Monday, 12 October 2020

Masks: the question people should be asking

Niall McCrae, freelance journalist

Kevin Corbett, healthcare consultant

Amidst the current coronavirus epidemic, suddenly it has become a social norm in Western society to wear a face covering. How did this dramatic transformation arise - is it motivated by science, collective spirit or mere compliance?


Covid-19 is the name given to a disease attributed to the genetic viral sequence SARS-CoV-2 (severe acute respiratory syndrome coronavirus; the first outbreak was in 2002).  In an effort to curtail the contagion, the British government made wearing of masks mandatory on public transport in July 2020. This was extended to shops in September, and in October to pubs and restaurants (except when seated). Since schools reopened in September, many teachers and pupils are wearing masks, despite no legal requirement. Masks have generally proliferated, with people choosing to wear them whenever they are outdoors.  

There is much debate about the effectiveness of facial coverings to prevent infection. But as masks are expected to be worn throughout the coming winter season, will they also protect people from influenza?

As we will explain, a ‘yes’ or ‘no’ answer to this question is elusive. Despite widespread mask-wearing, incidence and mortality of influenza is currently at normal levels for autumn. In England and Wales, deaths from influenza and pneumonia have exceeded those from Covid-19 continually since June. From 20th June to 4 September 20836 death certificates stated influenza or pneumonia compared with 6302 mentioning Covid-19. Influenza mortality is lower in summer; it is now increasing as expected in line with annual trends.

The Office for National Statistics (8 October 2020) reported an exceptionally low number of influenza deaths from January to August 2020, a period when most people did not cover their faces. In England and Wales there were 48,168 reported deaths due to Covid-19, 13,619 due to pneumonia and 394 from influenza. It is highly likely, however, that many more died from influenza, as Public Health England data show that the annual average of deaths in England from this disease in winter seasons 2014-2015 to 2017-2018 was 16156 (ranging from 11875 to 28330). It is also probable that a high proportion of Covid-19 fatalities were misdiagnosed: many were not tested for Covid-19, and false positives are a major problem with the widely-used test (which was not designed for diagnosing infectious disease).  Although SARS-Cov-2 is known as a ‘novel coronavirus’, the associated disease Covid-19 has no distinct symptoms and may easily be mistaken for influenza or vice versa.

For a wearer to believe that a mask protects people from coronavirus but not flu is equally dubious. Both types of virus are microbes of potential aerosol transmission. A mask may guard against droplet infection from other people coughing, but an airborne upper respiratory tract epidemic is so pervasive that people [the ‘host’ in immunological terms] living in normal social conditions rely on their immune systems to thwart adverse bacteria and viruses.  As accepted by leading virologists, the relationship between host, viruses and symptoms is not fully understood.  Fortunately, a high proportion of people appear to exhibit immunity, and a high proportion of people testing positive for SARS-CoV-2 are asymptomatic. The size of the pores in masks exceeds that of particles thought to comprise SARS-CoV-2, possibly explaining the demonstrable lack of efficacy in randomised controlled trials of masks.

In the journal Emerging Infectious Diseases, a World Health Organisation working group on interventions for an influenza pandemic stated:

WHO has recommended that mask use by the public should be based on risk, including frequency of exposure and closeness of contact with potentially infectious persons; routine mask use in public places should be permitted but not required.

The authors noted the observation of a medical officer in Alberta in Canada that cases increased after mandating of masks during the Spanish flu pandemic in 1918. The order was subsequently ridiculed. Although that paper was published in 2006, scientific evidence has not really changed since then. At the peak of the Covid-19 pandemic, authorities advised against universal mask use. Interviewed on the US television series Sixty Minutes (8 March 2020), Anthony Fauci, a leading member of the US government’s Coronavirus Task Force, said: -

 People should not be walking around with masks. There is no reason for wearing a mask.

Fauci believed that masks should be reserved for healthcare workers and infected patients. Jenny Harries, deputy chief medical officer to the British government, stated in March 2020 that masks do more harm than good, because wearers repeatedly touch their faces, and the virus is likely to be trapped in the mask thereby increasing the risk of inhalation.

A rapid review of the effectiveness of masks by the Royal Society and the British Academy, which persuaded the UK government to promote mask-wearing, explicitly stated a lack of robust RCT evidence for prevention of aerosol transmission.  A rather biased article in Nature (6 October 2020), which included plenty of anecdotal reports but limited scientific research to support its argument in favour of masks, nonetheless accepted that the evidence was inconclusive. Author Lynne Peeples noted that studies finding masks to be ineffective had been retracted from journals; this has been a troubling trend of censorial group-think. Indeed, the new mask orthodoxy has entailed disciplinary proceedings, as in the disciplinary investigation by New York University into Professor Crispin Miller for simply encouraging students to critically review research on mask efficacy.

So, contrary to the scientific evidence, governmental health advice has drastically changed, but like other Covid-19 policies, mask enforcement is now more of a political than a scientific decision. John Lee, retired pathologist and lockdown sceptic, said on TalkRadio (28 September 2020): -

We have politicians doping amateur science and scientists doing amateur politics. Mix the two together and it’s an awful brew.

We concur, and suggest that people should be routinely asked about their expectations of masks: Will it protect them from influenza? Either an affirmative or negative response would expose faulty thinking: masks do not appear to prevent flu, and a belief that such a permeable barrier stops coronaviruses only is scientifically baseless.  

Editorial note: articles in JAN interactive are not reviewed and are published at the discretion of the Editor-in-Chief. We welcome replies, rejoinders, comments and debate on all entries provided they are not offensive or personal and these will be published on JAN interactive.

 

Thursday, 24 September 2020

Does flu vaccination contribute to Covid-19 incidence?

 Niall McCrae

King's College London, UK

A troubling tendency in the Covid-19 pandemic is for governments to hector and to blame their citizens for the continuing incidence of the virus. On 21 September 2020 Professor Yvonne Doyle, medical director of Public Health England, urged everyone to get the flu vaccine, and that failure to do so would double their risk of dying from the coronavirus. Now flu vaccination is being integrated with the campaign against Covid-19, and the people are expected to play their part. However, there is no evidence that flu jab recipients are less prone to Covid-19; indeed, some data suggest the opposite.

A text message sent in April 2020 by Essex Wellbeing Service, which provides support to people with health and social needs, stated:

‘If you have had a flu jab in the past, you are more at risk from coronavirus’.

This was sent at the peak of the Covid-19 outbreak in Britain. The advice could be interpreted as alerting a population at risk: the target of the annual flu jab campaign is the same age group that is most susceptible to the novel coronavirus. However, many recipients of the message would take it literally: the flu vaccine, according to this official source, is a risk factor in itself.

Flu (Influenza) is a contagious upper respiratory tract infection with symptoms of headache, fever, chill, sore throat, muscle aches, fatigue, nasal congestion and cough. Severe cases lead to pneumonia, a common cause of death in older people. The first vaccine against influenza was produced in 1931 by Ernest Williams Goodpasture at Vanderbilt University, and vaccination became widely available after the Second World War. After the Asian flu pandemic of 1957-1958, which killed two million worldwide, routine flu vaccination was recommended by the US Centers for Disease Control. In 2009, health ministers across the EU agreed to a target of vaccinating 75% of older people against influenza.

A challenge for vaccine producers is the mutability of the virus. A new compound is needed every Autumn, based on prediction of which strains will emerge. In practice the vaccine reduces the frequency and severity of influenza, but it does not prevent a high death toll every year. A Cochrane Collaboration review in 2014 revealed that the vaccine reduced incidence by merely 6%.

In 2019 the UK was the first country in Europe to introduce Flucelvax Tetra, which was touted as 36% more effective. Unlike the existing flu vaccines, which incubate the virus in hens’ eggs, the new product is created in vats of cells from dogs’ kidneys, which are more like ours than those of poultry.

Covid-19 is a strain of coronavirus, for which no effective vaccine has been produced. Mortality from the current pandemic shows startling variation, some countries having rates of less than ten per million, while many in western Europe and the Americas having over six hundred deaths per million. Among the likely reasons are ecological (high population density and urbanisation), demographic (ageing and multicultural societies) and clinical (obesity and chronic disease such as diabetes mellitus). Also, there are significant differences in diagnostic practice and recording.

While governments and health authorities reject a putative link between Covid-19 incidence and flu vaccination, it is surely worthy of further enquiry that countries with highest uptake of the flu jab have the worst mortality from Covid-19.  In an article on the Gateway Pundit news website in May 2020, David Kurten and compared flu vaccine frequency in older people with Covid-19 deaths, using figures from Vaccines Today EU and Worldometer (22 September 2020), We found a correlation of 0.69. Four months later, the Covid-19 mortality data were updated, as follows:

Country

Flu vaccination               age 65+

(%)

Covid-19 mortality            (per million)

United Kingdom

72.6

615

Netherlands

64.0

367

Portugal

60.8

189

Ireland

57.6

362

Spain

55.7

661

Malta

55.5

52

Italy

52.0

591

France

49.7

481

Sweden

49.4

580

Finland

47.6

62

Denmark

40.8

111

Luxembourg

37.6

197

Germany

34.8

113

Hungary

26.8

72

Croatia

23.0

62

Czechia

20.3

49

Romania

16.1

234

Lithuania

13.4

32

Slovakia

13.0

7

Slovenia

11.8

68


Among countries omitted in the EU data was Belgium, which has the highest Covid-19 mortality rate in Europe, at 858 per million. While specific data for older people are not available on the official Belgian statistics website, flu vaccination coverage of the overall population is relatively high. Overall, a clear difference is apparent between east and west Europe, both in vaccine uptake and Covid-19 deaths.

Globally the highest uptake of the flu vaccine by seniors in 2018-2019 was in South Korea, at 83%. Third (after the UK) was the USA with 68%, and fourth was New Zealand with 67%. Neither New Zealand nor South Korea fit the hypothesis, these countries having a mortality of merely 5 and 8 per million, respectively. South Korea, Hong Kong, Taiwan and South Korea appear to have controlled Covid-19 well, despite their large populations and proximity to the source in China, perhaps due to cultural and technological factors. 

New Zealand’s low mortality is due to its geographical isolation and rapid barring of entry to foreigners (Iceland was able to achieve similar containment). In Europe and North America, which have high transit of people across borders and through airports, the virus rapidly spread. Arguably, lockdown was like shutting the stable door after the horse had bolted.

Despite some contrary cases, it is interesting that countries with high death rates (Belgium, Spain, Italy, UK, Sweden, France and USA) had all vaccinated at least half of their older population against flu. Denmark and Germany, with lower use of the flu vaccine, have considerably lower Covid-19 mortality. This pattern appears to override differences in coronavirus interventions: Italy and Sweden have similar mortality, but the former imposed a lockdown while the latter did not.  All western European countries have ageing populations, which could explain relatively high mortality compared to countries with a younger demographic profile (the average age of people dying from Covid-19 is over 80).    

A simple test shows a statistically significant correlation of 0.67. This is slightly lower than in May but is strengthened by weight of numbers. Of course, correlation is not causation, and this finding should be taken as indicative rather than conclusive. Variation between countries is likely to be multifactorial, but the flu vaccine should be considered in broader post-mortem investigation of this pandemic.

The possibility that flu vaccination lowers immunity to other upper respiratory tract infections was considered in a BMJ commentary by paediatrician Allan Cunningham:

‘Such an observation may seem counter-intuitive, but it is possible that influenza vaccines alter our immune systems non-specifically to increase susceptibility to other infections; this has been observed with DTP and other vaccines.’

A Pentagon study of military personnel by Greg Wolff showed an odds ratio for coronaviruses of 1.36 in a group vaccinated against influenza compared with an unvaccinated group. Similar findings were reported in studies of flu vaccines in children in the USA, Hong Kong and Australia.

It would not be difficult for investigators with access to Department of Health data to measure flu vaccination rates in people who died of Covid-19. If an inverse relationship exists, this could support government guidance for the flu vaccine. However, if a positive correlation is found, this would justify further investigation. This would be particularly important given the development of a coronavirus vaccine, which could increase susceptibility to influenza. This is not to convey any anti-vaccination stance, but to pursue evidence-based medicine.

Editorial note: contributions are not reviewed and are published at the discretion of the Editor-in-Chief. We welcome replies, rejoinders, comments and debate on all entries provided they are not offensive or personal and these will be published on JAN interactive.

Monday, 14 September 2020

Commentary on Darbyshire et al (2020)

 

Commentary on Darbyshire et al (2020) ‘The Culture Wars, nursing, and academic freedom’ Journal of Advanced Nursing doi:10.1111/jan.14507

William P Ball RN

PhD Student, School of Health and Social Care, Edinburgh Napier University, UK

e-mail: william.ball@napier.ac.uk

I enjoyed reading the recent editorial by Darbyshire et al (2020) which calls us as Nurses to stand against what seems to be an increasingly polarised and reductive popular discourse around contentious issues. I share many of their concerns about academic freedom and the observation that Nurses collectively seem to be shying away from speaking truth to power.

As a Registered Nurse and Population Health researcher, I particularly agree that the Nursing profession will always be closely invested in: “women's health; child development; surgery; science and evidence; pathophysiology; ethics; social justice; health inequity; sexuality; and more”, which obliges our engagement with such issues, even in the face of potential social media-led backlashes.

I wonder whether the major reason for a lack of engagement from the profession is mainly based on an individualistic attitude of self-defence? The relative lack of engagement related to social justice and equity issues is particularly striking to me. Anecdotal interactions suggest such issues are perceived to be ‘too political’ by some outside and even some within the profession. I believe this reflects a history of passively and collectively allowing orthodoxy to go unchallenged – a presumed requirement to be politically neutral, rather than just a desire for self-preservation through avoiding controversy and the personal or professional repercussions which may follow.

As Bell (2020) writes concerning the role of nursing in anti-racism, we have: “a nursing culture that is not consciously situated in a broader socio-political context.” This results in a profession and systems of education which are ‘politically soft’ – promoting apolitical approaches whilst also failing to acknowledge our role in reinforcing systemic oppressions. The profession may be best placed to address the issues raised through conscious and reflective processes like decolonisation (Moorley et al, 2020) in practice, education and research.

The authors also appeal to the long-term public support and good-will shown towards Nurses, as reflected in polling data which regularly rates us as the most trustworthy profession (Reinhart, 2020). It may be possible to leverage this public support in the discussion of contentious issues, although the extent to which this trust is dependant upon misconceptions about Nurses and Nursing is not known. If Nursing voices become more prominent or overtly political, public perceptions are likely to change, perhaps eroding the image of trustworthiness.

This issue is perhaps best exemplified by the rhetoric around Nursing work presented to the public in mainstream and social media. There has been widespread public recognition of the important work undertaken by healthcare staff during the COVID-19 crisis. Nurses (and other professions) have variously been described as ‘Angels’ and ‘Heroes’, with an abundance of war-like metaphors. Whilst this language is well-intentioned and probably used instinctively it contributes to ‘mysticisation’ of Nurses and Nursing work. Such stereotypes have the potential to be damaging to the Nursing profession in the long-term and should be vigorously challenged (Stokes-Parish et al, 2020).

References

Darbyshire, P., Patrick, L., Williams, S., MacIntosh, N., Ion, R. (2020), The Culture Wars, nursing, and academic freedom. Journal of Advanced Nursing. doi:10.1111/jan.14507

Bell, B. (2020), White dominance in nursing education: A target for anti‐racist efforts. Nursing Inquiry. doi:10.1111/nin.12379

Moorley, C, Ferrante, J, Jennings, K, Dangerfield, A. (2020), Decolonizing care of Black, Asian and Minority Ethnic patients in the critical care environment: A practical guide. Nursing in Critical Care. 25: 324– 326. https://doi.org/10.1111/nicc.12537

Reinhart, R. J. (2020), Nurses continue to rate highest in honesty, ethics. Retrieved from https://news.gallup.com/poll/274673/nurses‐continue‐rate‐highest‐honesty‐ethics.aspx

Stokes‐Parish, J., Elliott, R., Rolls, K. and Massey, D. (2020), Angels and Heroes: The Unintended Consequence of the Hero Narrative. Journal of Nursing Scholarship. doi:10.1111/jnu.12591

 

Editorial note: entries to JAN interactive are not reviewed and are published at the discretion of the Editor-in-Chief and may be subject to editing or removal by Wiley. We welcome replies, rejoinders, comments and debate on all entries provided they are not offensive or personal.

 

 

 

Monday, 7 September 2020

Response to the commentary written by Carmen Tung


Paolo IOVINO (Corresponding author), MSN RN University of Rome Tor Vergata, Rome, Italy. Email: paolo.iovino@uniroma2.it. Tel: +39 3479392534. ORCID: 0000-0001-5952-881X

Maddalena DE MARIA, MSN RN University of Rome Tor Vergata, Rome, Italy. Email: maddalena.demaria@outlook.it. ORCID: 0000-0003-0507-0158

Maria MATARESE, MSN RN University Campus Bio-Medico, Rome, Italy. Email: m.matarese@unicampus.it ORCID: 0000-0002-7923-914X

Ercole VELLONE, MSN RN University of Rome Tor Vergata, Rome, Italy. Email: ercole.vellone@uniroma2.it ORCID: 0000-0003-4673-7473

Davide AUSILI, PhD, MSN, RN Department of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy. Email: davide.ausili@unimib.it ORCID: 0000-0001-5212-6463

Barbara RIEGEL, PhD, RN, University of Pennsylvania, Philadelphia, United States. Email: briegel@nursing.upenn.edu ORCID: 0000-0002-0970-136X

We would like to thank Carmen Tung for her comments on our article “Depression and self-care in older adults with multiple chronic conditions: A multivariate analysis”. We particularly appreciate the interest she has demonstrated in the self-care research.

Self-care is considered an important strategy for ensuring well-being and keeping control of illnesses. Individuals who benefit most from self-care are typically those affected by one or more chronic conditions. We agree with Tung that self-care maintenance (SCM) is an important step in taking care of oneself. This mostly happens because SCM is the first set of behaviors that are taught by healthcare providers and the least challenging to understand for chronically ill individuals when it is time to return home after hospitalization. Self-care is also performed by healthy individuals; this is particularly evident in the situation we are living in these days when, above and beyond the disastrous effects that COVID-19 is having on society, the pandemic is changing the way people take care of themselves. Handwashing and social distancing are two examples of basic self-care behaviours that, among many others, are put into practice to prevent infections in the community. Currently, our research team is investigating the impact of the COVID-19 outbreak on the self-care behaviors of people affected by multiple chronic conditions. We hope our study will offer healthcare providers important information about how to strengthen these behaviors that may reveal particularly vulnerable.

We also think that patients undergoing lung transplant, such as those referred to by Tung, could bring to light interesting dynamics regarding the self-care process. We agree with her that these individuals possess a high level of skill and long experience with regard to self-care. Post-transplant populations typically have a history of one or more chronic conditions prior to transplant. In our opinion, this has contributed to sharpening their knowledge and expertise related to self-care behaviours.

Problems with depression are, unfortunately, present in the post-transplant population; this has been observed by one of the authors, who is engaged in the clinical care of patients undergoing bone marrow transplantation. We particularly advocate herein the recommendation emphasized by Tung: a systematic screening of depression is vital in these fragile populations, especially because we have found that this mental health problem can negatively impair self-care behaviors. This relationship is rather worrisome because self-care includes medication adherence, which is important in maintaining immunosuppression and reducing the risk of organ rejection. Cukor et al. (2009) found that depression was the only significant predictor of low medication adherence in kidney transplant patients. Another study found that this mental health problem diminished in the short term after hematopoietic cell transplantation but then increased significantly over the following years (Kuba et al., 2017). This finding is important because screening for depression symptoms should not terminate at post-transplant discharge; rather, ideally it should be carried out as part of the early post-transplant check-ups and continue from there. Independently of the outcome, screening for depression should also be accompanied by self-care educational interventions.

In our study (Iovino et al., 2020), we found a small or even absent effect of depression on self-care monitoring and management. This was probably due to presence of caregivers, because in our sample, families were a constant presence for their loved ones. We envisage that this would also be the case for transplant patients. According to our clinical experience and evidence from research (Lonning et al., 2018), post transplantation carries a renewed desire to live a healthier life. In particular, patients who do not undergo transplants following cancer may perceive their past chronic illness as no longer a threat. The fact that the disease is finally eradicated brings new hope and motivation to take better care of themselves. We could also hypothesize that people perceive self-care monitoring and management behaviors as being more important than SCM as they ensure well-being and survival. For example, the high number of drugs post-transplant patients must take (e.g. immunosuppressors and corticosteroids) are linked to serious side effects that need to be recognized and detected promptly to avoid complications. This may induce patients to conduct more intense monitoring.

Regarding the study mentioned by Tung, we suggest that, when investigating self-care, she consider all three self-care dimensions (self-care maintenance, monitoring and management) in the analyses since self-care practices are highly intercorrelated (Riegel et al., 2012). By taking all of them into account, adjustment of each behaviour’s estimate is warranted. Also, we suggest measuring self-care self-efficacy. This variable, defined as the belief in one’s own abilities to perform self-care, is known to act as a mediator in the relation between self-care behaviours and outcomes (Vellone et al., 2016). Lastly, we would recommend considering other confounding factors, above and beyond caregiver support, such as cognitive status, age, social support, and quality of life to obtain results that are less likely to be biased.

References

Cukor, D., Rosenthal, D. S., Jindal, R. M., Brown, C. D. & Kimmel, P. L. 2009. Depression is an important contributor to low medication adherence in hemodialyzed patients and transplant recipients. Kidney Int, 75, 1223-1229.

Iovino, P., De Maria, M., Matarese, M., Vellone, E., Ausili, D. & Riegel, B. 2020. Depression and self-care in older adults with multiple chronic conditions: A multivariate analysis. J Adv Nurs. , 76 (7), pp. 1668-1678.

Kuba, K., Esser, P., Mehnert, A., Johansen, C., Schwinn, A., Schirmer, L., Schulz-Kindermann, F., Kruse, M., Koch, U., Zander, A., Kroger, N., Gotze, H. & Scherwath, A. 2017. Depression and anxiety following hematopoietic stem cell transplantation: a prospective population-based study in Germany. Bone Marrow Transplant, 52, 1651-1657.

Lonning, K., Midtvedt, K., Heldal, K. & Andersen, M. H. 2018. Older kidney transplantation candidates' expectations of improvement in life and health following kidney transplantation: semistructured interviews with enlisted dialysis patients aged 65 years and older. BMJ Open, 8, e021275.

Riegel, B., Jaarsma, T. & Stromberg, A. 2012. A middle-range theory of self-care of chronic illness. ANS Adv Nurs Sci, 35, 194-204.

Vellone, E., Pancani, L., Greco, A., Steca, P. & Riegel, B. 2016. Self-care confidence may be more important than cognition to influence self-care behaviors in adults with heart failure: Testing a mediation model. Int J Nurs Stud, 60, 191-9.