With the approach of Fall and Winter, it is esssential for the more vulnerable to take precautions against COVID-19. As well as masking and hygene measures, there are two steps which will help in the coming months: your annual flu innoculation and ensuring you have adequate levels of Vitamin D. You should also address any co-morbidities that you may have. These will not stop you being infected by the SARS-CoV-2 virus but should ensure a less serious outcome if you are.
ANNUAL FLU VACCINE
This year more than ever it is essential to get a flu vaccination if you are in a vulnerable group or are in close contact with someone who is — another person in your household or your work brings you into contact. Protect yourself and protect others. Having both flu and COVID-19 around the same time will put a severe strain on both patient and the healthcare system.
In the UK, supplies are now being delivered. On Wednesday I got an SMS message from my GP about their session for over-65 year olds so I booked my slot for today at 11.39 to 11.42 on the NHS app. Rather than the normal layout, they had opened a side door as the entry/reception and the normal waiting room was divided so two people could be accommodated, with exit by the main doors. This worked remarkably well with the reception desk doing the checks (No, I am not allergic to eggs, no I do not have a temperature, yes I have had it before and the only side-effect was “a bit of a sore arm”.) It was then down the corridor, flash upper arm, inject and go. The whole thing took rather less than the 3 minutes and a lot less hassle than normal. All the staff and patients were suitably masked etc.
VITAMIN D
There is increasing evidence that Vitamin D deficiency is associated with higher incidence of COVID-19 or more serious symptoms. A retrospective study by the University of Chicago Medicine published this week showed:
"Vitamin D is important to the function of the immune system and vitamin D supplements have previously been shown to lower the risk of viral respiratory tract infections," said David Meltzer, MD, PhD, Chief of Hospital Medicine at UChicago Medicine and lead author of the study. "Our statistical analysis suggests this may be true for the COVID-19 infection."
The research team looked at 489 UChicago Medicine patients whose vitamin D level was measured within a year before being tested for COVID-19. Patients who had vitamin D deficiency (< 20ng/ml) that was not treated were almost twice as likely to test positive for the COVID-19 coronavirus compared to patients who had sufficient levels of the vitamin.
It is important to note that Vitamin D is not recommended as a treatment for COVID-19 but that deficiency will compromise the body’s immune system. The extent is rather dramatically shown in the Daily Mail graphic showing the results of a July study on patients in Indonesia. The vitamin is produced in the skin under UV exposure as well as being available from food and supplements. The incidence of deficiency is particularly prevalent in groups with naturally darker skin (in the US mainly African- and Hispanic-Americans; in the UK mainly people of African, Afro-Carribbean and South Asian descent.) The Chicago study notes.
Half of Americans are deficient in Vitamin D, with much higher rates seen in African Americans, Hispanics and individuals living in areas like Chicago where it is difficult to get enough sun exposure in winter.
These ethnic minority groups also tend to be in worse socio-economic positions with poor or crowded housing, often in multi-generational households. They also tend to work in jobs with considerable contact with the public. Guess which ethnic groups have been worst affected in both countries!
Exposure to sunlight is important. It is easy for Americans to forget that the whole of the UK is North of the contiguous US states. London is on the same latitude as the south of Hudson Bay. Lockdown has made the position worse and the UK government advisory institute, NICE, advises:
To protect bone and muscle health, the UK Government advises that everyone needs vitamin D equivalent to an average daily intake of 10 micrograms (400 international units). They advise that all people should consider taking a daily supplement containing 10 micrograms vitamin D during autumn and winter months. They also advise that people whose skin has little to no exposure to sunlight and ethnic minority groups with dark skin, from African, Afro-Caribbean and South Asian backgrounds, should consider taking a vitamin D supplement all year round. This advice would also apply to people whose skin has little to no exposure to sunlight because they are indoors shielding or self-isolating. Therefore, UK Government advice during the COVID‑19 pandemic is that everyone should consider taking 10 micrograms of vitamin D a day because they might not be getting enough from sunlight if they're indoors most of the day.
Please note: There is no need to buy dubious food supplements from the My Pillow Guy for$$$$$. Cheap generic Vitamin D tablets are usually available at pharmacies or even supermarkets (I get mine from Lidl.)
OTHER MEASURES
The UK government has an interest in reducing health costs because most healthcare is provided by the NHS. For that reason, they also spend on programmes that will be cost-beneficial in the long term. Promoting wellness is now an important part of its work in both medical and financial terms.
Existing conditions like obesity and diabetes are known to be extra risks for those with COVID-19 so the government has brought forward some projects that address these factors. The idea is to make general improvements to the nation’s health in preparation for an expected Fall/Winter spike. Most but not all are delivered by the NHS but I include these as examples. The NHS also has some excellent on-line resources which you might like to use.
Weight and General Fitness
The UK had several months of lockdown starting at the end of March when all but essential workers were required to stay at home, apart from essential shopping or for an hour’s exercise a day. Phased reopening is still not complete and COVID-safe measures have to be in place. Live performances of plays and music with social distancing for both audience and performers are starting up. Sporting events are taking place without spectators. Face coverings are compulsory unless eating or drinking in enclosed public spaces and on public transport (although not adequately policed!!).
As you can imagine, the lockdown measure caused some deterioration to the population’s general health. To counter the effects of this, the NHS introduced its “Better Health” project in early August
The scheme includes a “Kickstart” app to loose weight and become more active over a 12 week period.
With the need for social distancing on public transport limiting its capacity, the government sought to promote alternatives. One is cycling which, like some other facilities previously like swimming, GP’s will be able to “prescribe” for improved fitness. To aid transport, extra emergency bike lanes have been set up and vouchers issued to help people refurbish disused bikes. More walking is also being encouraged by widening sidewalks.
Type 2 Diabetes
People with type 2 diabetes are twice as likely to die from COVID-19. It costs the NHS over $13 billion a year and accounts for around 5% of prescriptions issued by GPs. (Insulin and other supplies like test strips are free with some patients now getting continuous monitoring devices). Type 2 diabetes is also common in older members of the ethnic minorities most at risk.
Support is already provided but from September 1, NHS England is rolling out a further trial of a regimen that has been shown to help patients and almost half have gone into remission.
The year-long plans will see those who could benefit provided with ‘total diet replacement products’, such as shakes and soups, for three months, alongside support to increase their exercise levels.
To help people maintain a healthy lifestyle and avoid complications linked to obesity patients will also be offered managed plans for reintroducing ordinary, nutritious food, with ongoing support from clinicians and coaches after that.
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The interventions will provide Total Diet Replacement products alongside virtual one-to-ones, group sessions and digital support.
A word of caution again. This regimen is not suitable for all type 2 diabetes patients and is carefully managed with support. Sudden weight loss may be injurious to your health so any plan should be supported by a properly qualified doctor or dietician.
Telemedicine
I alluded to one positive aspect of the NHS response to the coronavirus pandemic. The period has seen significant advances in telemedicine. In person consultations have been replaced by voice or video calls. When attendance is needed, this can be made more pleasant by tightly controlled appointments with fewer patients waiting to see a doctor. My only hassle was I had to buy my own digital sphygmomanometer to check my blood pressure (around $20!!)
NHS England already had a non-emergency helpline, NHS111 which is supplemented by an on-line symptom checker. The other nations have similar schemes. It now looks like 111 will be used to triage patients for accident and emergency departments.
Patients are being urged to call 111 before attending accident and emergency departments to help regulate the number of people in hospital waiting areas.
Under the new scheme, those in need of care for a serious but non-life threatening condition will be able to book an appointment at their nearest A&E to avoid a long wait at hospital.
The 111 First programme is intended to schedule slots at A&E to help maintain social distancing in hospitals, or direct patients to other services such as a GP or pharmacist.
I suspect this will be retained and extended after the pandemic. “Walk-in” attendances at A&E have halved during the crisis. Previously some city A&E departments has situations analagous to US ERs. Although primary care is provided by GPs, many young or mobile people tend not to register with them. This has led to them turning up at A&E will illnesses that could be dealt with elsewhere, rather like Americans without insurance. Many hospitals now have a “minor injuries unit” often mainly staffed by nurse-practioners who deal with sewing up cuts etc to take pressure off A&E. Some have 24/7 GP led units. The situation had become serious with many hospitals during busy periods breaching the 4 hour waiting limit target for patients with non-life-threatening illnesses. Having a triage system with pre-booked appointments would be a considerable benefit.
Of course not all of these initiatives are transferable to the US — I doubt if an insurance company would pay for a year-long diet and support plan if the patient could swan off to another company afterwards. I hope you are able to pick up a few ideas though. Telemedicine for example could provide a route to “medicare for all”.