackled in didn’t damn mask wearing so much as reach As we enter 2021 and covid-19 vaccines ways that don’t leave us as vulnerable to inconclusive results. Nor did it discuss, much are at last rolled out, misinformation is disinformation and misinformation as we less question, viral spread among mask undoubtedly going to pose a serious barrier do today. wearers. Abbasi deemed the Spectator article to uptake. The social media companies are Claire Wardle, co-founder and US director symptomatic of a “disagreement among at least showing a willingness to intervene. [email protected] experts” that came down to interpretation of But people wishing to undermine trust in the Eric Singerman, research assistant and policy adviser, the study, and he criticised its removal. vaccine won’t be using outright lies. Instead, First Draft If misinformation were only a problem of they will be leading campaigns designed Cite this as: BMJ 2021;372:n26 falsehoods, this case would be simpler. But misinformation includes well intentioned but misleading headlines. Whether or not the Spectator article off ered a reasonable interpretation of the study, the question of whether its headline misled remains. Focusing on fabricated content and demonstrably false claims misses a diverse range of content that is much harder to defi ne and deal with. Often, focusing on individual examples turns into a pointless game of whack-a-mole. We will never be able to fi nd, let alone tackle, all misinformation and disinformation. In the meantime, individual posts build larger, more problematic narratives. One photo depicting a soldier administering a vaccine, one tweet about a low grade fever after the bmj | 30 January 2021 141 BRIEFING What we know about covid-19 reinfection so far

W ith most coronaviruses, recovery confers a degree of immunity, but a small number of patients have caught covid for a second time.

Chris Stokel-Walker asks why and should we be concerned SILVA/DPA/PA LUCAS

ther things being equal, infections, although some have been more He points out that coronaviruses give long we can expect to see—even harmful, with at least two deaths. infections and their large genomic structures without this new variant— “Almost certainly, immunity from a mild can cause them to remain in the body at low repeat infections by about infection doesn’t last as long,” says Hunter. enough levels to remain undetected, ready “ O now,” says Paul Hunter, “But on balance, most second infections are to strike again. “They could last longer in professor in medicine at the University of going to be less severe because of a degree of diff erent parts of the body than respiratory East Anglia. immune memory and T cell mediation.” areas,” he says, citing persistent loss of smell There are four endemic coronaviruses that But Mossong says that, in his experience and taste as possible evidence that the virus circulate through humans, causing most with coronaviruses, those who experience can remain for a long time. respiratory tract infections. Infection with the mildest symptoms in their initial infection any of them can lead to immunity of diff ering have a higher likelihood of reinfection, What do the new variants mean for reinfection? lengths, typically a year or two, says Joël perhaps because they didn’t develop an SARS-CoV-2 variant B.1.1.7, fi rst identifi ed Mossong, head of and microbial immune response the fi rst time. The same in the UK, has been shown to be more genomics at the Luxembourg National Health goes for those who are immunosuppressed transmissible than previous variants. But Authority. “You do get reinfected eventually, and therefore would not have mounted an whether those who have already recovered but not every year,” he adds. immune response to the fi rst infection either. from the virus are at risk is another unknown. But SARS-CoV-2 is a new coronavirus and But what those people experience could be “I don’t know how likely that is to increase immunity is one of its biggest unknowns. less a reinfection, and more a reactivation of the chance of reinfections,” Hunter says. The Of 11 000 healthcare workers who had pre-existing covid-19 within the body, says increase in the number of infections from the evidence of infection during the fi rst spring Mossong. That’s far more diffi cult to ascertain. new strain will make reinfections more likely wave of the pandemic in the UK, none had but he hopes they will be less virulent. symptomatic reinfection in the second wave. Reinfection or reactivation? Yet the emergence of a new variant, P.1, As a result, researchers are confi dent that To diff erentiate between what is a may throw that into question. A pre-print immunity lasts at least six months. reinfection and what is an already extant paper tracking the likelihood of being infected Worldwide, 31 confi rmed cases of coronavirus refi ring the immune response with P.1, which emerged in Manaus, Brazil, reinfection have been recorded. “We is diffi cult because of sampling. It’s only late last year, indicates it “eludes the human know that reinfections can happen,” says understandable if patients give samples of immune response” triggered by previous Ashleigh Tuite, assistant professor at the both the second and fi rst infections to be variants. Reinfection is therefore likely. University of Toronto’s Dalla Lana School sequenced genetically. The virus genomes “The question is how much genetic drift of Public Health. “The bigger question is: from each sample would have to be diff erent or change can happen in the virus, such if reinfections are going to happen, how for it to be a reinfection. Most reported that your immune system doesn’t frequently are they happening?” “With a genetic sequence, you can reinfections recognise it any more,” says Tuite, With focus on vaccine rollout and tracking see whether it was the same variant,” have been who spoke before the P.1 variant variants, little work is being done to fi nd out. says Melvin Sanicas, a vaccinologist emerged. Vaccine manufacturers “If they’re happening a lot, but are less severe, and member of the Royal Society milder than have said their vaccines will be we’re not going to see them unless we design a of Tropical Medicine and Hygiene. first infections eff ective against B.1.1.7, which, says study to fi gure that out,” says Tuite. Published papers have examined reinfections Tuite, suggests it hasn’t changed enough to in Hong Kong using such methods. “There make people more prone to reinfection. Is disease from reinfection more severe? was good evidence to show it wasn’t the For now, the message is clear: “If you’ve Since the 1960s, scientists have known same,” Sanicas adds. recovered from SARS-CoV-2, it’s not an excuse that when some patients are infected with a But sequencing of this order is diffi cult, to forget about and not to virus for a second time, antibodies created to particularly currently. “Even in the UK, wear a mask,” says Sanicas. “We know that fend off the disease in the fi rst instance can which conducts sequencing of samples more you can have it twice.” And that means you compound its eff ectiveness on reinfection— regularly than most countries, only about can get it again and pass it on. known as antibody dependent enhancement. 5-10% are sequenced,” says Mossong. “For Chris Stokel-Walker freelance journalist, Newcastle- To date, most of the reported SARS-CoV-2 that to occur twice, for samples from the same upon-Tyne [email protected] reinfections have been milder than fi rst patient, the odds get smaller and smaller.” Cite this as: BMJ 2021;372:n99

142 30 January 2021 | the bmj