key: cord-0798865-3b5f46hs
authors: Rollett, Rebecca; Collins, Michelle; Tamimy, M Sarmad; Perks, A Graeme B; Henley, Mark; Ashford, Robert U.
title: COVID-19 and the Tsunami of Information
date: 2020-09-20
journal: J Plast Reconstr Aesthet Surg
DOI: 10.1016/j.bjps.2020.08.112
sha: 9d5a3ba878cd3e6a6bcf27770d9e2a0db783af6f
doc_id: 798865
cord_uid: 3b5f46hs

COVID-19 is the infectious disease caused by the recently discovered coronavirus, SARS-CoV2. This new virus and disease were unknown before the outbreak began in Wuhan, China, in December 2019. The number of publications COVID-19 related is exponentially increasing but there are also some retracted papers appearing on PubMed including those retracted from The Lancet Global Health and the New England Journal of Medicine. In a PubMed search for ‘COVID’ there were 1595 articles by the 1(st) April 2020. As of June 30(th), the number of articles has now reached 25913. In this editorial, 4 specific areas of information are looked at but the principles apply to many other areas of medicine. The specifics looked at are PPE for tracheostomy, testing for COVID-19, pregnancy and COVID-19 and surgical expectations during redeployment. We must make no mistake that we are seeing a disease that modern medicine has never encountered before. This article is not aimed at belittling or dismissing any of the advice of the Royal Colleges’ or PHE advice, but it demonstrates the tsunami of information and the ambiguity that surgeons are experiencing throughout the UK right now This is unlikely to be the end of progression regarding health care planning and development for un-encountered viruses(9). In the next few months and beyond there are likely to be adaptions and revisions of more documents advising on various aspects of health care surround COVID-19 management and for possible future viruses not yet seen by the modern world before.

In this editorial, 4 specific areas of information are looked at but the principles apply to many other areas of medicine. The specifics looked at are PPE for tracheostomy, testing for COVID-19, pregnancy and COVID-19 and surgical expectations during redeployment.

We must make no mistake that we are seeing a disease that modern medicine has never encountered before.

This article is not aimed at belittling or dismissing any of the advice of the Royal Colleges" or PHE advice, but it demonstrates the tsunami of information and the ambiguity that surgeons are experiencing throughout the UK right now This is unlikely to be the end of progression regarding health care planning and development for un-encountered viruses 9 . In the next few months and beyond there are likely to be adaptions and revisions of more documents advising on various aspects of health care surround COVID-19 management and for possible future viruses not yet seen by the modern world before.

COVID-19; COVID; Tracheostomy; PPE. In a PubMed search for "COVID" there were 1595 articles by the 1 st April 2020. As of June 29 th , the number of articles has now reached 25913. This creates a risk of information overload. There remains ambiguity about how, as surgeons, we should be protecting ourselves, our families and our patients.

In this editorial, 4 specific areas of information are looked at but the principles apply to many other areas of medicine. The specifics looked at are PPE for tracheostomy, testing for COVID-19, pregnancy and COVID-19 and surgical expectations during redeployment.

Table1 demonstrates the number of citable articles on these various topics with relation to COVID-19 as of the 29 th June 2020. In early March health care workers were being swabbed only if they presented as an inpatient with symptoms. As we entered April, more trusts were rolling out routine swabs for symptomatic frontline staff, starting with Critical Care staff. As April progressed it included swabbing all symptomatic healthcare workers (HCWs) and any symptomatic family members of theirs, including children -initially only over 5s, at the end of May it included the under 5s as nurseries and primary schools started their plans for reopening. As of the end of April any symptomatic key workers, not just HCWs, or their family members are being swabbed, aiming for key workers to be able to return to work as soon as possible if there is a negative result, rather than the 14 days asymptomatic isolation period. Now antibody testing is being rolled out for frontline HCWs. False negative results are reportedly up to 30%, although little is published on this. This means that many asymptomatic people or those with mild symptoms may return to work earlier than the recommended 7 days isolation. Currently with a negative swab, being afebrile for 48 hours and feeling well enough to work means that one can return. Advice is given regarding consideration of wearing surgical masks for all tasks (other than where FFP2/3 is indicated) if coughing is a symptom. After a positive result, one can return after 7 days if there has been no fever for 48 hours and the individual feels well enough to return. Our current practice at NUH, for any symptomatic health care workers who test negative for COVID-19, are still self-isolating for 7 days.

There was also ambiguity around guidance for pregnant HCWs, including surgeons. Initial guidance released from the Royal College of Obstetricians and Gynecologists stated that pregnant women were at no theoretical increased risk. They subsequently (four weeks later) changed their guidance to account for the psychological stresses that this would impose on pregnant mothers and an occupational health advice document was published online 7 (27/4/2020) which included a section for pregnant HCWs. Some of the guidance (or lack of) was taken from that of SARS-1 epidemiology from 2003 onwards. The guidance changed not because of any evidence but because HCWs were brought into focus on this matter.

So far, reported complications in pregnancy are uncommon, however, the virus has only been in existence in humans for 6 months so time will tell if there are, as yet unreported concerns.

The RCOG guidance and FAQs 8 state "from a recent UK study of 427 pregnant women with coronavirus…one in 20 babies born (12 babies in total) had a positive test for coronavirus, but only half of these babies -6 babies -had a positive test immediately after birth, suggesting that transmission of the coronavirus infection from a woman to her baby is low" so there is evidence that vertical transmission is occurring.

There is also evidence in the same study that "although almost one in five were born prematurely and were admitted to a neonatal unit, fewer than 20 babies were born very prematurely (when the women were less than 32 weeks" pregnant)"

At the time of publication there were no reported problems with foetal development or in the early neonatal period even in those infants who have subsequently tested positive for coronavirus. This article is not aimed at belittling or dismissing any of the advice of the Royal Colleges" or PHE advice, but it demonstrates the tsunami of information and the ambiguity that surgeons are experiencing throughout the UK right now. It"s understandable that as we gain more information about this virus, the guidelines and recommendations will continue to be updated. Despite having this understanding, in practice, these constantly changing and differing guidelines create risks not only for the HCWs but also for the patients. This becomes even more relevant as the community infection transmission rates have started to go down, the main source of infection may be the asymptomatic HCWs. Ambiguity is unhelpful in these circumstances.

Whilst there may be further changes to some of these documents most local teams are being

advised "wear what you feel safe in" until there is some clear guidance.

We must make no mistake that we are seeing a disease that modern medicine has never encountered before. We can only work off evidence and assumptions from previous diseases, such as SARS-1, on a remotely similar scale to this.

This is unlikely to be the end of progression regarding health care planning and development for un-encountered viruses 9 . In the next few months and beyond there are likely to be adaptions and revisions of more documents advising on various aspects of health care surround COVID-19 management and for possible future viruses not yet seen by the modern world before.

There are no conflicts of interest or funding associated with this submission.

CCC For Tracheostomy in COVID-19 Patients (2 nd version

Severe Acute Respiratory Syndrome Coronavirus as an Agent of Emerging and Reemerging Infection