The College of Optometrists has announced that, from Monday, June 15, ‘optometrists across England can expand their services beyond urgent and essential care. Optometrist practices will be able to provide patient care depending on their needs and symptoms, while still prioritising essential and urgent cases.’ This is because we are now entering what is described as the amber phase of lockdown (figure 1).
What is unclear is the detail of prioritisation. Some practices will be offering routine services under amber which, as not qualifying for Covid payments, are only available to patients able to pay privately. This is likely to continue until GOS services resume and, if the Covid payments cease at the end of June as is suggested, there may be a period where private services only are available in England.
Figure 1: Infographic from the College of Optometrists for the amber phase
Patient Passes
There has for some time been discussion about issuing ‘passes’ to people who are thought to no longer offer any threat of infection of Covid-19 to others. This might include people who have recovered from the disease and carry antibodies that might resist further infection. Though there is yet to be confirmation of such immunity existing and, despite concerns from many about the implications for civil liberties in creating a sub-group of people with preferential freedoms, I noticed the first of such passes becoming available. Through the private medicine provider CrossBorderMedCare, travellers and employees in the hospitality industry in Greece who receive a Covid-19 antigen test will be able to apply for a CoronaPass. The scheme enables users to apply for a pass based on their test results or other criteria demonstrating they are at a lower risk of carrying the virus. Following approval, they receive a CoronaPass QR code that can be stored on mobile devices (similar to downloading a boarding pass) or printed and presented for validation when necessary. I suspect this may be just the first of such schemes and so worth keeping an eye on.
Convalescent Plasma Trials
Matt Hancock made much play of his volunteering to donate plasma, having recovered from Covid-19, to support stocks of plasma for use in transfusions that would provide improved resistance to vulnerable patients. Volunteers are being sought and can register for donation at www.nhsbt.nhs.uk/how-you-can-help/convalescent-plasma-clinical-trial. Admirable as this scheme is, a major report out this week from the Wuhan area casts some doubt on the usefulness of such plasma donation.1 The randomised clinical trial included some 103 patients and looked at the time for clinical improvement within a 28-day period between those receiving plasma and those who did not. Though (happily) a lack of infected patients meant that the trial was terminated sooner than had been planned, no significant benefit was seen among the patients receiving the plasma. The researchers concluded, ‘among patients with severe or life-threatening Covid-19, convalescent plasma therapy added to standard treatment did not significantly improve the time to clinical improvement within 28 days.’
Chloroquine
Now that the use of chloroquine as a treatment for Covid-19 has been seriously questioned, a report this week suggests it has no benefit as a prophylactic drug. A double-blind trial examined outcomes in 821 asymptomatic participants in the United States and Canada who were randomly assigned to receive hydroxychloroquine or placebo within four days after spending more than 10 minutes within six feet of someone with confirmed Covid-19. The study concludes, ‘the data do not support the use of hydroxychloroquine as postexposure prophylaxis for Covid-19.’2
Opaganib
Opaganib, a new drug to me, is an orally-administered, sphingosine kinase-2 (SK2) selective inhibitor with anti-cancer, anti-inflammatory and anti-viral activities, and has been used in oncology, primarily for inflammatory and gastrointestinal indications. Several prior pre-clinical studies support the potential role of SK2 in the replication-transcription complex of positive-strand single-stranded RNA viruses, similar to coronavirus, and its inhibition may potentially inhibit viral replication. Pre-clinical in vivo studies3,4 have demonstrated that ‘opaganib decreased fatality rates from influenza-virus infection and ameliorated Pseudomonas aeruginosa-induced lung injury’. There is now considerable interest in the drug as potentially having significant use in treating those with severe Covid-19 disease.
Symptoms
A ship provides a useful isolated community to study infections. Reports from both a cruise liner (the Diamond Princess had 3711 passengers of whom 712 persons were infected with SARS-CoV-2) and an Antarctic exploration ship (217 passengers and crew, 128 tested positive) have shown how a significant number of infected people have no symptoms but are able to infect others; 58% and 81% respectively. Surely this is yet another argument for universal testing.
References
- Li L et al. Effect of Convalescent Plasma Therapy on Time to Clinical Improvement in Patients With Severe and Life-threatening COVID-19: A Randomized Clinical Trial. JAMA. Published online June 03, 2020. doi:10.1001/jama.2020.10044
- Bouleware DR et al. A Randomized Trial of Hydroxychloroquine as Post-exposure Prophylaxis for Covid-19. NEJM, doi: 10.1056/NEJMoa2016638
- Xia C. et al. Transient inhibition of sphingosine kinases confers protection to influenza A virus infected mice. Antiviral Res. 2018 Oct; 158:171-177.
- Ebenezer DL et al. Pseudomonas aeruginosa stimulates nuclear sphingosine-1-phosphate generation and epigenetic regulation of lung inflammatory injury. Thorax. 2019 Jun;74(6):579-591.