The first time your team treats COVID-19 in the community

First, you save yourself

• Get vaccinated and encourage your colleagues to be vaccinated.
• Wear a mask.
• Wash your hands.
• Screen patients for COVID-19 symptoms and risk (epidemiological and contact).
• Keep “red” and “green” streaming.
• Improve ventilation in your rooms if you can.
• If you can’t improve ventilation, consider the value of HEPA filters.
• Have a conversation as a team – “What if we had to manage five to 10 people at a time selfisolating at home with COVID-19?”

There is a predictable future in which people in New Zealand with mild to moderate disease caused by SARS-CoV-2 will be managed in their own homes by their GP teams. When this will happen at scale is unclear, but on 3 October, there were 31 active cases at home or in self-isolation.¹

We know that “breakthrough infection” happens in the vaccinated. We know that vaccinated and unvaccinated people with infection have similar viral loads in the early stages of infection, and we can assume they have similar ability to transmit the virus.²

We know there will be transmission and cases of COVID-19 in the pool of unvaccinated people in our community. With the widespread availability of vaccination services, the unvaccinated will be those too young and those who have opted not to be vaccinated.

Remembering that “all models are wrong, but some are useful” (British statistician George Box), Te Pūnaha Matatini recently published a report predicting the impact of a COVID-19 outbreak in New Zealand within various contexts. In particular, the modelling explores how different rates of vaccine coverage might affect the health burden from COVID-19.³

We could reach a state where 85 per cent of the eligible population over the age of five years is vaccinated. This is realistic based on the current vaccine uptake and what we are seeing with childhood vaccination rates, and with the expectation that Medsafe will approve the Pfizer–BioNTech COVID-19 vaccine for the five-to-12 age group, as has happened overseas. The vaccine does appear to still be highly effective against the dominant Delta variant.

Let’s assume society will tolerate continued baseline public health measures, such as improved air filtration and ventilation requirements, or, where these cannot be met, mandatory mask use and some density or capacity restrictions for indoor venues. Imagine that vaccine passports are in use, there is support for people to isolate, and rapid testing occurs at workplaces and schools.

Let’s predict that continued investment in, and the impact of, what the authors of this modelling describe as the current strong “test-trace-isolate-quarantine system” is no longer politically acceptable after we reach a certain level of vaccine uptake,3 as we have seen in the UK and other countries.

Given these assumptions, the model predicts approximately 5546 cases, 311 hospitalisations, and 33 deaths over a 12-month period.³

Further scenarios can be found in the report. For example, in an ideal world with 95 per cent vaccine uptake for the over-fives, maximal test-trace-isolation-quarantine, baseline public health measures and a highly effective vaccine, the number of predicted cases is as low as 532, with 18 hospitalisations and two deaths over a year.³

This caseload could be handled in current managed isolation and quarantine facilities, but a more realistic scenario sees facilities overwhelmed and an expansion of the current numbers being cared for at home or in self-isolation.

The Ministry of Health makes it very clear in their Primary care quick reference guide that “the responsibility for the clinical care of people undergoing investigation for COVID-19 and those with confirmed COVID-19 who are not in a managed isolation facility, rests with their general practice team”.⁴

DHBs and public health units are charged with developing “wrap-around” systems to provide social and welfare supports for people isolating at home, but we are expected to “closely monitor the severity of their illness, their comorbid conditions and clinical state”.⁴

To help, we are directed to support in our local HealthPathways tool (healthpathwayscommunity.org).

Work is being done at a national level to update this resource, to make it even more user-friendly, and to invest in the telemonitoring equipment and time that will be needed from GP teams to manage COVID-19 in the community, but “good things take time”

Professor Dee Mangin recently shared the experience of the team she leads at McMaster Family Medicine in Ontario, Canada, where, on the background of 600 cases being diagnosed a day at the peak of the initial pandemic response, practices were monitoring 10 to 15 patients with COVID-19 in the community at any time.

They found that telemonitoring equipment was needed at around two to three pulse oximeters per 1000 patients on a practice list, and they set up daily telephone “ward rounds” to check in with patients. A recording of the webinar is available online (tinyurl.com/CommunityCovidWebinar).

The processes and protocols they used are also well worth exploring (tinyurl.com/CovidPathway). The most used sections are highlighted in a glorious salmon pink (Figure 1). Professor Mangin’s team have committed to keeping the management section updated with the latest guidance, but remember, this is relevant to the Canadian health system and the medications that are accessible there.

Here in New Zealand, PHOs across the country are working on resources to support practices during COVID-19 as we await the development of national guidance. Several resources are available on the Pinnacle website (tinyurl.com/ PinnacleResources).

For example, we have developed a “one-page guide” to home monitoring – Triage and follow up of patients with potential/proven COVID-19 – which can be downloaded, printed and stuck on a wall above your telehealth station to support clinical decision-making during a daily “phone round”.

Using the best scoring tools we could find, and a pragmatic approach to the limitations of telehealth monitoring, this flow chart supports practices to stratify patients as low, modest, moderate or high risk.

It provides tools to assess the level of clinical impact of the disease and suggests appropriate ongoing management, including supporting the decision not to admit but to provide people with palliative care if their age and comorbidities suggest there will be no significant benefit from in-hospital treatment.

The majority of people who get COVID-19 have either asymptomatic disease (12 per cent) or mild to moderate symptoms lasting five to 14 days. Symptoms tend to arise about two to five days after a person has been infected, but can take up to 14 days to show. The virus can be passed on to others before the infected person knows they have it – from up to two days before symptoms develop.

The now dominant Delta variant presents with “classical symptoms” (fever 72 per cent, cough 46 per cent, sore throat 34 per cent, shortness of breath 19 per cent, nasal congestion/runny nose 16 per cent) similar to those for the Alpha, Beta and wild-type variants.⁵

There are two danger periods for disease progression: around day five to six after symptom onset, when patients may get increasingly breathless as viral pneumonia develops; and day 10 to 12, when an overwhelming immune system “cytokine storm” can result in shock and multiorgan failure (Figure 2).⁶

Monitoring of patients in the community aims to identify and support the 80–90 per cent of people who will recover without treatment other than symptom support, care for those whose premorbid state means they would not benefit from intensive care, and get the 10 per cent who progress to the right place for the right care at the right time. This may require daily, or in some cases twice daily, tele-health consultations for up to 14 days.

There is a national therapeutics committee developing New Zealand-specific recommendations on pre-hospital COVID-19 management, which will provide up-to-date guidance when we need it. Currently, experience from overseas signals we may need to be able to flex into providing more than just symptomatic support for people we are managing in the community.

In the US, “infusion clinics” are proliferating to provide access to monoclonal antibody treatments, such as sotrovimab, which may reduce progression to serious disease in some people.⁷ Inhaled budesonide may improve the time to self-reported recovery by two to three days in a subgroup of people,⁸ and colchicine may reduce progression to severe illness by 1–2 per cent in people with PCR-confirmed COVID-19.⁹

These and many other medications are under investigation (search for “COVID-19” on clinicaltrials.gov), but the mainstay of current treatment is “PHEFR” (paracetamol, honey, eat well, fluids and rest).

Approximately 10 per cent of people will have symptoms that extend for several weeks or months. Long COVID was discussed in detail in an earlier article (“First time”, New Zealand Doctor, 1 September). These patients will often require a multidisciplinary approach to care.

One key role that GPs can play, described in a useful article from Trish Greenhalgh and colleagues from the UK, is to validate the story of patients, who often feel rejected by the system as their complex and difficult-to-control symptoms defy confirmatory testing and medical intervention.¹⁰

Jo Scott-Jones is medical director for Pinnacle Midlands Health Network, has a GP practice in Ōpōtiki and works as a GP across the Midlands region