All paediatricians are complicit in delivering a racist healthcare service

Cite this article as:
Zeshan Qureshi and Anna Rose. All paediatricians are complicit in delivering a racist healthcare service, Don't Forget the Bubbles, 2021. Available at:
https://doi.org/10.31440/DFTB.33938

We’re supposed to be the nice ones. The friendly, fun, caring and supportive speciality – right? We’re the ones who have teddies on our stethoscopes and know all the words to Disney songs. In the hospital, we’d like to think we’re the Good Guys – but maybe we’re not when it comes to race. 

The COVID-19 pandemic has been a monumental challenge to the NHS and has, undoubtedly, showcased the everyday heroism of our staff. It has also thrown a sharp light onto the ongoing racial inequalities in our society and healthcare systems. Racial disparities in the pandemic have been widely documented – and make for sobering reading. Analysis of national hospital data suggests that people of black and other minority backgrounds are up to twice as likely to die from the virus, as compared to white Britons – with some groups, such as black African-born men living in Britain, having an even higher risk [1]. Despite this, we have little doubt that the major impetus for the unprecedented emergency measures, national lockdowns, and political obsession was not the deaths of the poor, the ethnic minorities, or those in low and middle-income countries – but the perceived threat to wealthy, predominantly white, Westerners.

In an eerie parallel to the racial inequalities highlighted by the pandemic, the past year has also seen racial tensions in the USA reach boiling point. Following several high-profile incidents of police brutality, there was an eruption of social unrest and protest in America and around the world. The systemic disregard of black lives is not just written in blood on American pavements. It is written into the systems that surround us in our everyday working lives. As a speciality, and in the NHS as a whole, we must confront these engrained systemic inequalities, if we are to provide truly equitable care to all of our patients. 

In this blog series, we will examine how clinical outcomes for common paediatric conditions are worse for children from minority ethnic backgrounds. Stillbirth, low birth weight and preterm birth are all more common in minority groups as compared to white northern European populations [2,3,4 ]. Outcomes for common chronic conditions, such as asthma and type 2 diabetes, are also worse for children within minority groups [5,6]. This could be because care received by children with chronic conditions is worse. Non-white children with renal failure are less likely to pre-emptively receive a renal transplant, for example [7]. There are also complex social and environmental roots to these adverse health outcomes – such as increased poverty in non-White groups [8] — and we will try to investigate these issues in more detail. 

We will also explore how paediatrics has normalized white Northern European genetics, physiology and behaviour, leading to biased clinical decision making. Normalization of one ethnic group has lead to the classification of other normal values (in both the laboratory and social sense) as pathological or inappropriate. In other words – you are only normal if you are white and normal. Neutrophil counts are often lower in black babies [9]. Rather than reporting ethnically normal ranges babies often end up having multiple blood tests due to a lack of awareness of the variation. Parents get told that their neutrophil count is low, but it’s acceptable for a black baby (rather than categorically stating that their count is normal). Worst still, it might be classified as a disease – benign ethnic neutropenia – despite not being associated with increased morbidity or mortality.

Within medical education, we are guilty of peddling irrelevant and outdated racial and religious stereotypes. These hold little educational value, but risk enforcing dangerous bias within our future doctors. Any paediatrician would be able to tell you about the association between Tay-Sachs disease and Ashkenazi heritage, or sickle cell disease and sub-Saharan Black Africans. Such associations are often over-simplified and over-emphasized, to the point of creating a disease-ridden caricature, particularly in exam questions. Most of these stereotyped conditions are very rare, and over-emphasis during medical school risks blinkering us to more common diagnoses. We’ll explore how racial bias is ingrained in medical education in the UK, and try to come up with some ideas on how we can improve MedEd to be more diverse and inclusive in the future. 

There also seems to be a disproportionate concern that those from Muslim backgrounds might be consanguineous, and that we need to ask about this even when it is not relevant to the presenting complaint. Conversely, when genetic testing is being sent off, a detailed family tree needs to be drawn. It should include details of any consanguinity – yet it seems that a white family is less likely to be asked. As first or second cousin marriages are no longer a social norm in the UK, they have become defined by pathological associations with genetic conditions, such as inborn errors of metabolism. And whilst there are, of course, differences in the prevalence of disease alleles in different populations, and an increased risk of recessive disorders in families with intergenerational consanguinity, it does not automatically follow that a child from a Muslim background has a recessive disorder, or that a white British child does not. The same considerations need to be given to other cultural practices that might be different to the social norms of Northern and Western Europe. Putting children on a vegetarian diet is often classed as a ‘restrictive diet’ – despite the fact that it is only restrictive based on traditional Western standards – and might, in fact, hold health benefits [10]. 

Finally, in our series, we will examine how systemic racism within the health service tolerates – and sometimes even facilitates –  the unacceptable behaviours demonstrated by some parents. One thing that sets paediatrics apart from adult medicine is that patients are almost never seen alone, and a parent is often required to deliver care. This can present a dilemma to staff when confronted with a racist parent. Any punishment directed towards the parents might directly harm their child. We will explore how guidelines should be developed to help clinicians handle racist parents, whilst minimizing the effect on the clinical care of our patients. 

It can be painful for us – as individuals and as a speciality – to consider that we might be complicit in a racist system that ultimately leads to poorer health outcomes for some children. Just because something is painful, does not mean we shouldn’t do it. We hope that you’ll join us for this series of short articles, as we try to explore how we can begin to move from a white-centric healthcare system to a child-centred one.

James Baldwin quote on racism

Selected references

1) The IFS Deaton Review. Are some ethnic groups more vulnerable to COVID-19 than others? 

2) Gardosi J, et al. (2013). Maternal and fetal risk factors for stillbirth: population-based study. BMJ 346:f108.

3) Kelly Y, et al. (2008). Why does birthweight vary among ethnic groups in the UK? Findings from the Millenium Cohort Study. Journal of Public Health, 31:131–137.

4) Aveyard P, et al (2002). The risk of preterm delivery in women of different ethnic groups. British Journal of Obstetrics and Gynaecology 109:894-899.

5) Asthma UK (2018) On the Edge: How inequality affects people with asthma. Available at www.asthma.org.uk

6) RCPCH (2020) State of Child Health: Diabetes. Available at www.rcpch.ac.uk

7) Plumb LA et al. (2021) Associations between Deprivation, Geographic Location, and Access to Pediatric Kidney Care in the United Kingdom. CJASN. 16:194-203.

8) Office for National Statistics (2020) Child poverty and education outcomes by ethnicity. Available at www.ons.gov.uk.

9) Haddy TB, Rana SR, Castro O. (1999) Benign ethnic neutropenia: what is a normal absolute neutrophil count? J Lab Clin Med. 133:15-22.

10) Kalhoff H. et al (2021) Vegetarian Diets in Children—Some Thoughts on Restricted Diets and Allergy. International Journal of Clinical Medicine. 12:43-60.

COVID and RSV HEADER

COVID and RSV

Cite this article as:
Laura Riddick, Damian Roland and Andrew Tagg. COVID and RSV, Don't Forget the Bubbles, 2021. Available at:
https://doi.org/10.31440/DFTB.33694

There was a time, perhaps a century ago, when the only virus we really worried about was RSV. Children, snot dripping from their noses, would come in coughing, and struggling to breath and, as days grew shorter and nights grew longer we knew that bronchiolitis season was upon us once more.

But things have changed. We worry about a different virus now and there is plenty of evidence to show that the usual seasonal variations in RSV have flattened. It was heartening to see the data showing that the mid-winter peak was no more as we kept ourselves to ourselves. Non-pharmacological interventions – physical distancing, respiratory hygiene and restricted movements – meant that the scourge of the paediatric emergemcy department was held at bay. Until…

Half a world away…

Bronchiolitis presentations peaks in June – July in Australia (remember it is our winter in the Southern hemisphere). Last season there was a 98% reduction in RSV (and a 99.4% reduction in cases of influenza (Yeoh et al., 2020). But let’s take a look at the surveillance data from Western Australia to see what has been going on of late.

Western Australia RSV incidence- Based on Foley et al. 2021

McNab et al. (2021) looked to see what had been going on in Victoria, a state that had much stricter lockdown measures than WA. Whilst there was clear suppression of the winter cases of bronchiolitis, these began to increase by the beginning of the year, coinciding with the return to school after the long Christmas break Normally, in February, the Royal Children’s Hospital would return 5.6% positive RSV swabs. In 2021, they returned 32.8%. More worryingly, this peak is higher than the pre-COVID winter peak (30.4%)

RSV incidence in Victoria
Victorian Australia RSV incidence- Based on McNab et al. 2021

But this snapshot doesn’t give you the whole picture. Let’s just slide the data along a few short weeks…

Victorian Australia RSV incidence- Based on McNab et al. 2021

These data have been echoed all over Australia and New Zealand with a ramping up of out of season RSV positive cases. What is most concerning is that numbers appear to be higher than the usual peak and the patients older (mean 18.2 months compared to 7.3 – 12.5 months). Why could this be? It could be, as Foley et al. (2021) suggests due to an increase in RSV-naïve babies born during that first wave coupled with waning herd immunity.

What does this mean for paediatricians in the Northern hemisphere who are about to face this surge in cases?

Getting started?

Paediatricians at the frontline need to be able to see what is going on and so PERUKI will shortly be launching BronchSTART. The aim of this prospective observational study is to both track the potential surge so that health policy is informed as much as possible but also to describe its epidemiology. As highlighted above the data suggests a potentially wider age range and steeper spike but these are from retrospective studies By reporting potential cases (in children under two years of age) presenting to over 50 Emergency Department across the UK, in real-time, clinicians and researchers will be able to really understand the impact and outcomes of this respiratory disease.

Given the challenges of identifying and managing children who may have RSV, COVID-19, or both, some guidelines have been produced by the RCPCH.

What do the guidelines say?

The RCPCH guidelines focus on THREE key areas:-

  • Reducing hospital attendances with mild cases
  • Pathways and guidance for testing and cohorting
  • Minimising patient time on High flow and reducing the exposures to AGPs

The guidelines are designed to reduce potential unnecessary referrals from primary care to the emergency department. Hopefully, reducing the number of children presenting (and then mixing with each other in the waiting room) will lessen the burden on paediatric emergency departments. It offers a traffic light system for reviewing patients, with suggestions of how to manage some borderline cases in the community with secondary care input.

NHS bronchiolitis pathway

When it comes to testing, the aim is to be able to minimise the spread of COVID-19 and protect clinically vulnerable children.  As with what is happening in most hospitals, the recommendation is to only test patients being admitted to the hospital. Any further testing is then influenced by the patient’s condition and the prevalence of COVID in the hospital, as well as cubicle availability.  

Using Point-of-Care-Testing (POCT)/rapid testing for patients going to PICU and HDU may limit cubicle occupancy, and improve cohorting of patients. Additional COVID testing then should be considered in cases where respiratory panels are negative (or suggest low-risk causative organisms such as bocavirus or rhinovirus). Additional testing should also be considered if aerosol-generating procedures (AGPs) are required or parents are displaying symptoms. 

The RCPCH defines the prevalence as low (<0.5%), medium (0.5≤2%) and high (>2%). Currently, the national prevalence is low, however, nearly all of the UK was high during the first wave in March 2020. When the prevalence is high the guidelines suggest treating all AGPs as high risk in terms of PPE requirements. It also suggests that parents and staff are regularly screened and tested.

Given that AGPs provide a high risk for transmission, the recommendation is for rapid but weaning of high-flow with guidance provided by north and south Thames retrieval service protocol used.

For those of us in clinical practice, the guidelines remain largely unchanged. Non-pharmacological measures- physical distancing, good respiratory hygiene and use of appropriate PPE are key. Cohorting patients into red and blue, hot and cold or low/high-risk zones may add some value unless physical distancing can be maintained.

As case numbers rise, and cubicle capacity becomes an issue then departments need to come upwith a risk mitigation strategy to protect the vulnerable.

COVID and RSV flow chart

Bottom line

  • Support community services to reduce strain on hospital services
  • Use testing to help cohort and plan patient care
  • Wean or reduce AGPs where safe to do so
Infographic depicting RSV and COVID guidelines

Selected references

Foley, D.A., Yeoh, D.K., Minney-Smith, C.A., Martin, A.C., Mace, A.O., Sikazwe, C.T., Le, H., Levy, A., Moore, H.C. and Blyth, C.C., 2021. The Interseasonal Resurgence of Respiratory Syncytial Virus in Australian Children Following the Reduction of Coronavirus Disease 2019–Related Public Health Measures. Clinical infectious diseases: an official publication of the Infectious Diseases Society of America.

Huang QS, Wood T, Jelley L, et al. Impact of the COVID-19 nonpharmaceutical interventions on influenza and other respiratory viral infections in New Zealand. Nat Commun. 2021;12:1001. https://doi.org/10.1038/s41467-021-21157-9

McNab, S., Do, L.A.H., Clifford, V., Crawford, N.W., Daley, A., Mulholland, K., Cheng, D., South, M., Waller, G., Barr, I. and Wurzel, D., 2021. Changing Epidemiology of Respiratory Syncytial Virus in Australia-delayed re-emergence in Victoria compared to WA/NSW after prolonged lock-down for COVID-19. Clinical Infectious Diseases: An Official Publication of the Infectious Diseases Society of America.

Oh, D.Y., Buda, S., Biere, B., Reiche, J., Schlosser, F., Duwe, S., Wedde, M., von Kleist, M., Mielke, M., Wolff, T. and Dürrwald, R., 2021. Trends in respiratory virus circulation following COVID-19-targeted nonpharmaceutical interventions in Germany, January-September 2020: Analysis of national surveillance data. The Lancet Regional Health-Europe6, p.100112.

Public Health England. Weekly national Influenza and COVID19 surveillance report: Week 49 report (up to week 48 data) 3 December 2020. https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/940878/Weekly_Flu_and_COVID-19_report_w49.pdf. Accessed July 20, 2021.

Tang, J.W., Bialasiewicz, S., Dwyer, D.E., Dilcher, M., Tellier, R., Taylor, J., Hua, H., Jennings, L., Kok, J., Levy, A. and Smith, D., 2021. Where have all the viruses gone? Disappearance of seasonal respiratory viruses during the COVID-19 pandemic. _Journal of Medical Virology

Waterlow, N.R., Flasche, S., Minter, A. and Eggo, R.M., 2021. Competition between RSV and influenza: Limits of modelling inference from surveillance data. Epidemics35, p.100460.

Williams, T.C., Lyttle, M.D., Cunningham, S., Sinha, I., Swann, O.V., Maxwell-Hodkinson, A. and Roland, D., 2021. Study Pre-protocol for “BronchStart-The Impact of the COVID-19 Pandemic on the Timing, Age and Severity of Respiratory Syncytial Virus (RSV) Emergency Presentations; a Multi-Centre Prospective Observational Cohort Study”. Wellcome Open Research, 6(120), p.120.

Yeoh DK, Foley DA, Minney-Smith CA, et al. The impact of COVID-19 public health measures on detections of influenza and respiratory syncytial virus in children during the 2020 Australian winter. Clin Infect Dis 2020.

Croup

Cite this article as:
Laura Riddick. Croup, Don't Forget the Bubbles, 2021. Available at:
https://doi.org/10.31440/DFTB.32637

It’s 0200 hours in the Emergency Department and you hear a seal …

As children have returned to school we have seen more croup through the ED so it’s time to refresh your memories!

What is it?

Viral laryngotracheobronchitis. It is essentially inflammation around the main large breathing structures and caused usually by parainfluenza 1 + 3. Other respiratory viruses including SARS-CoV-2 and RSV may also be involved. This inflammation causes a tell-tale cough and noisy breathing due to the obstruction to flow. There may be signs of increased work of breathing too such as sub-costal recession or a tracheal tug. They are generally quite well and are running around the waiting room!

Who gets it?

A lot of children – roughly 2-3% of all children per year! These kids are usually between six months and four years of age, and occurs at the beginning of autumn, though this spring we are seeing a lot of cases. Children with croup may present with a preceding coryza-like illness and a low-grade fever. This then develops into a barking “seal-like” cough and, for some reason, always seems worse at night. Boys are more commonly affected than girls, and some children seem to get it yearly.

How do we treat it?

This depends on your assessment of the child. Croup is a self-limiting viral illness and treatment tends to look to short term reduction in the inflammation to improve the work of breathing. Historically clinicians have used Westley scoring system to score croup and assess their severity before giving medication.

Westley Croup scxore
Westley Croup Score

In children who look unwell, it is important to not upset them by avoiding unnecessary interventions such as excessive handling or performing an ENT exam.

Steroids

If the child is able to take the medication, dexamethasone or prednisolone should be given to all cases of croup where any stridor or increased effort in breathing is present.

Dexamethasone appears to be more efficacious than prednisolone. It has an onset of action within 1 hour (30 minutes – 4 hours) and has a half-life of up to 36-72 hours (Schimmer 2005). There has been debate overdosing with doses of 0.15mg/kg, 0.3mg/kg and 0.6mg/kg of dexamethasone. Ultimately, 0.15mg/kg not inferior to 0.6mg/kg. At the time of writing both NICE and the BNFc recommend 0.15mg/kg as the initial dose of dexamethasone. If there are concerns about re-occurrence patients are occasionally sent home with an additional dose to be taken 12 hours later.

Prednisolone tends to be favoured in the primary care setting, at a dose of 1mg/kg with two additional daily doses. There appears to be no significant clinical difference between the two different steroids in terms of the need for additional treatment or length of stay. Dexamethasone was associated with a reduction in re-attendances, which may be due to the shorter half-life of Prednisolone (Gates 2018, Schimmer 2005)

Nebulised budesonide (2mg stat dose) is reserved for children who cannot take the dose. This may be because it was spat ou tor because they are working too hard to breathe. A Cochrane review in 2018 shows that budesonide is not superior to dexamethasone, with Westley Croup scores better in the dexamethasone group at 6 and 12 hours compared to budesonide. A combination of treatment does not appear to lead to additional benefit (Gates 2018)

Adrenaline/epinephrine

In severe cases, when the child has features of severe work of breathing, including significant recession, hypoxia or tiring, nebulised adrenaline has been used (0.4-0.5ml/kg, maximum 5ml of 1:1000). Adrenaline provides short term relief from respiratory distress and can be a bridge to getting steroids on board. The effects are short-acting and wear off after a couple of hours. It can be repeated every 30 minutes, although if you need repeat doses, anaesthetics and senior colleagues should be involved in this patients’ care.

How do we not treat it?

In the olden days parents tried treating croup at home with steam inhalation (not effective). In hospitals, humidified oxygen has also been tried though this has not been proven to be effective either (Moore 2007). Heliox (oxygen and helium combined) has also been looked at as it may improve airflow. The evidence is limited and safety and efficacy remain questionable (More, 2018). There is no evidence that salbutamol works in croup.

They sound better, what’s next?

If they are well and the stridor has resolved, patients can be discharged home with safety-netting advice. The effects of dexamethasone should last as croup itself is usually limited to 2-3 days of symptoms. Parents need to be aware that some symptoms of respiratory distress can return, usually the following night.

Patients may require a prolonged period of observation if:

  • stridor is still present at rest, or there is increased work of breathing
  • the child is very young (<3 months)
  • an adrenaline nebuliser had to be given
  • there is a past history of severe croup
  • there is a history of upper airway problems (i.e. laryngomalacia or subglottic stenosis)
  • concerns about the child returning (i.e. long-distance, social concerns)

When is it not croup?

  • Epiglottitis – a rare condition thanks to the HiB vaccine. A child would present with sudden onset, fever, drooling and looks unwell holding the head back and neck extended. This is a medical emergency and keeping the patient calm is paramount.
  • Tracheitis– thankfully also rare. It presents with the child acutely unwell after a prolonged course similar to Croup.
  • Anaphylaxis/allergy – this may be accompanied with angioedema, rash and wheeze, and requires swift treatment with IM adrenaline
  • Quinsy/retropharyngeal abscess
  • Foreign body – Usually the history would help suggest this, with a sudden onset history in a well-child.

COVID and croup

Most children admitted into hospital are now swabbed for COVID. This can provide a challenge – balancing upsetting the child (and making the upper airway obstruction worse) and performing an invasive swab. It is sensible not to swab the child whilst there is still concern about acute stridor and work of breathing..

There have been some case studies to suggest a small cohort of patients with croup who were SARS-CoV-2 positive are less responsive to the usual treatment (Venn 2020). These cases may need prolonged admission due to lack of response and the need for additional supportive therapy.

Selected references

  1. Al-Mutairi B, Kirk V. Bacterial tracheitis in children: Approach to diagnosis and treatment. Paediatr Child Health. 2004;9(1):25-30. doi:10.1093/pch/9.1.25
  2. Garbutt JM, Conlon B, Sterkel R, et al. The comparative effectiveness of prednisolone and dexamethasone for children with croup: a community-based randomized trial.  Clin Pediatr (Phila). 2013;52(11):1014–1021.
  3. Gates  A, Gates  M, Vandermeer  B, Johnson  C, Hartling  L, Johnson  DW, Klassen  TP. Glucocorticoids for croup in children. Cochrane Database of Systematic Reviews 2018, Issue 8. Art. No.: CD001955. DOI: 10.1002/14651858.CD001955.pub4. Accessed 28 April 2021
  4. Moore M, Little P. Humidified air inhalation for treating croup: a systematic review and meta-analysis.  Fam Pract. 2007;24(4):295–301
  5. Moraa I, Sturman N, McGuire TM, van Driel ML. Heliox for croup in children. Cochrane Database of Systematic Reviews 2018, Issue 10. Art. No.: CD006822. DOI: 10.1002/14651858.CD006822.pub5
  6. Schimmer B P, Parker K L. Adrenocorticotropic hormone: adrenocortical steroids and their synthetic analogs: inhibitors of the synthesis and actions of adrenocortical hormones. Goodman and Gilman’s the pharmacological basis of therapeutics, 9th edition. New York: McGraw‐Hill, 20051459–1485
  7. Smith DK, McDermott AJ, Sullivan JF. Croup: Diagnosis and Management. Am Fam Physician. 2018 May 1;97(9):575-580. PMID: 29763253.
  8. Sparrow A, Geelhoed G. Prednisolone versus dexamethasone in croup: a randomised equivalence trial. Arch Dis Child. 2006;91(7):580-583. doi:10.1136/adc.2005.089516
  9. Venn AMR, Schmidt JM, Mullan PC. A case series of pediatric croup with COVID-19 [published online ahead of print, 2020 Sep 15]. Am J Emerg Med. 2020;S0735-6757(20)30829-9. doi:10.1016/j.ajem.2020.09.034
  10. https://www.rch.org.au/clinicalguide/guideline_index/Croup_Laryngotracheobronchitis/
  11. https://cks.nice.org.uk/topics/croup/
Moral injury HEADER

Psychological distress in healthcare workers

Cite this article as:
Gladymar Perez and Rie Yoshida. Psychological distress in healthcare workers, Don't Forget the Bubbles, 2021. Available at:
https://doi.org/10.31440/DFTB.32653

We know that healthcare workers are at a greater risk of burnout, however you chose to define it. This study takes a look at the impact of COVID on the psychological distress of those on the frontline.

Roberts T, Daniels J, Hulme W, Hirst R, Horner D, Lyttle MD, Samuel K, Graham B, Reynard C, Barrett MJ, Umana E. Psychological Distress and Trauma in Doctors Providing Frontline Care During the COVID-19 Pandemic in the United Kingdom and Ireland: A Prospective Longitudinal Survey Cohort Study.

Background

This study aimed to assess the prevalence and extent of psychological distress and trauma of doctors working in the UK and Ireland during the first wave of the COVID-19 pandemic.   

Doctors working in Emergency Medicine (EM), Anaesthetics and Intensive Care Medicine (ICM) were asked to complete online surveys at the acceleration, peak and deceleration of the COVID-19 first wave, providing an insight into their psychological well-being at different phases of the pandemic. Exposure to previous infectious disease outbreaks have shown that elevated psychological distress is associated with the development of chronic stress, depression, anxiety, physical health problems, increased sickness rates, emotional exhaustion and impaired performance at work. Given that the COVID-19 pandemic will undoubtedly have a significant impact on the mental health of healthcare workers in the UK and Ireland, this study is important to understand the extent of the pandemic’s impact in these settings. The study also looked at personal and professional factors associated with increased distress in an attempt to identify those who are most at-risk and may benefit from early intervention.  

Methods

The study was carried out using a prospective online three-part longitudinal survey administered at the acceleration, peak and deceleration of the COVID-19 first wave.  Primary outcome measures were psychological distress and trauma, measured using the General Health Questionnaire for distress and the Impact of Event Scale -Revised for trauma.  These tools have been extensively utilised across different settings and cultures. The survey was distributed to doctors working in Emergency Medicine (EM), Anaesthetics and Intensive Care Medicine (ICM) in the UK and Ireland through existing trainee research networks, faculties and Royal Colleges.   Following participation in the first survey, the subsequent surveys were emailed directly to participants.  Survey distribution dates were decided based on public health data on the number of confirmed cases and deaths in the UK and Ireland.   The following dates were used:

  • Acceleration phase UK: 18/03/2020 – 26/03/2020, Ireland: 25/03/2020 – 02/04/2020
  • Peak phase UK: 21/04/2020 – 05/05/2020, Ireland: 28/04/2020 – 12/05/2020
  • Deceleration phase UK: 03/06/2020 – 17/06/2020, Ireland: 10/06/2020 – 24/06/2020

Personal and professional characteristics relating to participants’ current role, and their preparedness and experiences during the pandemic were also collected. 

Results 

Of the estimated 34,188 eligible doctors, the response rate for the initial acceleration survey was 15.9% (n=5440).  Peak and deceleration response rates were 71·6% (n=3896) and 56·6% (n=3079) respectively. (Ed. note- Though you could argue that the peak and deceleration responses were actually 11% and 9% of all eligible doctors). Prevalence of psychological distress was highest during the acceleration phase at 44·7% then declined through peak and deceleration phases of the first wave to a level comparable to pre-pandemic levels, reflecting a degree of natural recovery. The prevalence of trauma was highest at the peak of the pandemic at 23·7%. The figures for both psychological distress and trauma were substantially higher than for the general population.  The most significant personal and professional predictors associated with distress and trauma related to familial safety; personal safety and established mental health conditions.  Whilst ethnicity was not strongly associated with distress, it was a stronger predictor of trauma (R2 = 0·03).   

Strengths

This is a large-scale longitudinal study that prospectively examined the psychological wellbeing of frontline doctors, using GHQ-12 and IES-R, validated self-report measures for assessing  distress and trauma respectively. These outcome measures have been used in previous infectious disease outbreaks. A pre-specified analysis plan was published and is available online. 

This study included responses from 5440 frontline doctors throughout the UK and Ireland, an impressive response rate given that it was undertaken in the midst of a pandemic and was achieved thanks to the collaboration of multiple Emergency Medicine and Intensive Care research networks. (TERN, PERUKI, RAFT, ITERN, TRIC)  

Due to the extent of data collected, findings from this study offer an essential insight into the mental health of frontline doctors in an infectious disease outbreak.  These can be used to inform policy-makers on the development of interventions in the current pandemic and future outbreaks.  The three phase approach means interventions can be targeted in a timely manner.    

The study identifies ethnicity as a novel, key predictor of trauma.  By including the impact of ethnicity in the study the researchers have recognised the important role that ethnicity has played in this pandemic, given the higher rates of reported mortality in ethnic minority groups.  

Limitations

The surveys were distributed in a specific time frame that was based on the number of cases in both countries as a whole without accounting for the regional variation which occurred. 

As such, the researchers recognise that the variation in regional peaks may have influenced accurate capturing of psychological distress and trauma rates. In addition, pre-pandemic levels of distress and trauma in the cohort included in the study, remain unknown. 

There was a considerable drop-out rate in responses throughout the study with a 56.6% response at the final deceleration phase.  The researchers note that there was no significant difference in either the GHQ-12 or IES-R scores between those who dropped out and those who remained in the study.  However, the reason for participants’ lack of response is unknown and these participants may have been experiencing increased distress. Alternatively, a number of those without any concerns may have felt it no longer necessary to complete the survey, therefore, exaggerating the finding of significant trauma in those who did respond.

Don’t Forget about Malaria…

Cite this article as:
Emma Hulme and Chris McKenna. Don’t Forget about Malaria…, Don't Forget the Bubbles, 2021. Available at:
https://doi.org/10.31440/DFTB.32891

Sunday (April 25th) is a day to refocus our lens of the past 14 months living and working through the global COVID-19 pandemic and be reminded of the ongoing global battle countless countries are continuing to fight against Malaria. Today is World Malaria Day, a day to celebrate the victories, reflect on the challenges, stand in unity with our global colleagues and remember those many children and individuals who are still losing their lives to a preventable disease. 

Malaria is a life-threatening disease caused by parasites that are transmitted to people through the bites of infected female Anopheles mosquitoes. It is preventable and curable.

My first experience of how dangerous malaria could be was in Kenya in 2003. I was a febrile third-year medical student, sitting in the back of a pick-up truck following a seemingly endless dirt track to the nearest Health Centre with my unconscious friend who had just had a seizure.  Whilst we both had a rocky few days, we both made full recoveries and are counted amongst the privileged few to survive without ongoing sequelae. Malaria had managed to get through the defensive mosquito nets and antimalarials, but we had access to a vehicle for rapid transport, access to money for treatment, and some knowledge as medical students to ensure we got to the right place, at the right time, and got the right treatment. Many are not so fortunate.

Fast forward five years to Uganda in 2008. I would never get used to the cries of mothers who had carried their children unimaginable distances to our rural hospital only for it to be too late and then to watch the sight of them carrying their lifeless bodies home to be buried. It all just seemed so futile – if only they had a bed net or could have gone to a clinic sooner. Sadly, as in many preventable diseases, the most deprived communities are affected disproportionately and children under five years old carry the biggest death toll.

This year we have been bombarded with daily infection rates and death tolls as increasingly large figures appear on our screens. Clinicians and the public alike were shocked and horrified by these growing numbers. Have we become “statistic-fatigued”? Do the numbers no longer hold their impact? For those of us not living in a malaria-endemic area, the personal experiences are few and far between. These malaria statistics hold the stories of many but the identity of none. Let’s look afresh at these huge numbers and allow ourselves to be shocked and horrified, figures that have remained unacceptable for years, decades, and millennia.

The current yearly figures from WHO report 229 million cases of Malaria worldwide with a death toll of 409 000 the majority (67%) of these being children under 5 years old. That means a child is dying from Malaria every 2 minutes. This is not OK!

Data taken from Targetmalaria.org

 

A concerted global effort over the past few years has saved hundreds of thousands of lives with preventative malaria programmes. The World Health Organisation (WHO) estimates in excess of 1 billion malaria cases and 7 million deaths have been prevented since 2000. The number of countries being declared malaria-free is also increasing. This helps reduce huge systems and economic burdens on a country. The WHO’s E-2025 report is announcing that 26 countries and territories are within reach of zero malaria cases by 2025. This is really encouraging yet there is still a long way to go for many countries, particularly in Africa.  

Every Win Counts

Rural Bo District – Sierra Leone, 2011, Sitting in the shell of a clinic that had been built and subsequently abandoned by an NGO after the civil war, we see over one hundred children, sixty of these testing positive for malaria. A simple treatment, but with no health providers for two hours, one exceedingly difficult to access. 


Fast forward nine years, and I’m sitting in a similar rural setting in Bonthe District, but there is finally a referral process to ensure these children and their mothers can get to the referral hospitals in the major population centres for appropriate management and treatment. 

One of the most effective weapons in continuing this fight is the younger generation, those that grew up in a time where Malaria is no longer an unconquerable giant, but something that can be overcome.  The ‘Zero Malaria’ and ‘Drawing the Line’ campaigns empowered young people to keep taking ground. ‘’Malaria we will not let you steal from us anymore… We are the generation that can end Malaria!’’

Young people across Africa have seen the impact of malaria on their lives and futures and are motivated to take action. Even if malaria doesn’t kill, it prevents young people from going to school, realising their full potential, and building their futures. Recent surveys have shown that young people are keen to volunteer in distributing mosquito nets, sharing information about malaria, as well as engaging with their community and national policymakers to prioritise malaria. 

Malaria experiences from our colleagues at Mbarara University EMIG

As a medical student who has been trained in Uganda – a country where malaria is a major public health problem that is associated with slow socio-economic development and poverty, and the most frequently reported disease at both public and private health facilities. One always hears ‘Common things occur commonly and rare things occur rarely”. Malaria goes beyond being common in our communities; “You can’t just convince a senior house officer or attending that you have learnt something from their ward if you don’t know how malaria manifests in their speciality– for example malaria in pregnancy or severe malaria in paeds. We are expected to be “singing” (having them at our fingertips) the signs and symptoms, investigations, laboratory findings, the treatment plans, and the complications of malaria, like nothing else.

“It goes beyond experiencing malaria as clinicians—some of our colleagues had to become caretakers during their younger years to care for their parents suffering from malaria, which can leave some of them with traumatizing experiences. CoArtem and Panadol are like some food in the home. They should always be there” – Fourth Year Medical student MUST-EMIG.

“Complications of malaria are one of the popular things that we are commonly tested on about on ward rounds” – Fourth-year medical student and founder of MUST-EMIG

So back to 2021, COVID-19, and the challenges ahead…

There are real fears that the challenge of COVID-19 has been a huge threat to the progress made in eliminating Malaria. Many places have faced an increased burden on already fragile health systems. There have been disruptions to the distribution of materials including mosquito nets and antimalarials, as well as reports of increasing reluctance to seek medical care for patients with a fever due to the fear of the stigma of COVID-19. The WHO’s estimates that malaria interventions have been reduced by between 15 and 25 per cent during the pandemic. Furthermore, in 2020, the COVID-19 pandemic likely caused 40-50,000 excess deaths from malaria that otherwise could have been prevented. 

Behind the scenes underreporting also exists and the reality of the global refugee crisis and countless internally displaced persons (IDP) means many are facing ‘syndemics’ of COVID-19 and malaria, combined with any other crisis du jour in a variety of environments. 

So what has been happening with malaria elsewhere? 

Unsurprisingly, the number of malaria cases identified in 2020 in those with recent travel history to an endemic area have fallen. Malaria tests performed (on adults and children) at the Manchester Foundation Trust have fallen by 68% compared to 2019, with 92% fewer positive cases. As travel corridors start to re-open, those working in malaria-free countries will need to start thinking ‘could this be malaria?’ once again. While this fall in testing numbers is not surprising, it doesn’t mean that you shouldn’t include malaria on your list of differentials when warranted.  There is a great refresher on the website and here’s a memory jog for those of us who haven’t thought about malaria for a while.

Think Malaria

  • Fever or anaemia in a child who has recently returned from a malaria-endemic area
    • Ordering appropriate investigations (ideally timed with fever spikes)
    • Familiarise yourself with local protocols
    • Microscopy (thick and thin smears) remains the gold standard. Rapid Diagnostic tests are valuable, particularly in resource-limited settings, but are less sensitive
  • Involve infectious disease services early if required!
  • Severe malaria includes the clinical suspicion with confirmed parasitological and at least one of the following: 
  • High parasite density (≥5%)
  • Impaired consciousness
  • Seizures
  • Circulatory collapse/shock
  • Pulmonary oedema or acute respiratory distress syndrome (ARDS)
  • Acidosis
  • Acute kidney injury
  • Abnormal bleeding or disseminated intravascular coagulation (DIC)
  • Jaundice (must be accompanied by at least one other sign)
  • Severe anemia (Hb <7 g/dL)

OR

  • The inability to take any oral antimalarials even after administration of an antiemetic.
  • A child with malaria can have a bacterial co-infection, be sure to address that if suspected!
  •  It is vital to differentiate uncomplicated vs complicated (severe) malaria early.
  • Oral outpatient management for uncomplicated malaria is reasonable, but urgent inpatient management for severe malaria is required. 

A call to action

Moving forwards there is a call to urgent action to ensure that all the progress that has been made is sustained and built upon. Global and national leaders need to continue to prioritise funding and facilitate research and development into new interventions as well as the delivery of effective prevention and treatments to the most vulnerable areas. There needs to be ongoing recognition and support for those health care workers delivering care in such challenging circumstances to ensure access to Malaria prevention, testing and treatment for all. 

Ultimately, there is hope. The end is in sight and malaria eradication is possible. We had a great start with the Global Malaria Eradication Programme started in the 1950s, but the reality of the times prevented further success. Let’s not forget every child and family behind the statistics. Be outraged by the numbers but also encouraged by the wins. Keep talking about malaria. Encourage and support our global colleagues. Listen to their experiences, learn from them, and keep standing united together to eradicate Malaria.

What can you do today?

Share the post. Encourage our global colleagues today – we stand with you #endmalaria #zeromalaria #drawtheline #zeromalariastartswithme #worldmalariaday. Remember Malaria! Listen to your patients, take a travel history, ensure you make referrals appropriately. Engage the ID team early if you are unsure! 

Selected references

Dyer O. African malaria deaths set to dwarf covid-19 fatalities as pandemic hits control efforts, WHO warns. BMJ 2020; doi:10.1136/bmj.m4711

Mendenhall, E., 2020. The COVID-19 syndemic is not global: context matters. The Lancet, 396(10264), p.1731.

RBM Partnership to End Malaria. (2021). World Malaria Day 2021 Key Messages.

Singer, M., Bulled, N., Ostrach, B., & Mendenhall, E. (2017). Syndemics and the biosocial conception of health. The Lancet, 389(10072), 941–950. doi:10.1016/s0140-6736(17)30003-x 

World Health Organization. (2020). World malaria report. Geneva, Switzerland: World Health Organization.

https://targetmalaria.org/ Accessed 13/4/2021

https://endmalaria.org/ Accessed 13/4/21

https://www.theglobalfund.org/en/ Accessed 13/4/21

Haematology Laboratory Manchester University Foundation Trust (personal communication)

Dr Emma Hulme

MBChB, MPH, MRCGP, DTM&H, DCH, DRCOG, DFRSH

Emma works as a GP in a city practice and in the Emergency Department at the Royal Manchester Children’s Hospital. Before training in General Practice she worked in a number of countries overseas in maternal and child health roles and currently leads the Global DFTB Bubble. The rest of her time is spent chasing after her 3 little people and trying to find a quiet corner for 5 minutes peace!

Christopher McKenna, MPH

Chris is a former critical care paramedic turned final year medical student at the University of Queensland – Ochsner Clinical School in New Orleans, Louisiana. Originally from NJ, he has spent time working on pre-hospital system development in Somaliland and Sierra Leone, as well as time with various NGO/IGO in the Philippines. He is eager to return to Australia for his internship in 2022 with the ultimate goal of pursuing a career in PEM/EM. When not at the hospital, he can be found dreaming about travelling post-COVID, avoiding falling into the Gulf of Mexico/Mississippi River in the search of the perfect burger, or at pub trivia with his partner at a local brewery.

COVID and Hydroxychloroquine

Cite this article as:
Alison Boast. COVID and Hydroxychloroquine, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.24968

There has been lots of media attention around hydroxychloroquine use for COVID-19 in recent days, largely stemming from this press release where Donald Trump discussed its effectiveness.

 

However, as many have since pointed out, the evidence is very limited, and care needs to be taken when trying new drugs in a clinical context, even in a pandemic. There are many risks associated with using a drug for a new indication, particularly in patients who are otherwise unwell.

 

What is hydroxychloroquine?

Hydroxychloroquine is a prescription medication currently used in both adults and children for autoimmune diseases including lupus and for the treatment of malaria.

 

What is the evidence so far?

The evidence for hydroxychloroquine can be divided into two types – in vitro (in the test tube) and in vivo (in people).

In vitro evidence

The in vitro evidence for hydroxychloroquine is promising. It works in two ways:

  1. Direct inhibition of SARS-CoV-2
  2. Immune modulation

Severe disease occurs in COVID-19 due to the pro-inflammatory cascade and cytokine sstorm causing acute respiratory distress syndrome (ARDS). The inflammatory cytokine interleukin-6 (IL-6) has been particularly implicated in this pathway, and there is evidence to show that hydroxychloroquine has anti-inflammatory effects decreasing the production of a number of cytokines including IL-6.

In vivo evidence

The evidence for hydroxychloroquine in COVID-19 is currently limited to a few small prospective studies in adults. These studies have many methodological limitations increasing the risk of bias, and more randomised controlled trials are required before commenting on its efficacy. There are also concerning reports of cardiac toxicity with hydroxychloroquine use, which highlights the importance of only using new drugs in the context of clinical trials.

 

What evidence is there in children?

In short – none!

So far there have been no clinical trials of hydroxychloroquine in children. As it is already used in children with other conditions, we do know that is safe in the ‘well’ child and have some information about appropriate dosing. However, if it is prescribed to children with moderate to severe disease COVID-19, we cannot assume that the distribution around the body and clearance (pharmacokinetics) and its interaction with the body (pharmacodynamics) is the same.

 

Where to from here?

As per the World Health Organisation experimental therapies should not be used outside of registered clinical trials. The future use of hydroxychloroquine in children with COVID-19 is therefore dependent on whether clinical trials are conducted.

 

Why is this important?

For any new therapeutic agent to be used in children it requires the same rigorous assessment in clinical trials in adults. Often due to ethical issues and the inherent challenges of performing clinical trials with children, these studies do not occur. This is a huge issue in paediatrics in general, as almost all new drugs are only tested thoroughly in adults.

Paediatricians are often forced to prescribe drugs ‘off label’ (use of drugs for a different age group, indication, dosage, frequency or route) or ‘unlicensed’ (where a drug is used despite it not being approved by the licencing body such as Therapeutic Goods Australia). Many commonly used drugs are actually prescribed ‘off label’ including ondansetron, salbutamol and even paracetamol. There are well-documented risks of adverse effects with off-label and unlicensed prescribing. Without clinical trials there is no other option.

 

In conclusion…

It would be great if hydroxychloroquine was the wonder-drug we were all waiting for, with the in vitro data certainly promising. However, further clinical trials to assess its efficacy and safety are required, particularly before its use in children.

 

References

Liu J, Cao R, et al. Hydroxychloroquine, a less toxic derivative of chloroquine, is effective in inhibiting SARS-CoV-2 infection in vitro. Cell Discov. 2020;6:16.

Mackenzie AH. Dose refinements in long-term therapy of rheumatoid arthritis with antimalarials. Am J Med. 1983;75(1a):40-5.

Yao X, Ye F, et al. In Vitro Antiviral Activity and Projection of Optimized Dosing Design of Hydroxychloroquine for the Treatment of SARS-CoV-2. Clin Infect Dis. 2020.

Chen Z, Hu J, et al. Efficacy of hydroxychloroquine in patients with COVID-19: results of a randomized clinical trial. medRxiv. 2020. **PREPRINT

Chen J, Liu L, et al. A pilot study of hydroxychloroquine in treatment of patients with common coronavirus disease-19. J Zhejiang Univ (Med Sci). 2020;49(1):0-.

Gautret P, Lagier JC, et al. Hydroxychloroquine and azithromycin as a treatment of COVID-19: results of an open-label non-randomized clinical trial. Int J Antimicrob Agents. 2020:105949.

Coomes EA, Haghbayan H. Interleukin-6 in COVID-19: A Systematic Review and Meta-Analysis. medRxiv. 2020:2020.03.30.20048058. **PREPRINT

Savarino A, Boelaert JR, et al. Effects of chloroquine on viral infections: an old drug against today’s diseases? Lancet Infect Dis. 2003;3(11):722-7.