The Bearer of Bad News

"Against this backdrop of rising infections, rising hospitalizations and rising numbers of people dying from coronavirus, it is  absolutely vital that we act."

"We simply cannot have the kind of Christmas that we all yearn for."

"This virus [a new mutation of COVID-19 appearing in South Africa] is highly concerning because it is yet more transmissible and appears to have mutated further than the new variant that's been discovered in the U.K." 

"Thanks to the impressive genomic capability of the South Africans, we’ve detected two cases of another new variant of coronavirus here in the UK."

"Both are contacts of cases who have travelled from South Africa over the past few weeks."

"This new variant [from South Africa] is highly concerning, because it is yet more transmissible, and it appears to have mutated further than the new variant that has been discovered in the UK."

British Health Minister Matt Hancock

 

"[The new variant in the UK] is very different to the variant in South Africa, it’s got different mutations."

"Both of them look like they’re more transmissible. We have more evidence on the transmission for the UK variant because we’ve been studying that with great detail with academic partners. We’re still learning about the South African variant."

:[Vaccines that have already been developed should be effective] because the vaccine produces a strong immune response and it’s broad and acts against lots of variation in the virus."

Susan Hopkins from Public Health England

There is no current evidence to suggest that the new variant is affected any differently by vaccines  Reuters

The SARS-CoV-2 virus that causes COVID-19 appears incorrigibly immune to every human-inspired effort to bring it under control. The virus almost appears to taunt scientific efforts to better understand its viral properties, much less to invent new protocols that might have the effect of diminishing its predatory advances. All viruses mutate over time; it is why vaccines produced annually for the seasonal flu can only partially address all the altered elements of any season's flu virus; the vaccine producers wait until the last possible moment to assess as accurately as possible all of the most current flu viruses' qualities before finalizing their vaccine for distribution for that year.

Experts were aware of a number of SARS-CoV-2 mutations, tracking them and evaluating their effects. The two issues of greater infectability and more potentially serious effects of infection uppermost concerns. At least one of those concerns has now been realized in a new strain that has hugely accelerated infectiousness in the U.K. Authorities are trying to cope, just at a time when it was hoped that measures could be eased for the holiday season; instead areas of high infection have had to return to lockdown.

 

The UK has now been effectively placed in quarantine by the international community.’ The closed ferry terminal at Dover. Photograph: Kirsty Wigglesworth/AP

 

Countries in Europe and North America and Asia have closed off flights and other modes of travel from Britain in light of the current situation; the nightmare of all countries already coping with desperate numbers of infections, hospitalizations and deaths is an exacerbation caused by another viral strain brought in from an outside source. Ironically, Britain, struggling to contain its own mutant strain, now realizes that an even more seriously infectious mutant strain has already infiltrated the country, one that originated in South Africa.

Leading to huge swaths of Britain being placed under strict COVID-19 restrictions responding to a highly infectious virus variant now sweeping the country, raising infection cases to record levels. Almost 40,000 new infections of the mutated variant of the coronavirus, estimated to be up to 70 percent more transmissible, has been responsible for case numbers and hospitalizations to soar. Deaths, numbering 744, also represents the highest figure since April.

London, southeast England and Wales are now seeing tight social mixing restrictions, reversing plans to ease curbs over Christmas across the nation. From December 26, additional parts of southern England are set to be among those added to the highest level of social mixing restrictions where 16 million already have been placed in Tier 4 restrictions. Those parts of the country locked into lower tiers are also slated to face tighter curbs.

 

Passengers wait in line at the Eurostar terminal at St Pancras International, amidst the spread of the coronavirus disease (COVID-19) pandemic, in London [Hannah McKay/Reuters

 

Nearly everyone in Scotland and Northern Ireland has seen their governments announce entire populations to be subjected to the highest level of restrictions following Christmas. On average, according to the health minister, 1,909 COVID hospital admissions take place every day, with 18,943 people in hospital with the virus at the present time, levels rivalling the situation in April when the coronavirus took Europe by storm.

All this, and coincidentally the discovery by British scientists of another, more virulent variant having arrived leading Britain to place new restrictions on visitors from South Africa, calling on those who recently had been in the country or in contact with anyone recently arrived, to self-isolate immediately. The public being assured that all such measures are temporary until such time as officials are better able to understand the variant and what it portends.

Last week, officials in South Africa announced the detection of a  new variant by their scientists, appearing to be fuelling a rapid rise in infections in the country. Now, even as Britain is grappling with a steadily increasing outbreak linked to a variant originating in England, they must as well turn their attention to a South African variant. One, Minister Hancock announced, that might be more contagious even than the U.K. variant, both of which are "out of control" in the country.

People walk and cycle in London [Hannah McKay/Reuters]

'Typical' COVID Presentation Symptom Giveaways

"We know that when patients with psychiatric diseases get sick, it kinds of mentally de-compensates. And we realized that the reason that her [emergency room patient] schizophrenia reaactivated was because of COVID-19."

"A few hours later she spiked a fever and then we realized, 'Oh gosh, there's more to this story than just atrial fibrillation."

"Theoretically, you know that this going on. And it's something we've been talking about. But to actually see that happen right in front of me was like, 'Oh my God'."

"I was fortunate that I had taken appropriate precautions with her. I was wearing a mask, I was wearing a gown. But I was just kind of going through the motions, just doing it because everybody else was doing it."

"And then when she spiked a fever, it really became much more internalized."

Dr.Gregg Miller, emergency room physician, Seattle

"We're just seeing so many strange presentations of this that basically we're in a state where almost anybody coming in with anything is a potential COVID case."

"We're taking precautions with everybody now. We're treating every single patient as a potential COVID patient."

"What's become very frightening is that, initially we had this very clear case diagnosis. It was travel and a cough and shortness of breath and fever."

"But what we've been finding is almost anything can be a presentation of COVID-19."

"We've seen patients whose only presenting symptom is headache or their only presenting symptom is abdominal pain and we swab them and they're positive."

Dr.Brett Belchetz, emergency medicine, Toronto

Covert cases could represent around 60% of coronavirus infections.

Image: REUTERS/Toby Melville

In his Montreal hospital emergency department, Dr.Zachary Levine by early this week had seen about 20 presumptive cases of COVID-19. then, a 37-year-old woman had come in. She qualified for testing because she had minor chills. But she had also suffered weeks of bloating and abdominal pain; those would never have qualified her for testing, without the presence of the chills of a minor nature. But you never can tell, and when her test came back, it told that she was indeed COVID-positive.

Most others he had seen had exhibited classic symptoms, and then there was another case that failed initially to qualify for testing, a women in her 70s who had recently returned from a trip to the Caribbean, with fatigue and malaise. No fever, no cough. "Luckily I wore a mask/visor/gown and gloves out of an abundance of caution", said Dr.Levine. An X-ray revealed chest abnormality, so he sent her for COVID testing; yet another positive.

A patient being wheeled into Elmhurst Hospital in Queens. The C.D.C. director said on Tuesday that as many as 25 percent of people infected with the coronavirus may not show symptoms.Credit...Johnny Milano for The New York Times

In Dr.Miller's experience, a psychiatric patient entered the Emergency Room, delusional, hearing voices, she had a history of schizophrenia. She was asked to wait for a psych bed to become available. She waited a full day. This was a major hospital outside Seattle, in a busy ER, not unusual for specialized treatment. Then her fever spiked, alerting medical staff that something more than mental illness had presented.

Emergency Rooms and Intensive Care Units in hospitals across Canada and the United States have been separated; patients suspected or diagnosed with COVID-19 plugged into one side; those with no symptoms on the other. Then doctors increasingly realized the difficulties they were experiencing in ruling out anyone as a possible carrier of the COVID virus.

Trying to cope with an emergency in the pandemic, with the tension-filled expectation of sudden surges, hospitals have been faced with limited protective equipment along with backlogs for testing, exacerbating an already vexing situation. Dr.Belchetz was informed by one of his colleagues of a patient who arrived with a head laceration. "Everyone assumed it was nothing to worry about". Head wound? ERs are well accustomed to dealing with them.

But in this particular instance after questioning the patient, it was revealed how the wound had occurred. The man had passed out and then had fallen, hitting his head on a hard surface, and sustaining the wound. There were no typical symptoms at presentation; no cough, no fever, but it was clear he wasn't getting enough oxygen. When the test came back, it revealed that he too, had COVID-19.

Despite all of this, Dr.Miller failed to fully realize the extent of the situation of unusual, atypical presentations, but when in the early weeks of the pandemic a woman came to his ER with an erratic heartbeat and a history of atrial fibrillation -- with her heart wildly beating at close to twice normal rate, he and his colleagues focused on that; getting her heart rate under control. Before realizing she was another COVID patient.

Recently, Dr.Miller along with a few colleagues published a paper on early lessons from the pandemic in the Seattle area. The message, he said, is not that it's useless to separate COVID from non-COVID. "You can do it, you just can't assume that because you've done that, the rest of your ER or your clinic is COVID-free". The virus is both sinister and insidiously diagnosis-tricky.