COMMENTARY

COVID-19: Antibody Tests & Kick-starting Non-COVID NHS Services

Prof Karol Sikora

Disclosures

May 16, 2020

This transcript has been edited for clarity.

Hello, this is Professor Karol Sikora here, talking this time about antibodies in the fight against COVID-19, and also, how do we kick-start the NHS to get back to normal in the UK? I'm looking at a report from NHS Providers, which has as its members, organisations that employ over 85% of NHS staff.

Antibodies

So first of all antibodies. The largest single study of a survey of people in a country comes from Spain. It was published this week, and it's only in Spanish and it's not been peer reviewed like so much of the COVID literature. And it looks at the number of people in the populations across Spain that have antibodies, either immunoglobulin M (IgM) or immunoglobulin G (IgG), specific to coronavirus. And the answer is around 5%, which is amazingly low.

We've looked at our staff in the Rutherford Cancer Centres, and it's around the same, it's actually 8.4%. We're doing it again 4 weeks on, this week in fact, but the preliminary data on that suggests it's still about the same.

There doesn't seem to be a lot of seroconversion going on. And we don't understand what that means.

We've heard a lot about the Government earlier this week, through Public Health England, purchasing a whole lot of diagnostic kits from Roche [and Abbot] that can be used to pick up IgM and IgG specific antibodies. But at that level, it's not going to be much good as a tool for giving people what they want - they want an immunity passport. There are profound ethical difficulties with that because you end up with two classes of people: those that are immune and those that are not.

'Immunoprivilege'

Those that are immune, in theory, can avoid social distancing. They can go to restaurants where the staff would all be immunopositive, and so on. The new word I read in The Lancet last week was immunoprivilege because of this. It can't be. Out there, there are three classes of us: those under threat from getting COVID, the infected, and those that have definitely recovered from it, proven positive both by antigen testing and antibody testing.

We need to separate people out, but we haven't got the test to do that as yet. So profound difficulties.

You look at all areas of society, of getting people safely back to work; look at the problems with school teachers going back to work on the 1st June, or not, depending what actually happens.

You look at office blocks in London, currently locked up, completely empty. How do you get people back?

You look at the creation of COVID-free zones for healthcare, around cancer services, radiotherapy departments, chemotherapy suites. And then finally, you have international travel. How are you going to deal with that - to issue some sort of medical advice to travellers, and medical regulatory advice to governments to protect their borders from having an influx of COVID-positive people?

So, the Spanish study is really welcome. And it's been done before. The Diamond Princess cruise ship [was] a highly infected boat in Yokohama harbour, 700 people testing positive for the virus, nearly all in their 70s, because that's the demographic of cruise ships, and yet the antibody rate was less than 10%, something like that, later on.

So a real puzzle to us all, the immune system.

Of course, it probably means that the antibodies are just one of the many immune defence systems we use to battle against coronavirus. Some of the others would be secreted molecules of IgA, immunoglobulin A, which comes out in the saliva and the back of the nose [and] goes through the gut. We produce 2-3 grams of this a day - I didn't know that. I had to go to my old immunology books to find out, and that could be very powerful at mopping up the virus before it gains entry to the main immune system.

Then cellular mechanisms: T cells, natural killer cells, and lymphocytes generally, and other macrophages, and so on, creating a response to the virus.

So we've got a lot to learn. Hopefully, the information from Spain [will help]. On a map showing the centre of Spain, Madrid, and the commuting distance, is quite heavily [infected], with antibodies up to 15% in those areas compared with the coastal regions, the holiday places that we all know and love in Spain, and they're less than 6%, giving you a total country average of 5% [after tests] on 60,000 people.

So very interesting report, and we'll see a lot more of that as the days go on.

The New Normal

So now the second report is 'the new normal'. Don't you just hate it, the concept of the title? Two phrases I hate.

  1. The new normal

  2. It's based on science

There is no science in this business of COVID. It's all hearsay evidence, personal preference and fear.

'The New Normal' is a report entitled 'Balancing COVID-19 and other healthcare needs' ,and it really is very timely and this comes from NHS Providers.

And it is quite a good statement of the problems. I'm not so sure the solutions are that good, maybe because there aren't any, and they have to be local, and they have to be based on the type of treatment you wish to offer.

But if we look at the key messages, there's no doubt the NHS has been fantastic at dealing with COVID-19. Nightingale hospitals, a triumph of modern logistics, bringing in all sorts of partners, tremendous cooperation, getting together of key workers to move the whole thing forward.

The same in our hospitals, they've been transformed: COVID-free, COVID-19 screening, understanding that we can't have visitors, trying to reduce footfall during outpatient clinics by [using] phone, by Skype, all these things have happened.

You know, they could have happened a long time ago when you look back, but we've made elderly patients get several buses often to get to the hospital, or find a car park to park, get volunteers to drive them in. A lot of it's unnecessary - it can be done online, and that's what's going to happen from now on wherever coronavirus goes after this.

So, the NHS has done well for COVID-19. But everything stopped; it's become a COVID-19 machine. And we need to get out of this mode.

Sure, we have to plan that there might be a second wave, that we might need more critical care capacity, that we may run into winter pressures and have a combination [of] the disaster scenario: winter pressures on top of an active second wave corona pandemic in the autumn. That's the worst case. We have to plan for it. But let's hope for the better case, that the virus essentially goes away, it gets bored, just like many of us are bored with the newspapers these days.

When it does go away, we can then get back to business. We can get back to business now: the NHS plan from England is to look at COVID-free hubs to deal with cancer patients.

And starting with surgery, links to the independent sector, that's all being carried out now.

What this report looks at is dealing with the significant backlog of cancer surgery that's out there. Other elective procedures also, [such as] aortic stenosis that needs to be dealt with, otherwise people will die of cardiac failure and arrhythmias.

Rehabilitation of healthcare needs has to be carried out. And we need to look at the economic and social consequences of having an ineffective health service that's focused simply on COVID-19.

There's no doubt demand has accumulated. One estimate is there are 8 million people on NHS waiting lists. OK, some of them can afford to wait. I guess if you have a cataract, and you've had it for years, you can afford to wait a few more months whilst this blows over before you need to go.

But a lot of things are quite distressing, joint pains, back pain requiring surgery, put on hold, even minor operations for things have also been put on hold.

Getting Back to Work

We've got to get back to work somehow. And this report looks at ways in which we could get there.

It looks to ways of prioritising the way forward for all sorts of organisations, and it has to be a combined effort. My area of interest is cancer, and there we have patients coming through the 2-week wait, that's only 25% of them, through urgent appointments, to see various consultants, a 3-week wait, and through routine appointments, which are supposedly 3 months but often, in fact, a lot more, up to 6 months.

Now, with cancer, if you've delay, we know you get upward stage migration. So a stage 1 cancer becomes stage 2 or 3; stage 2 cancer becomes stage 4 and so on. The precipitous disaster that's coming, if we don't get people moving through the system, they're going to go through this stage migration.

The second disaster that's going to come is that once we get rolling again, and I really hope in the next 2 weeks to see some traction here, the system will be inundated with cancer patients. They'll all come together. All of April's will come. May's will come and June's will all pile up: 3 months of cancer patients in the month of July.

That's the optimistic view. The pessimistic view is that we still have corona way beyond July, and that we still have problems, and the actual wave of cancer won't come till October, when you'll have 6 months of patients coming together. And certainly, if there's a 6 month delay, there'll be stage migration in the first month, which would be April's patients that should have presented then.

And just look around for the evidence: the biopsy data from the path lab, very few biopsies, down to about 10% of cancer biopsies normally for April; the endoscopies often cancelled, blanket cancellations, CT use, MRI use for cancer diagnosis, [all] right down.

Imagination Needed

So we know it's happening. It's how we can get out of this that's really the key. And the solution is obviously to use imaginative methods to make sure that, just as we seconded people from around the hospital to go and work on COVID-19 wards, let's get people to help with cancer and cardiac disease, and move forward on that basis.

Let's use the independent sector to deliver radiotherapy and chemotherapy. There are something like 40 places you can get chemotherapy outside the NHS, including home delivery services. Let's make a map and use those.

For radiotherapy, there's something like 24 centres, mainly in the southeast, but there are some scattered around the whole country. Let's use them to make sure people don't have to wait. Let's be imaginative about the schedules we use, converting IV to oral drugs, looking at super fractionation, where we give one or two treatments of radiotherapy, which in many cases is as good as long protracted courses, reducing the footfall in the hospitals, visitors, car services and so on, is really important as we come to close down on this pandemic.

Whatever we do that R0 has to be below 1 or around 1, we can't afford to let it drift up by health service activity. So we have to be really smart.

The one thing we've been missing in this country is testing. Testing has been badly organised, bad logistics, slow to understand the need for PCR (polymerase chain reaction) testing. The antibody, it's intellectually satisfying and important information, but probably because of the low incidence of antibodies, less important in public health terms.

Sometimes, I wonder when you look back at the year 1854 in Soho, John Snow removing the handle of a pump that he traced to the epicentre of the cholera epidemic of that time. What would he have thought about how we've gone about testing in the UK with Public Health England? I don't think he'd have been very impressed.

Karol Sikora, thank you for listening. I'm very interested in your views as always.

You can follow Prof Karol Sikora on Twitter

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