Talk Evidence
Talk Evidence covid-19 update - pneumonia, guidelines, preprints and testing
09 Apr 2020
For the next few months Talk Evidence is going to focus on the new corona virus pandemic. There is an enormous amount of uncertainty about the disease, what the symptoms are, fatality rate, treatment options, things we shouldn't be doing. We're going to try to get away from the headlines and talk about what we need to know - to hopefully give you some insight into these issues. This week 5.00 - Carl gives us an update about pneumonia in primary care, should you give antibiotics when you're not sure if it's bacterial or viral 10.00 - The importance and difficulty of making guidelines now 15.00 - We hear from guideline maker Per Vandvik, about making guidance. 21.40 - Preprint servers for medicine are showing their use in this fast changing situation. Joseph Ross from Yale School of Medicine, and one of The BMJ's research editors, talks to us about the kind of information we're seeing on medRxiv. 31.10 - Testing. What are the tests, and when do we want specificity, and when do we want sensitivity. Nick Beeching from the Liverpool School of Tropical Medicine joins us to explain. Reading list: www.bmj.com/coronavirus Rapidly managing pneumonia in older people during a pandemic https://www.cebm.net/covid-19/rapidly-managing-pneumonia-in-older-people-during-a-pandemic/ https://www.medrxiv.org/ Covid-19: testing times https://www.bmj.com/content/369/bmj.m1403
Chapter 1: What is the main topic discussed in this episode?
Welcome back to Talk Evidence. As we said last week, we're focusing on the COVID-19 pandemic and the emerging evidence that we're getting about it. Last week we focused mostly on the epidemiology of the pandemic, the questions that are going around about how many people in a population are affected and what that means for our modelling. and how we can work out what the fatality rate is.
We also talked a little bit about some antiviral treatments.
Chapter 2: What is the current understanding of pneumonia in primary care during COVID-19?
This week we're going to be talking about guidelines, using some of that information that we're getting out, and also a little bit about testing. To do that, as always, I'm joined by Helen MacDonald and Carl Hennigan. Helen, can I get you to introduce yourself?
Sure, I'm Helen MacDonald. I'm the UK Research Editor at the BMJ.
Chapter 3: Why is it challenging to create guidelines during a pandemic?
And Carl. Hi, I'm Carl Hennigan. I am Professor of Evidence-Based Medicine at the University of Oxford and Editor-in-Chief of BMJ EBM.
Carl, what have you been up to this week as busy pulling together the evidence?
Yeah, we've been pulling together a lot of evidence, particularly for primary care and in the community.
Chapter 4: How do guideline makers ensure quality and relevance in their recommendations?
There's huge uncertainties and trying to bring evidence from other areas in acute respiratory infections. And that's really difficult to do when you're saying COVID is brand new and trying to provide good advice about how to treat people in the community.
huge uncertainties and huge evidence-based questions that need to be answered and i think we'll come out of this with a sense of a need to re-look at how evidence is developed how it's particularly kept up to date and how it's disseminated to the front line and i think we're going to require some rethink of where we're at and what we're doing
So a question I've had during all of this is, you know, we know a lot about respiratory diseases in general, but as you said, this is a really specific new one. So are we getting a sense of, is this, you know, like other ones or do we have to sort of scrap all of the stuff we know and start again and build a whole new evidence base about this?
Well, I think first is to say when people say this is a new virus or a new emerging infection, I think you'd still have to pause there and say it's not 100 percent certain.
Chapter 5: What role do preprint servers play in disseminating medical information during a pandemic?
I want you to just think since 1970, we've discovered about 1500 pathogens. of which 70% of them come from animals. Some people are well aware of some, like Ebola, HIV, but they're not aware of many circulating diseases that have been discovered, like metanemovirus, that give rise to viral infections and viral pneumonia.
So our real ability of what I call influenza-like illness and what's going on is actually pretty primitive. But what we do know is these viruses are all around us, circulating all the time. And then at some point they emerge into an epidemic or in sometimes a pandemic. We're more understanding about what happens with influenza.
but less uncertain about SARS, because we've only had one episode really before in 2003. We've had the Middle Eastern respiratory syndrome virus, and now we've got this big outbreak. And I assume this will kick off a large piece of work, particularly about the ecology.
Chapter 6: What types of COVID-19 tests are available and when should they be used?
How do we interact? How do we live with these viruses? And what's the best way to treat them? Now, the problem is when you look at it, there are no pharmacological treatments right now that have been shown to work that actually improve your outcomes.
And that's where there's a huge sort of number of trials going on trying to reduce the uncertainties and answer questions about what we may use, particularly to reduce your viral load, but particularly to reduce the complications.
And it makes it even harder then to know what to do with that evidence and how to synthesize it and collate into everything else that we already understand. So we'll get onto that in a second. But in talk evidence, we usually do a start and a stop every week, something to start, something to stop. There seems to be no rules in COVID-19, so we're tearing that up a little bit.
But does anyone have anything new that they want to bring? Anything that you found out this week that you would like to talk about?
I want to hear from Carl on primary care and pneumonia, because that really fascinated me.
Yeah, no, I think it's a very interesting issue. Before we get there, let's just step back a bit and think about what's happening in the infection. One of the problems here is we're seeing this emergence of supersized hospitals, of sucking people into hospitals and these big centres. And we've got this 19-gale hospital happening in London, and we're going to send 4,000 people there.
But if you look at the evidence of what's happening in Italy and Spain, as you bring people into hospital, it becomes a sort of super center for the infection. 10% of all the infections in Spain are in health care workers. Then you come into hospital. If you haven't got the infection, you're going to definitely get it. So it becomes a vector of carrying on the infection.
So one of the things for us is to start to consider, is it an appropriate way to deal with everybody by bringing them into hospital? Or can you reverse that policy and start to think about, actually, can you keep people in the home setting? And if you did that, you could give them good advice. You could probably give them a pulse oximeter. You could give them a thermometer.
And you could have daily contact to understand what's going on, to watch out for those who deteriorate. Because I think there are two important issues here. One is the deterioration into what we call viral pneumonia. And viral pneumonia tends to be slow onset. Day five, day seven, you start to deteriorate.
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