By Dr. Paul Nelson, medical doctor, clinical epidemiologist and Public Health Consultant, is the founder of FeverFreeZoneTM (https://www.feverfree.zone), and an expert in Covid-19 mitigation strategy.
Thomas Hobbes envisaged a world without society as nasty, brutish and short and Gandhi reminds us that the true measure of any society can be found in how it treats its most vulnerable members. During the Covid-19 pandemic the UK care home residents have suffered, and many have died. The protection of residents in care homes has been hugely problematic. Early in the pandemic the discharge back to care homes of older people contagious with C19 looks in retrospect to have been wilfully cavalier and a gross underestimation of the challenge. It led to the virus sweeping through care homes in the first wave, causing vast numbers of largely preventable deaths. That experience has perhaps led to rebound drastic and inhumane measures denying sometimes confused elderly people both touch and contact with loved ones as well as the freedom to move about in the care home for many months. This situation persists though efforts to facilitate the safe entry of relatives and loved ones into care homes are finally bearing fruit with trials of PCR testing and of new rapid testing methodologies for visiting relatives.
The news of efficacious vaccines is wonderful and gives us all hope for the end of the pandemic, yet the news also threatens to become a distraction to focused efforts to protect residents of care homes whilst allowing the best quality of life for residents in the months and potentially years ahead where the virus still threatens.
There is a genuine risk, that the emergence of the vaccine could be used consciously or unconsciously to divert attention and resources from C19 mitigation strategies which allow for and facilitate resident/visitor contact and some degree of freedom of movement of residents. Already Tedros Adhonan (WHO director-general) has warned that the vaccine will not be a panacea, not in the next year and
perhaps not ever as levels of immunisation may never reach herd immunity levels, mutations may occur and seasonal comebacks may become the norm. Pandemic preparedness must be in place in societies to protect them and particularly their vulnerable elderly. Now is the time to put in the infrastructure to protect care homes though layers of mitigation including screening for symptoms and critically objective assessment of signs of disease.
The challenges for care homes are to balance compassion with safety, on a background of low levels of resourcing. Obvious solutions to safety like PCR testing to ensure people entering the care home do not have Covid-19 are slowly being adopted for staff but only on a weekly basis, so that interim infection and transmission remains a risk. New innovations like lateral flow testing are slowly being piloted although pan sector adoption with government backing is way off. However, for once social care is high on the news agenda taking column inches in the broadsheets and tabloids and is taking centre stage TV news reports and on social media. For once government is in the spotlight about their leadership and response and being challenged as to how they manage the next stage of the pandemic for the frail elderly particularly in care homes. The stakes are now high not to get it wrong again and moreover to ameliorate the situation.
In early November The Scottish government published enhanced advice for supporting those who give and receive social care and specifically advocated daily symptom assessment and particularly temperature assessment for residents and staff in care homes. This is very good news since body temperature, although one of the primary signs of covid-19 has not been fully formally leverages as mitigation strategy in the UK. If measured correctly and consistently it can be a useful marker of infection risk and if data collected can be useful in disease surveillance and as the basis of population screening pro- gramme. Previously concerns about validity and accuracy have prevailed and the opportunities have not been seized.. Now it finally the usefulness and necessity for temperature assessment has been recognised and it is time for those who have implemented it to look at their processes and outcomes and ensure quality assurance. For those who have yet to adopt temperature assessment, process and quality are king.
That said the care industry has been way in advance of government guidelines on symptom assessment, realising that a precautionary approach early on a background of confusing, contradictory and deficient official advice. That information has improved and care home owners have had taken then initiative adding mitigations above and beyond publicly recommended measure. Many have added in temperature assessment of staff, visitors and patients where Public Health guidelines have lagged behind the situation on the ground.
In care homes, Temperature assessment has become widespread although often in an ad-hoc way without proper processes procedures and audit. In this light there is some doubt about the value of the temperature assessment process, assessment accuracy and validity with- out data being kept or used in the audit, it is easy to think that temperature assessment is largely theatre.
It is important, and perhaps now likely that in view of the formal official public health advice from the Scottish government to care homes to implement daily symptom and temperature assessment that, standard procedures and equipment and the collection of data will become the norm. This will drive a focus by care homes on the accuracy and trust in the assessment as meaningful and helpful. This is good news as it adds another meaningful layer to broader mitigations against Covid 19 and is welcome and easy to implement even while the effectiveness of novel tests are still in doubt and while we endure the long wait for the vaccine.
Objective temperature assessment now has its official sanction, let us get it in place and ensure that it is done so meaningfully and is not just theatre. That is it must be done according to a standard operation procedure using accredited equipment that is fit for purpose and there should be staff training and accreditation and a process of quality assurance. This is not only desirable but also essential Even if and when full eradication is here those care homes that have adopted best practice will be best placed to protect residents from early viral respiratory illness. Other infections such as flu have always threatened our elders in care homes and the Covid-19 pandemic has shone a bright light on our deficiencies in precautionary screening measures to protect them. Now is the time to get the infrastructure in place to protect the most vulnerable in our society for the next stage of this pandemic and be prepared for the next.