Long-term conditions and severe acute respiratory syndrome SARS-CoV-2 (COVID-19)

On 31 December 2019, the World Health Organization (WHO) China office was notified of cases of pneumonia of unknown aetiology originating in Wuhan, Hubei Province of China (WHO, 2020a). A previously unknown virus was identified in infected individuals, who presented with severe acute respiratory symptoms. The virus was named severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), and the condition it causes is designated COVID-19. The virus belongs to a large family of enveloped RNA viruses. This is the seventh member of the coronavirus family that is known to be caused by a zoonotic transmission from animals into humans. The initial outbreak was traced to a live animal market in Wuhan. The origin of the virus is assumed to be from an animal, but the exact mode of transmission to man is unknown (British Medical Journal, 2020).

The virus is similar to SARS-like coronaviruses transmitted from bats, but it is distinct from the severe respiratory syndrome coronavirus (SARS-CoV) and Middle East respiratory coronavirus (MERS-CoV), which caused epidemics earlier this century (Zhu et al, 2020). The transmission mode of SARS-CoV-2 is thought to be person-to-person, through respiratory droplets and physical contact (Public Health England (PHE), 2020).

Morbidity and mortality

In early April 2020, the number of confirmed cases in this pandemic was well over 1 million people worldwide, and this figure is continuing to rise on a daily basis (Johns Hopkins University and Medicine, 2020). The observed case-fatality ratio in the UK was 10.7% at the time of writing (7 April 2020).

A number of factors require further consideration when interpreting this figure. Widespread testing has not been available in the UK, as a decision was made to test only individuals who were already seriously ill and receiving care in acute hospital settings as a priority (Department of Health and Social Care (DHSC), 2020). More widespread testing of patients with mild disease who subsequently recover would naturally lower the UK case-fatality ratio. A further consideration when interpreting UK mortality figures reporting is that deaths usually attributed to other causes in a hospital setting testing positive for the virus will be attributed to COVID-19, although the viral disease may not be the main cause of death (British Medical Journal, 2020). Conversely, patients being cared for in a community setting who have not been tested for the virus but have died with respiratory symptoms that resemble viral pneumonia will be excluded from reporting figures (DHSC, 2020).

A retrospective case study report from China of 138 patients who were admitted into hospital in January 2020 with laboratory-confirmed COVID-19 explored patient characteristics and the risk of adverse outcomes (Wang et al, 2020). The research findings identified that critically ill patients requiring intensive care were older and had underlying health conditions. Higher rates of mortality from complications associated with the effects of the virus on the body were also reported in these ‘at-risk’ groups (Wang et al, 2020).

Complications of COVID-19

Any patient who presents with a fever and/or acute respiratory symptoms, such as breathlessness and a dry cough, and who has been in contact with the virus within the previous 14 days should alert visiting community nurses that they may be infected with COVID-19. Box 1 highlights the most common symptoms associated with the onset of the infection.

Box 1.Common symptoms of COVID-19

The WHO recommends standard universal precautions, including offering the patient a face mask to wear if this can be tolerated. The guidance regarding the use of personal protective equipment (PPE) by community nurses recommends that, in households with a member who requires shielding, single-use plastic aprons and gloves and a fluid-resistant surgical mask should be used. In households with any member who is suspected or confirmed to have COVID-19, the PPE remains the same, with an additional requirement for a risk assessment to consider whether eye and face protection should be used (PHE and DHSC, 2020). Hand and respiratory hygiene should be maintained, and any PPE must be used within clinical practice in line with available guidelines (WHO, 2020b). Any patient with suspected COVID-19 should be isolated, and, if the person tests positive to the virus, this is a notifiable condition (DHSC, 2020).

Yang et al (2020) undertook a retrospective cohort study of 52 critically ill adult patients with SARS-CoV-2 pneumonia who were admitted to an intensive care unit in China. A main outcome measure was studying the differences in survivors and non-survivor characteristics at 28 days. Secondary outcome measures included the incidence of SARS-CoV-2-related acute respiratory distress syndrome (ARDS) and the numbers of patients requiring ventilation. Non-survivors included patients who were older, more likely to develop ARDS, those requiring ventilation and those more likely to have organ damage, including acute kidney injury, cardiac injury and liver dysfunction. The authors concluded that patients who are older and have comorbidities and ARDS are at a higher risk of mortality from COVID-19. The most distinctive characteristics of the 32 non-survivors in this study were chronic hypertension, other cardiovascular disease and diabetes. In a retrospective study exploring the clinical characteristic of 1099 patients with confirmed COVID-19 (Zhang et al, 2020), the main outcome measures were admission to intensive care, the requirement for mechanical ventilation and death. The case of every patient admitted to hospital was categorised as severe or non-severe. Some 173 patients were considered to have severe clinical symptoms. In this group, the patients were significantly older and more likely to have pre-existing comorbidities. Individuals with increasing number of comorbidities were associated with an increased risk of complications and death from COVID-19. The authors discussed that compromised respiratory function on admission related to worse outcomes. It appears that the development of severe respiratory symptoms leads to complications associated with the development of severe viral pneumonia. The leading cause of death for patients with COVID-19 is ARDS (British Medical Journal, 2020).

Approximately 80% of people who develop COVID-19 will have only mild symptoms (Zhang et al, 2020). However, it seems that people with diabetes appear to be at significantly increased risk of more severe COVID-19 symptoms. In one study of 52 patients admitted to intensive care with COVID-19, 32 deaths occurred within the group (Hartmann-Boyce et al, 2020). In the non-survivors group, 22% had an underlying diagnosis of diabetes. Further research is required in order to understand and quantify the risks of COVID-19 for people living with diabetes more fully. People with diabetes are generally considered to be more at risk of influenza and pneumonia and are routinely offered immunisation as protection, and it is thought that risk is reduced with good glycaemic control (Gupta et al, 2020). COVID-19 infection for individuals with diabetes increases the risk of emergency states of hyperglycaemia with ketones diabetes ketoacidosis (DKA) and hyperosmolar hyperglycaemic state (HSS) (Association of British Clinical Diabetologists, 2020).

Fang et al (2020) have hypothesised that the coronavirus SARS-CoV-2 binds to target cells via angiotensin-converting enzyme (ACE2) found in the lungs, intestines, kidneys and blood vessels. In patients with diabetes who are treated with ACE inhibitors or angiotensin 11 type-1 receptor blockers (ARBs), the amount of available ACE2 is substantially increased, which, in turn, increases the viral load in the body and, therefore, the severity of the disease. However, UK expert opinion suggests that not enough is known regarding the mode of action of the virus and that patients should be advised to continue to take ACE inhibitors and ARBs as prescribed (Brown, 2020). Community nurses can support patients with diabetes with regular assessment of overall health and early detection of any changes in condition. Good glycaemic control is of vital importance, and the nurse may need to liaise with diabetes specialists in order to properly support individuals with managing diabetic care. For people who become unwell or symptomatic during this pandemic, specialist advice from a local diabetes team will be required so that the patient is safely managed in the most appropriate setting according to their needs.

There is discussion that obesity puts individuals at increased risk from the virus and makes them more likely to develop severe disease. NHS England (2020) identified that individuals with a BMI of 40 or above are at increased risk from COVID-19 infection. Obesity rates are now being explored as a risk factor for increasing mortality rates and severe disease (Dietz and Santos-Burgoa, 2020). A review of research studies focusing on H1N1 influenza during April 2009 until January 2010 indicated that obesity and severe obesity are risk factors for hospitalisation and for patients requiring mechanical ventilation (Fezeu et al, 2011). Obesity appears to be associated with compromised respiratory function, although further research is required in order to understand the risks more fully.

Patients considered at very high risk and requiring shielding

NHS England has issued professional guidance to health professionals regarding patients who are considered ‘very high risk’ (NHS England, 2020). In March 2020, the NHS started to identify and contact every individual considered by the Chief Medical Officers to be at the greatest clinical risk from COVID-19. This list identified the following patients: those with solid organ transplants, specific cancers, immunosuppression, severe respiratory conditions, rare diseases and inborn error of metabolism as well as pregnant women with significant heart disease. The letter informed this group of individuals that they should be shielded by staying at home at all times and avoiding all contact for a period of at least 12 weeks.

The Chief Medical Officers in the UK have now written to all GPs advising them that these groups are categorised as vulnerable and at increased risk from COVID-19.

Box 2 contains the full list of conditions that have been identified as increasing an individual's risk of contracting severe COVID-19. The public-facing health advice at present is that individuals with any of the long-term conditions highlighted in Box 2 should be particularly stringent in following social distancing measures and consider carefully how they can reduce all unnecessary close contact outside the home. GPs have been asked to identify patients with a number of long-term conditions and living with complex comorbidities who are significantly at risk of life-threatening complications or death caused by COVID-19. It is intended that further advice will be issued regarding this group imminently (NHS England, 2020).

Box 2.Summary of individuals who are or may be at increased risk of severe illness from COVID-19

• Aged 70 years or older (regardless of medical conditions)
• Any long-term condition that requires an adult to be instructed to get a flu jab as an adult each year on medical grounds), including:
• chronic (long-term) respiratory diseases, such as asthma, chronic obstructive pulmonary disease (COPD), emphysema or bronchitis
• chronic heart disease, such as heart failure
• chronic kidney disease
• chronic liver disease, such as hepatitis
• chronic neurological conditions, such as Parkinson's disease, motor neurone disease, multiple sclerosis (MS), a learning disability or cerebral palsy
• diabetes
• problems with the spleen—for example, sickle cell disease or if the spleen has been removed
• a weakened immune system as the result of conditions such as HIV and AIDS, or medicines such as steroid tablets or
• chemotherapy
• being seriously overweight (a BMI of 40 or above)
• those who are pregnant

(NHS England, 2020)

Discussion

The main message for health professionals is that individual risk increases with increasing comorbidities.

Community nurses routinely care for frail, older patients with significant comorbidities who should be considered at high risk of adverse outcomes if they contract COVID-19. Protecting these patients is no easy task, as they often rely on a combination of professionals, family, friends and carers every day. The person's care requirements render both shielding and social distancing impossible if essential nursing and personal care are to be provided in the community. All health and social care workers must adhere to universal precautions and consider whether multiple visits may be reduced by combining provision of health and care needs, thus reducing the risk to the patient. Further, all health professionals should monitor their own health and reduce unnecessary contacts with others. Community nurses can routinely assess patients on their caseload for any developing symptoms of COVID-19 and identify the onset early in order to work collegiately with other members of the primary health care team following an agreed pathway to provide a planned and co-ordinated response in accordance with the patients' wishes and preferences. There are plans to test ‘critical’ NHS key workers in the coming months but with no mention yet of community-based nurses and their patients. Recently published National Institute for Health and Care Excellence (NICE) guidelines (2020) provide general guidance for the management of suspected cases of COVID-19 in primary care but are aimed mainly at general practice. At present, there is no guidance available to specifically address best practice for patients with this condition for community nursing teams directly providing nursing care in a patient's own home. Future guidelines must consider how best to care for individuals in every care setting, and community nursing should be an integral part of a whole-systems response to future emergencies.

Conclusion

At present, there is no treatment for COVID-19 infection, so vigilance and strict adherence to infection control measures for patients and healthcare workers alike appear to offer the best protection for everyone. Community nurses continue to visit patients on their caseload in order to provide essential healthcare. Routine appointments for review of long-term conditions are suspended, and all non-essential clinical work has stopped. Patients on community nursing caseloads will have minimal health reviews undertaken by primary and secondary care.

Patients with long-term conditions might also rely on the community nurse to provide care that is usually the domain of others. Community nurses are well-equipped to coordinate with and support the person with a long-term condition as well as regularly assessing every vulnerable patient on the caseload for symptoms of COVID-19 infection.

Community nurses will continue to provide compassionate care to vulnerable groups in their home and, as always, devise pragmatic solutions to overcome challenges that arise in order to do the right thing for each patient in their care.

KEY POINTS

• Four out of five people will have only mild COVID-19 symptoms
• Patients most at risk of serious illness related to the virus are older people and individuals with comorbidities
• Any patient entitled to the flu injection is considered vulnerable and should be advised to be extra vigilant in taking precautions
• Patients' long-term conditions should be carefully managed during this outbreak
• COVID-19 puts patients at risk of diabetic emergency from diabetic ketoacidosis, hyperglycaemia with ketones and hyperosmolar hyperglycaemic state

CPD REFLECTIVE QUESTIONS

• Are you able to advise patients living with diabetes about their condition and feel confident in promoting good glycaemic control and being able to recognise a diabetic emergency?
• Do all the patients on your caseload have a care plan that identifies their wishes about preferences for care should they develop COVID-19?
• What is your evidence that you are effectively managing the patients' long-term condition/s during this crisis?
• How can you best shield vulnerable patients on your caseload and what actions can you take to ameliorate risk?