SARS-CoV-2 belongs to a family of single-stranded RNA viruses known as coronaviridae, a common type of virus which affects mammals, birds and reptiles.
In humans, it commonly causes mild infections, similar to the common cold, and accounts for 10–30% of upper respiratory tract infections in adults. More serious infections are rare, although coronaviruses can cause enteric and neurological disease. The incubation period of a coronavirus varies but is generally up to two weeks.
Previous coronavirus outbreaks include Middle East respiratory syndrome (MERS), first reported in Saudi Arabia in September 2012, and severe acute respiratory syndrome (SARS), identified in southern China in 2003,. MERS infected around 2,500 people and led to more than 850 deaths while SARS infected more than 8,000 people and resulted in nearly 800 deaths,. The case fatality rates for these conditions were 35% and 10%, respectively.
SARS-CoV-2 is a new strain of coronavirus that has not been previously identified in humans. Although the incubation period of this strain is currently unknown, the United States Centers for Disease Control and Prevention indicate that symptoms may appear in as few as 2 days or as long as 14 days after exposure. Chinese researchers have indicated that SARS-CoV-2 may be infectious during its incubation period.
The number of cases and deaths outside of China overtook those within it on 16 March 2020
It is currently unclear where the virus has come from. Originally, the virus was understood to have originated in a food market in Wuhan and subsequently spread from animal to human. Some research has claimed that the cross-species transmission may be between snake and human; however, this claim has been contested,.
Mammals such as camels and bats have been implicated in previous coronavirus outbreaks, but it is not yet clear the exact animal origin, if any, of SARS-CoV-2.
Increasing numbers of confirmed diagnoses, including in healthcare professionals, has indicated that person-to-person spread of SARS-CoV-2 is occurring. The preliminary reproduction number (i.e. the average number of cases a single case generates over the course of its infectious period) is currently estimated to be between 1.4 to 2.5, meaning that each infected individual could infect between 1.4 and 2.5 people.
Similarly to other common respiratory tract infections, MERS and SARS are spread by respiratory droplets produced by an infected person when they sneeze or cough. Measures to guard against the infection work under the current assumption that SARS-CoV-2 is spread in the same manner.
As this coronavirus affects the respiratory tract, common presenting symptoms include fever and dry cough, with some patients presenting with respiratory symptoms (e.g. sore throat, nasal congestion, malaise, headache and myalgia) or even struggling for breath.
In severe cases, the coronavirus can cause pneumonia, severe acute respiratory syndrome, kidney failure and death.
The case definition for COVID-19 is based on symptoms regardless of travel history or contact with confirmed cases. Diagnosis is suspected in patients requiring admission to hospital with signs and symptoms of pneumonia, acute respiratory distress syndrome or influenza, and in those with a new, continuous cough or fever who are well enough to stay in the community (see Box 1). A new symptom, a loss or changed sense of normal smell or taste (anosmia), was added on 18 May 2020. A diagnostic test has been developed, and countries are quarantining suspected cases.
Patients who meet the following criteria (inpatient definition):
Clinicians should consider testing inpatients with new respiratory symptoms or fever without another cause or worsening of a pre-existing respiratory condition.
Patients who meet the following criteria and are well enough to remain in the community:
Individuals with a cough, fever or anosmia who live alone should now stay at home for 7 days from the onset of symptoms. Households should all self-isolate for 14 days if one member shows symptoms.
Clinicians should be alert to the possibility of atypical presentations in patients who are immunocompromised. Alternative clinical diagnoses and epidemiological risk factors should be considered.
The government launched its coronavirus action plan on 3 March 2020, which details four stages: contain, delay, mitigate, research. On 12 March 2020, the UK moved to the delay phase of the plan and raised the risk level to ‘high’.
On 16 March 2020, Johnson said that the UK is “now approaching the fast growth part of the upward curve” and, without drastic action, cases could double every 5 or 6 days. He announced social distancing measures, such as working from home and avoiding social gatherings, as well as household isolation for those with symptoms,.
Further social distancing measures were announced on 18 March 2020, including closing all schools in the UK except for vulnerable children and those of key workers, such as pharmacists and other health and social care staff, teachers and delivery drivers. Restaurants, cafes, pubs, leisure centres, nightclubs, cinemas, theatres, museums and other businesses were also told to close.
On 22 March 2020, Johnson announced that the most clinically extremely vulnerable people, including those who have received organ transplants, are living with severe respiratory conditions or specific cancers, and some people taking immunosuppressants, should stay in their homes for at least the next 12 weeks (see Box 2).
Those classed as “clinically extremely vulnerable” have been strongly advised to stay at home at all times and avoid any face-to-face contact until 30 June 2020 (referred to as shielding). Clinically extremely vulnerable people may include the following people (disease severity, history or treatment levels will also affect who is in this group):
And on 23 March 2020, Johnson announced a strict lockdown of the UK to be enforced by police, instructing people to stay at home except to buy essential food and medicines, one form of exercise a day, any medical need, and travelling to and from essential work. He said that all gatherings of more than two people in public must stop and, with immediate effect, all shops selling non-essential goods, libraries, playgrounds, outdoor gyms and places of worship must close. All social events, including weddings, baptisms and other ceremonies, but excluding funerals must be cancelled, he added.
On 16 April 2020, the lockdown was extended for at least another three weeks.
A relaxation of the lockdown was announced by Johnson on 10 May 2020. The goverment published a 60-page ‘recovery strategy’ on 11 May 2020, which sets out the next phases of the UK’s response to the virus, including easing some social restrictions, getting people back to work and reopening schools.
As of 28 May 2020, 3,918,079 tests for COVID-19 have been carried out in the UK. On 2 April 2020, health secretary Matt Hancock outlined plans to dramatically increase testing across the UK to 100,000 tests a day by the end of the month, a target that was initially met. The new target is 200,000 tests a day by the end of May 2020.
Tests can now be accessed by everyone with symptoms. This applies across the whole of the UK and tests can be booked via nhs.uk/coronavirus.
An NHS test and trace service was launched across England on 28 May 2020. Anyone who tests positive for the virus is contacted by the service to share information about their recent interactions. People identified as being in close contact with someone who tests positive will have to self-isolate for 14 days, regardless of whether they have symptoms.
Testing is also now available to care home staff and residents in England, and NHS workers where there is a clinical need, whether or not they have symptoms.
Pharmacy staff in England and Scotland should book tests online via gov.uk and they will be conducted at drive-through testing sites across the country, as well as via home testing kits.
Pharmacy staff in Wales with symptoms of COVID-19 are able to access testing through their Local Health Board.
The government has also announced the start of a new national antibody testing programme, with plans to provide antibody tests to NHS and care staff in England from the end of May 2020. Clinicians will also be able to request the tests for patients in both hospital and social care settings if they think it is appropriate.
Patients have been advised not to go to their community pharmacy if they are concerned that they have COVID-19. Those with a new, continuous cough or a high temperature or anosmia (a loss or changed sense of normal smell or taste) who live alone should self-isolate for seven days from the onset of symptoms. Households should all self-isolate for 14 days if one member shows symptoms. There is no need for people with minor symptoms to telephone NHS 111 or to be tested for COVID-19.
However, given the outbreak has coincided with the cold and flu season, it is likely that patients may present in the pharmacy with queries about the virus, or with concerns about their cold or flu symptoms.
Community pharmacies were told by NHS England and NHS Improvement on 27 February 2020 that, in the unlikely event that a suspected case does present, they must prepare a “designated isolation space”.
If the pharmacy does not have a suitable room to isolate a suspected patient, an area that would keep a patient at least two metres away from staff and other patients in the pharmacy should be prepared so that it can be cordoned off.
Patients who present with a new, continuous cough or a high temperature or anosmia should be told to return home immediately and self-isolate. If, in the clinical judgement of the pharmacist, the person is too unwell to return home, they and any accompanying family should be invited into the designated isolation space where emergency services should be contacted.
The Royal Pharmaceutical Society is publishing ongoing guidance on contingency planning for COVID-19, which includes measures to protect the pharmacy team, such as limiting the number of people within the pharmacy at the same time, keeping at least two metres apart from staff and people coming into the pharmacy, and sectioning the pharmacy to encourage social distancing with floor markings (using tape) or barriers. The RPS has also produced a table to help pharmacists distinguish between COVID-19, a cold, the flu and hayfever.
Those with cold and flu symptoms that are not indicative of COVID-19 should be managed as usual, or using the pathway developed by The Pharmaceutical Journal.
The General Pharmaceutical Council said on 3 March 2020 that it recognises pharmacists may need to depart from established procedures in order to care for patients during the coronavirus outbreak and that regulatory standards are designed to be flexible and to provide a framework for decision-making in a wide range of situations.
In a joint statement with ten other health regulators, the GPhC said: “Where a concern is raised about a registered professional, it will always be considered on the specific facts of the case, taking into account the factors relevant to the environment in which the professional is working”.
An updated standard operating procedure (SOP) for community pharmacies, published on 22 March 2020, sets out measures to protect pharmacy staff, including advising customers to keep a distance of at least two metres from other people, limiting entry and exit to the pharmacy and installing full screens to protect members of staff from airborne particles (see Learning article section ‘Enforcing social distancing’ for further details).
There has been some confusion around advice on personal protective equipment (PPE) for community pharmacists published by Public Health England. Guidance originally published on 2 April 2020 was updated on 10 April 2020, to recommend that pharmacy staff should only wear PPE when in “contact with possible or confirmed cases of COVID-19”. The original version of the guidance simply stated that fluid-resistant (Type IIR) surgical masks (FRSM) were recommended if social distancing could not be maintained.
The updated guidance now states: “If social distancing of 2m is maintained there is no indication for PPE in a pharmacy setting. If social distancing is not maintained, though, direct care is not provided, sessional use of FRSM is recommended for contact with possible or confirmed cases of COVID-19”. Sessional use means for the duration of duties in a specific clinical care setting or exposure environment.
The guidance from PHE differs from that of the RPS, which says that pharmacy staff working in community pharmacies and general practice should wear FRSMs if they are unable to maintain a social distance of 2 metres from patients and staff, and emphasises that it is still important to try to maintain social distance when wearing surgical masks wherever possible. The RPS also advises that gloves, apron and surgical masks should be worn by staff in direct contact with a patient, for example, when a person is too unwell to go home and is being cared for in the designated isolation space.
For hospital pharmacists, specific recommendations on PPE apply depending on the context, eg, inpatient areas, emergency departments, etc.
Guidance has been issued by pharmacy organisations on how community pharmacies in England can accept patient returns of unwanted medicines while minimising risk to pharmacy teams. Since coronaviruses can survive on certain surfaces for up to five days, it recommends that all returns should be double bagged and placed directly in waste medicines bins. Controlled Drugs should be double bagged and placed in the CD cabinet for five days before denaturing. A suggested procedure is detailed within the guidance.
Staff who have symptoms of COVID-19, or live with someone experiencing symptoms, should stay at home. Those who fall into one of the vulnerable groups at particular risk of complications from COVID-19 should not see patients face-to-face, regardless of whether the patient has possible COVID-19. Remote working should be prioritised for these staff.