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You are breathing my air; New insights on respiratory pathogens - Dr Mark Burgin

12/05/20. Dr. Mark Burgin BM BCh (oxon) MRCGP discusses whether continuing to tolerate high levels of deaths from respiratory infections will be acceptable in a post COVID world.

Public health measures reduced the rate of death from pneumonia in 1900 (200 per 100k population) to 1950 (about 40/100k equivalent to 30k deaths a year).

Since then there was little progress until introduction of the Pneumonia vaccine (Strep Pn bacteria) about 20 years ago (now 40/100k), surprisingly there was little impact from antibiotics.

Viruses are found in most community acquired pneumonia (rhinovirus, influenza, RSV, parainfluenza, coronaviruses, adenoviruses) suggesting person to person spread is key.

Immunisation against all these viruses is difficult but we could prevent the spread of respiratory viruses through the application of known public health measures.

Living and working in groups

Until COVID 19 it was culturally acceptable to attend school and work and even social gatherings with clinically obvious upper respiratory tract infections (viral URTI).

There has been no attempt to isolate people with a viral URTI or to take reasonable health and safety steps to reduce the exposure to infected people.

Simple and obvious steps such as remote working, increasing ventilation, wearing masks and providing sinks close to the desk (hand washing) have not been considered.

Social distancing could dramatically reduce respiratory infections but is disruptive and there are other Public health techniques that could be used.

Superinfectors

One of the key issues in transmission of respiratory viruses is the superinfector who passes the infection to tens or hundreds of others.

They may not have symptoms but they shed viruses at a much higher rate than other people so like Typhoid Mary they cause local outbreaks.

Genetic analysis of those who become superinfected may provide an explanation as to why they are vulnerable but developing a general test for superinfection is likely to be easier.

Making reasonable adjustments for those recognised to have this disability of their immune system so that they do not become infected in the first place could be crucial to control.

Contact tracing

Ethically contact tracing causes problems with confidentiality, in South Korea where they sent texts telling the person when they were close to an infected person.

It is the only technique that detects a possible infection before the person shows symptoms and therefore is essential when trying to break the chain of infection.

For serious respiratory infections like COVID 19 this can assist the eradication of the infection once herd immunity has been established as an exit strategy from lockdown.

In legal cases where a vulnerable person has become infected due to poor Health and Safety at work it is possible to take viral swabs and arrange a genotype to identify the infection.

Conclusions

Public health has been many times more effective than technology and simple steps such as changing airflow patterns in offices, public transport and schools do not require new technology.

There has been a historic reluctance to address the burden of respiratory disease in the UK partly due to waiting for a high-tech solution and partly a feeling that death is inevitable.

We have the means to defeat respiratory infections, the average loss of life in the COVID outbreak was estimated at 13 years and despite antibiotics pneumonia causes significant mortality.

Solicitors can assist claims where a claimant who develops pneumonia is known to be vulnerable by instructing an infection control expert witness to gather evidence.

Doctor Mark Burgin, BM BCh (oxon) MRCGP is on the General Practitioner Specialist Register.

Dr. Burgin can be contacted on This email address is being protected from spambots. You need JavaScript enabled to view it. and 0845 331 3304 website drmarkburgin.co.uk

Wunderink Causes and management of community acquired pneumonia in adults The BMJ 2017;358:j3546 state of the art review

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