There is a significant amount of research being carried out on COVID-19. Scientists around the world are working to understand the chemical structure of the virus, how it attaches to cells in the lungs, and how that process can be slowed using medication.
Here, Dr Kieran Breen, our Head of Research and Innovation, answers some questions about the disease, busts some myths, and explains more about social distancing…
What is the psychological impact of the virus?
An article published recently by King’s College London has examined the potential impact of the COVID-19 pandemic on mental health, which is an area of increasing global concern. The study looked at the changes in adult mental health in a large number of people in the UK, before and during the lockdown. Both having COVID-19 itself and the strict lockdown measures had an impact on every aspect of day-to-day life. The lockdown had restrictions on social contact, the ability for many people to work, and reduced access to services.
Initial results obtained in late April 2020 reported that mental health in the UK had deteriorated compared with pre-COVID-19 trends. These emphasised the needs of women, young people, and those with preschool aged children. There was a serious impact on employment and livelihoods, income, and personal debt. There is also a substantial amount of worry about future insecurity. Current studies are being carried out to determine whether the easing of restrictions can reverse some of these worries.
How can I take part in vaccine trials?
A new NHS service has been launched to help people across the UK sign up for information on new COVID-19 vaccine trials. The new NHS Covid-19 vaccine research registry will help large numbers of people be recruited into the trials over the coming months, potentially leading to an effective vaccine being identified and made available to the UK public against coronavirus earlier. It has been developed as part of the UK Government’s Vaccine Taskforce. There are a number of vaccines being identified and safety-tested at the moment, but only large scale trials can give scientists the information needed about how effective they are.
The National Institute for Health Research (NIHR) working with the NHS aims to recruit over half a million people onto the registry, which will allow people to be put in touch with the vaccine trials in the coming months. Researchers are looking for people from all backgrounds, ages and parts of the UK, including both people with or without existing health conditions, to take part in vaccine studies, to make sure that any vaccines developed will work for everyone.
The service is available to anyone aged 18 or over, living in the UK. To register, people fill in some personal and contact details, and answer a series of basic health screening questions on an NHS.UK website form. When a suitable volunteer has been identified, the researchers will send an email or text to anyone who matches the criteria for their study. This will provide more information about the study - and offer the user the opportunity to contact the research team and find out more, or express an interest to take part. To find out more, visit: www.nhs.uk/researchcontact. More information about taking part in research and other opportunities to take part in COVID-19 research can be found at www.bepartofresearch.uk.
More about antibodies
We have now had a chance to follow people over time after they have developed and then recovered from the symptoms of COVID-19. This will help us to understand better the condition as well as to inform various treatments including the development of vaccines. Most of the studies have concentrated on antibodies in the blood rather than also assessing t-cells, so we only see half of the picture. The trend appears to be that those who have had a mild form of the disease, or may even have been asymptomatic, rapidly lose expression of the antibodies. However, people with very severe symptoms retain very strong antibodies. This underlines the importance of monitoring antibody levels following vaccination, as well as monitoring the t-cell response. However, it also questions the value of the antibody test, at least for some people.
How can the virus be transmitted?
A recent letter submitted to the WHO from an international group of scientists has suggested that, in addition to the virus being transmitted in droplets such as when you sneeze or cough, the virus can also be present in the air in much smaller particles.
There isn’t strong evidence for this yet, but it is something that we need to take into account. So, in addition to wearing masks to prevent the virus being released by those who may be infected, in order to protect others, we need to consider that the virus may remain in the air for longer than we had previously thought.
The best way to deal with this is to ensure that there is good air circulation so that any virus that is in the air can be removed. Ordinary air conditioning, such as the use of fans, is not sufficient as this just moves the virus around. Therefore, wherever possible, the best approach is to open a window in order to ensure that the air circulates well and that any virus can be removed from enclosed spaces. But the wearing of masks is key to preventing transmission.
I would recommend that people do so in order to remain safe.
Is there any update on the body’s immune response to the virus?
Recent research from London has suggested that the level of antibodies against the COVID-19 virus within the blood may decrease after time, potentially making people more susceptible to getting COVID-19 for a second time. This is especially so for those who had a mild form of the disease or even those who were infected but who did not develop the symptoms.
But other research in Sweden suggests that other elements of the immune system may also play a role in the development of longer-term immunity. Antibodies are produced by B cells, but these are only one part of the immune system. We also have T cells, which can be considered as memory cells and maintain elements that can recognise foreign agents, such as viruses, for a longer period of time.
However, these are not detected by normal antibody tests. Normally, when a foreign agent such as a virus enters the body, the B-cells produce an antibody to spark off an immune response to remove it from the system. But, in certain cases, T-cells are activated to develop the immune response and these maintain a longer and stronger immunity. This has only been studied in a small group of patients in a trial in Sweden, so more research needs to be carried out to confirm this. However, if it is confirmed, it could be very important as it will have an impact on the development of a vaccine against the virus.
Does the virus affect on the brain?
As researchers continue to assess the longer term impact of COVID-19 within the body, there are reports that the virus may have an effect on the brain. There is an increase in the incidence of stroke in people who have been diagnosed with the disease and there have also been reports of delirium, anxiety, confusion and fatigue.
We don’t know yet whether this is due to a direct effect of the virus on the brain cells or a secondary response following the activation of the body’s immune system to the virus. It is important to monitor all of this information so to build up a better understanding of the condition and how it may develop in the longer term.
People who have been diagnosed with COVID-19 and consider that they have developed longer-lasting symptoms associated with the virus should report these to their GP or specialist so that they can be monitored over time.
What does antibody testing tell us?
Antibody testing has been introduced for NHS staff and will eventually be made available for other key workers, although no date has been announced.
The aim of the test is to tell us whether somebody has previously been infected with the coronavirus and has therefore developed an immune response. A recent research publication has reported that the level of immunity varies very much between people and we don’t know how long the immune response will last.
The findings suggested that some people who developed mild symptoms at an early stage may no longer have this immunity. This could be due to their body being able to deal more efficiently with the virus at the early stage, thus accounting for the mild symptoms, although they may not have developed a lasting immune response.
The study suggested that younger people with mild symptoms lose the immunity faster than older people with more severe symptoms. However, this was only one study and others are required to confirm this, although we must not assume that all those who have been diagnosed will have a long-lasting immunity to the disease.
This information will also be of particular interest in the design of vaccines and how long they may be effective.
Can I catch COVID-19 a second time?
Following on from the previous point, we don’t yet know whether you could be able to catch the disease a second time. If you lose the immunity, it may be possible to be re-infected, and we don’t know how long the immune response lasts or how strong it is.
There have been stories in the media about people having it a second time, although this refers to the symptoms rather than people who had a definitive test.
This is why those identified by the “test and trace” system need to self-isolate, even though they may have previously had the disease. We need to remain cautious and consider the potential of catching it again, and always maintain good hygiene and social distancing wherever possible.
Why is there a lower incidence in children and young people?
While there has been a report for a relative increase in the number of cases of COVID-19 in children and younger people, this is still much lower than older people or those with a greater susceptibility to the condition.
Children generally have milder symptoms of COVID-19. However, a small proportion develop a severe disease requiring ICU admission and prolonged ventilation, although death is extremely rare.
The challenge is that some people consider children as “disease carriers” – they get infected with the virus although they do not develop the symptoms. So, this may impact on whether there could be a second wave when the schools open in September.
What is the drug remdesivir?
Remdesivir is a drug that was originally developed to treat the Ebola virus, although it was not particularly effective. It has also been tested on other respiratory viruses including SARS and MERS.
Results from initial trials on COVID-19 have suggested that it may shorten the recovery times (by around four days) of some patients, although it has not been found to significantly improve a person’s overall chance of surviving the disease.
The drug is most effective when it is given to a patient at an early stage. It acts to block the virus from duplicating itself and therefore overwhelming a person’s immune system. It has been licensed to treat people hospitalised with severe COVID-19 who have specific symptoms and will not be suitable for all patients.
There have been stories that the US has purchased all of the world’s stock and that it will not be available elsewhere. However, there are currently stocks in the UK, which should be sufficient based on the projections of the number of cases.
What is contact tracing?
Once we come out of lock-down, it is important that we ensure that the spread of COVID-19 is kept to a minimum. The Government has proposed that those who are in close contact with a person diagnosed with the condition should be informed and tested so that they can be isolated as soon as possible, if they have developed it. This could be done, for example, using a mobile phone app that detects who you have been within two metres of. It sounds simple, but it will actually be more complex. For example, the NHS have one app, and apple/google have another, and they are unlikely to be compatible. People then need to have them on their phone which is switched on. The 100,000 tests for COVID-19 per day will also need to be in place. This has been tried in other countries using different approaches. South Korea has successfully used a tracking app through smartphones to trace contacts, although there are some concerns about privacy with this approach. Other areas have adopted more low-tech approaches. For example, San Francisco has asked public health professionals to conduct voluntary phone interviews with COVID-19 patients, and they then call anyone that the patient has been in contact with and ask them to quarantine themselves for 14 days. Whatever approach we finally adopt in the UK, it will be vital to ensure that the spread is kept to a minimum and that people who develop the condition are identified at an early stage and isolated.
Could stem cells provide a cure?
There have been a number of stories in the press reporting trials from other countries which report that stem cells could provide a cure for COVID-19. There is no evidence that this is the case. If stem cells are injected into the body, it is unlikely that they will actually get to the lung. Even if they do, the chance that they will change into lung cells to replace the cells which have been damaged by the virus is minimal so it is difficult to understand how they would actually provide any benefit for patients.
What is “inflammatory syndrome” in children?
There have been a number of reports of children developing a sudden inflammatory response. However, not all of these have tested positive for COVID-19 so it is not clear whether the condition is associated with the disease. Other viruses or factors may also be responsible. However, the number of cases is very low and these are being monitored closely.
How long does the virus last on surfaces?
A report has been published with updated information on how long the virus lasts on different surfaces. The evidence suggests:
It is important that all surfaces are cleaned thoroughly in line with current guidelines.
When is a vaccine likely to be available?
When the virus enters the body, it sparks of an immune response with the generation of antibodies in the bloodstream. These are specific for the virus, bind to it and remove it for the system. These then should provide immunity against it and remove it from the system if it enters again. To generate a vaccine, we need to use a part of the virus that will generate antibodies against the virus, recognise it and destroy it if somebody becomes infected. This will ensure that people don’t develop the symptoms. A large amount of work has gone into understanding the structure of the virus and predicting which part is most likely to spark of the immune response against it without it actually causing damage to the body. This can be a delicate balance and can take months or even years. A coordinated effort around the world has meant that clinical trials on potential vaccines are now starting. The initial studies will assess whether the part of the virus used as the vaccine is safe, so the study starts with a very low dose and works up.
The vaccine should also be effective – it produces an immune response, which is specific for the vaccine and will remove it from the system without attacking other parts of the body. This is the stage that is almost impossible to predict. We may get a particle that generates a strong and specific response from the start, or we may need to tweak it to generate variations until we are certain that the protein used as the vaccine is both effective and safe. The next challenge then is actually producing it in large enough quantities. Unlike a normal chemical drug like aspirin, the vaccine usually needs a more complex manufacturing process, so will take longer. We also need a large number – possibly billions. So, realistically, it is likely that a vaccine won’t be available for routine use until early next year. But, based upon the effort that has gone into this around the world and speed at which we have reached this stage, I hope that this may be earlier.
Will the number of cases decrease in the summer, like flu?
As COVID-19 is a new virus, it is difficult to predict how it is going to progress within the community. The main reason why there are fewer cases of the flu in the summer is that we are generally healthier. We can travel and get more fresh air; therefore, there is a lower chance of the flu virus being transmitted. However, we can’t predict what will happen with COVID-19.
Firstly, it spreads much more rapidly. It is estimated that flu is transmitted from one person to another at a rate of 1 to 1 (or less). For COVID-19, this can be 1 to 3 i.e. one person with the condition can infect up to three others if they are in direct contact. However, not all will develop the same symptoms, and some may never even realise that they have been infected by the virus.
Based on the flu, the transmission should decrease in the summer, but there are so many other factors involved so it is impossible to predict at the moment. The lock-down is having a positive effective on the spread of the virus. However, the end of the lock-down will probably coincide with the onset of summer so there will be many factors which will impact on the rate of transmission.
Why do the symptoms differ between patients?
We know that some people are more at risk to the effects of COVID-19, including those with respiratory conditions such as asthma as their lungs are generally weaker. Similarly, the elderly are generally more fragile and less well able to deal with infection. To understand why two similarly healthy younger people will respond very differently to the virus, we need to understand how it acts.
When it enters the body, it targets cells in the lungs. The Coronavirus specifically binds to a protein that is present on the surface of cells in the lungs. It is possible that some people will have greater levels of this protein than others, so this will put them at greater risk. However, it is currently not possible to detect the levels.
Once the virus binds, it then sparks off an immune response and this is what gives rise to the clinical symptoms. Again, this will vary between people. An example is how people respond to pollen and develop hay fever. Some people will never get it, while others do, and some quite badly. Additionally, with hay fever the symptoms can differ - with some people sneezing (due to an immune response in the nose) or others wheezing due to an immune response in the lungs.
What about the two-metre distancing rule?
The two-metre guide was introduced based on an estimation of how far small droplets could travel through the air after a person has sneezed or coughed. However, a recent study from Belgium has looked at people as they move. If you cough as you walk along, the droplets will remain in the air - in your “space” – for the person coming behind you. They suggested that for people walking at a normal speed, you should be three metres behind the person in front. For jogging, this should be 10 metres and for cycling, 20-30 metres is best. This will allow the droplets to disperse before the person behind comes along.
Can I catch COVID-19 a second time?
The current evidence suggests that once you have had the infection, you build up a certain level of immunity against the virus and are therefore unlikely to develop the symptoms again, at least in the short term. However, as it is a new virus, we don’t know how long this will last. Based on other viruses, it is likely that the immunity will last for at least a number of months. This is one reason why the diagnostic tests to test for antibodies – which are produced when somebody has had the disease – will be important. However, these are not yet available and are still in the early stages of production.
Hydroxychloroquine is being used in the US to treat COVID-19. Should it be prescribed here?
There is currently no solid evidence that it is effective, although some people who have “self-medicated” with the drug have suffered severe side effects with one death. A number of trials are currently being carried out in Europe. An anti-viral drug, Remdesivir, has also been approved for use in Europe for the treatment of a small number of cases with very specific symptoms and a number of trials are also underway.
Has there been any confirmation on whether the virus survives longest on hard or soft surfaces?
The virus will survive equally long on both hard and soft surfaces. However, it is more unstable in liquids, although it can only be destroyed using soap or hand gels (wash your hands for 20 seconds) and it can remain active for some time in stagnant water. It will only be destroyed at relatively high temperatures – usually greater than 60 degrees. While it is less stable in a freezer, this alone is insufficient to destroy it. So, you should wash your hands before cooking and it is recommended to wipe all surfaces and products with an anti-bacterial wipe to keep them clean.