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Foundations’ team researching how the COVID-19 response facilitates Irish health system reform

Health system foundations for Sláintecare implementation in 2020 and beyond - co-producing a Sláintecare Living Implementation Framework with Evaluation: Learning from the Irish health system’s response to COVID-19 is a Health Research Board Applied Partnership Award funded from 2019 to 2021. A study protocol was recently published on HRB Open available here https://hrbopenresearch.org/articles/3-70/v1

This applied research uses qualitative and quantitative research methods to coproduce a Living Implementation Framework with Evaluation (LIFE) linking evidence, policy and practice that feeds into real-world Sláintecare implementation. In partnership with senior leadership in the Sláintecare Programme Implementation Office, the Department of Health and the HSE, the researchers are scoping, documenting, measuring and analysing the Sláintecare relevant COVID-19 responses.

Dr Sara Burke is the Principal Investigator on the Foundations’ project with co-applicants Prof Steve Thomas and Dr Sarah Barry, all based in the School of Medicine’s Centre for Health Policy and Management. The Foundations’ core team previously worked with the Oireachtas Committee on the Future of Healthcare that devised Sláintecare in 2017 and currently lead the Irish team which is monitoring the COVID-19 response monitor for the European Commission and WHO Europe through the European Observatory on Health Systems and Policy.

This research project is informing the implementation of Sláintecare with Laura Magahy, Deputy Secretary General in the Department of Health and Executive Director of the Sláintecare Implementation Office as the lead knowledge user. Dr Colm O’Reardon, Acting Secretary General in the Department of Health, Dr Josep Figeuras, Director of the European Observatory on Health Systems and Policies, Dean Sullivan, Chief Strategy and Planning Officer, HSE, Dr Colm Henry, Chief Clinical Officer, HSE and Liam Woods, Acute Operations, HSE are also co-applicants.

The LIFE initially takes the form of a clusters of COVID-19 health system responses most relevant to Sláintecare. For each response, indicators will be collected which enables monitoring overtime. The spreadsheet is accompanied by a series of rapid reviews, narrative descriptions of multiple case studies, research papers, stakeholder engagement and formative feedback. These collectively make up the ‘LIFE’, informing dialogue with the project partners and co-applicants, which is happening in real time (living), influencing health policy and system decision-making and implementation as the project progresses.

The first major publication from the project is entitled ‘Understanding Service Reorganisation in the Irish Health & Social Care System 1998 to 2020’. This work led by Dr Sarah Barry includes a policy analysis, key informant interviews and a rapid review of relevant international literature will be published shortly. The aims of this specific study are to learn from reorganisation in the Irish health and social care system over the past 20 years, to inform the process of Regional Health Areas implementation as part of the Sláintecare programme of health reform, and to create a space for system reflection and learning.

Already the Foundations’ project is credited with influencing the 2020 Programme for Government, the HSE 2020 Winter Plan as well as informing more long-term health system reform in Ireland and contributing to international health systems and policy research. It is an example of excellent policy-relevant research, collaborative partnerships between researchers and knowledge users, building relationships and evidence that are embedded in policy and system reform.

Dr Sara Burke, Research Assistant Professor, Public Health & Primary Care, Trinity College Dublin, Speaking to an Oireachtais Committee on the Future of Healthcare about inequality and access

TILDA research and the continued response to COVID-19 in Ireland

Since the outbreak of the COVID-19 pandemic, the TILDA research, management and administrative support teams have been continuing to work and coordinate COVID-19 research to assist Government and health authorities with their response to the crisis. TILDA researchers have been publishing a variety of reports that supply key information on Ireland’s older population to provide important data for future policy recommendations as Ireland progresses with its roadmap to reopening the country.

The TILDA dataset continues to serve as an unparalleled resource for understanding the health, social and economic situation of Ireland’s older population, a cohort disproportionately affected by the crisis. TILDA researchers have reoriented their research to advance studies using TILDA data from Wave 5 (collected 2018). TILDA continues to be a recognised evidence source for COVID-19 response in Ireland on McMaster University’s Global Guide to COVID-19 evidence sources.  

The analyses of Wave 5 data in the second quarter of the year has provided national estimates of the prevalence of factors relevant to COVID-19 response planning, including: a short report on TILDA’s sample of nursing home participants; a report on internet access and use among adults over 50 in Ireland; and a joint report from TILDA and ALONE examining the issues of loneliness and social isolation with specific reference to the COVID-19 pandemic in Ireland.

The first of these reports entitled ‘’TILDA Nursing Home Data: A short report to inform COVID-19 responses for our most vulnerable’’, describes the characteristics of TILDA participants from two data sources: nursing home interviews with TILDA participants who transitioned to nursing homes, and information gathered on deceased participants through end-of-life interviews completed by family members and friends. The report can be found here: https://www.doi.org/10.38018/TildaRe.2020-08

In June, TILDA produced a report to show how older adults navigate the online world and document the prevalence of technological devices as people of all ages have become more reliant on the internet to stay connected and conduct tasks such as financial banking, shopping, social and leisure activities and social interaction. The findings show a high level of access, and frequent and varied use of the internet among older adults in Ireland, though traditional forms of communication such as postal service, radio and TV remain important sources of receiving information. The report, ‘’Internet access and use among adults aged 50 and over in Ireland: Results from Wave 5 of the Irish Longitudinal Study on Ageing’’  can be found here: https://www.doi.org/10.38018/TildaRe.2020-06

This report was also covered in the Irish Times, Medical Express and News Medical Life Sciences with the report shared in Spain and the U.K. the U.S. also.

A joint report between TILDA and the charity ALONE examines the issues of loneliness and social isolation with specific reference to the COVID-19 pandemic in Ireland. Measures introduced to curtail the spread of COVID-19, including social distancing, self-isolation and ‘cocooning’ among the over 70s, have meant disruption to familiar routines and social interactions, particularly among older adults. The report highlights a rise in feelings of increased anxiety, loneliness and social isolation in older adults during the pandemic which may have a negative effect on the wellbeing of older adults. The report describes loneliness among adults aged 70 years and older in Ireland using TILDA data in conjunction with usage of the UCLA loneliness scale. Estimates of the prevalence of loneliness in each county is also reported alongside a description of the association between loneliness, health, and psychological wellbeing indicators. Social integration and isolation is measured using the Berkman-Syme Social Network Index (SNI), and analyses how it relates to sociodemographic characteristics and health and psychological wellbeing. Estimates of the prevalence of social isolation in each county are also reported. Data from ALONE gathered since the introduction of measures to curtail the spread of COVID-19 shows the impact of the pandemic, particularly ‘cocooning’ measures, among the older population. The report entitled ‘’Loneliness and social isolation in the COVID-19 Pandemic among the over 70s: Data from The Irish Longitudinal Study on Ageing (TILDA) and ALONE’’ can be found here: https://www.doi.org/10.38018/TildaRe.2020-07

The press release was covered by news outlets in Ireland, the UK and internationally.

TILDA will lead the gathering of new data documenting the experiences of adults who have been affected by the COVID-19 crisis, through two HRB funded COVID-19 rapid response research projects. In the first project led by Professor Rose Anne Kenny and Dr Mark Ward of TILDA, researchers will survey 6,000 TILDA participants about how their health, behaviours and attitudes have changed in the pandemic in a project entitled ‘’Altered Lives in a time of crisis:Preparing for recovery from the impact of the COVID-19 pandemic on the lives of older adults’’. The second project led by Dr Nollaig Burke, will examine blood samples from TILDA participants to see if they have been exposed to the virus that causes COVID-19 and explore associated risk factors. More information on the projects can be found here.

TILDA researchers have been conducting more analyses examining the link between COVID-19 severity of infection and Vitamin D levels. TILDA researchers have conducted joint research with researchers at the University of Liverpool and produced an editorial publication and two reports.

An editorial entitled ‘’Editorial: low population mortality from COVID‐19 in countries south of latitude 35 degrees North supports vitamin D as a factor determining severity’’ was published in Alimentary Pharmacology and Therapeutics. The research looks at marked variations in mortality from COVID‐19 between different countries. Researchers concluded that when mortality per million is plotted against latitude they estimated that countries that lie below 35 degrees North have relatively low mortality from COVID-19. Evidence suggested a possible role for vitamin D in determining outcomes from COVID‐19. The research was conducted by Professor Rose Anne Kenny and Dr Eamon Laird of TILDA in collaboration with Prof Jonathan M Rhodes and Prof Sreedhar Subramanian of the University of Liverpool. 

The editorial can be found here:  https://doi.org/10.1111/apt.15777

The research was also covered in news outlets in the US and Norway.

The first of the reports ‘’COVID-19 mortality increases with northerly latitude after adjustment for age suggesting a link with ultraviolet and vitamin D’’ saw researchers test their hypothesis that there was no link between mortality and latitude below a defined threshold, and that thereafter mortality increased with latitude. The study analysed COVID-19 mortality rates per million population in 117 countries with 150 or more COVID-19 cases. Data were accumulated on each country, examining people aged 65 and over, incorporating data on population density and air pollution, while latitude was entered for each country’s capital city. The findings showed association between COVID-19 mortality and latitude exists above 28 degrees, not far from the latitude (35 degrees) beyond which populations often have insufficient ultraviolet B exposure, to maintain normal vitamin D blood levels through winter and spring.

The study published in the British Medical Journal can be found here: http://dx.doi.org/10.1136/bmjnph-2020-000110

A second paper entitled ‘’Perspective: Vitamin D deficiency and COVID‐19 severity – plausibly linked by latitude, ethnicity, impacts on cytokines, ACE2, and thrombosis (R1)’’ was published in the Journal of Internal Medicine to review the evidence. The findings gathered substantial evidence to support an indirect link between vitamin D deficiency and COVID‐19 severity. Researchers suggest further evidence could come from a study of COVID‐19 outcomes in large cohorts with information on prescribing data for vitamin D supplementation or assay of serum unbound 25(OH) vitamin D levels. The study suggests vitamin D supplementation should be strongly advised for people likely to be deficient.

The study can be found here: https://doi.org/10.1111/joim.13149

The report and its findings featured in a number of international outlets including Nach Wecht (Germany) and Dhaka Tribune (Bangladesh).

As data emerge, we communicate TILDA materials along with other public information on the crisis from reliable sources, through our Twitter and Facebook platforms.

A quick and cost-effective test for COVID-19 antibodies for frontline healthcare workers

Frontline and healthcare workers are at high risk of developing COVID-19 in the current pandemic. Using swab tests to detect the virus that causes COVID-19 (SARS-CoV2), we can tell who is currently infected, but this does not tell us who goes on to develop immunity to future re-infection.

A research team from Trinity College Dublin, led by Dr Gareth Brady and Dr William McCormack, are to establish a serology test for COVID-19 that will screen for antibodies to the virus and identify those who have been infected.

The project, which will be conducted in the Trinity Translational Medicine Institute (TTMI), is funded by Science Foundation Ireland under the State’s COVID-19 Rapid Response Funding programme.

While several COVID-19 virus antibody tests are under development internationally, few have been validated, and those that have are both costly and in high demand worldwide. This new research project in Ireland will focus on validating an existing serology test for SARS-CoV2 antibodies.

Partnering with a UK-based CRO (Peak Proteins) to produce quality recombinant antigens for the assay, the team will validate the test using positive samples from the SJH/TTMI COVID BioResource (Professors Niall Conlon, Cliona Ni Cheallaigh & Aideen Long) before evaluating the test on a broader population base.

If successful, the result will be a test that can quickly and cost-effectively screen the Irish population, including healthcare and frontline workers, for post-infection immunity.

What is the issue?

We don’t know how many frontline and healthcare workers in Ireland have developed antibodies and immunity to the COVID-19 virus, SARS-CoV2. For this, we need a reliable test to detect antibodies to SARS-CoV2 in the body. Few reliable tests are currently available, and those in use are both expensive and in high demand.

What will the research do?

The research, led by Trinity College Dublin, will develop an existing test for SARS-CoV2 antibodies for use in Ireland. It will screen blood samples from patients in Ireland who have had COVID-19, to see if antibodies can be detected.

What will the impact be?

The research will develop a quick and cost-effective antibody test for use in Ireland to screen for immunity to future infection with the COVID-19 virus. This will help us to identify individuals who are likely to be immune, and who can more safely work with members of the public and with patients.

Speaking about the exciting development, Dr Gareth Brady & Dr William McCormack, said:

“We have linked up with a very experienced, UK-based CRO to produce high quality recombinant antigen for this SARS-CoV2 serology test. The assay we seek to replicate has recently been approved by the FDA and we are confident of delivering a highly sensitive and specific assay that will be cost-effective and could be used to screen the Irish public for SARS-CoV2 immunity.”

Dr Gareth Brady and Dr William McCormack

Managing the health of vulnerable groups during COVID-19

A new research project will explore the use of Telehealth to enhance the management of vulnerable groups during the COVID-19 pandemic.

The project is being led by Professor Orla Hardiman, Professor of Neurology in the School of Medicine, TCD and Consultant Neurologist at Beaumont Hospital.

The project is one of the 6 proposals, awarded to the School of Medicine, TCD, so far, under the State-backed ‘COVID-19 Rapid Response Call’.

Attendance at the specialist amyotrophic lateral sclerosis (ALS)/ motor neurone disease (MND) multidisciplinary clinic (MDC) at the National Centre (Beaumont Hospital) is associated with better outcomes. While patients and caregivers value the “one stop shop” nature of the service, they find travelling long distances to the clinic burdensome as the condition progresses.

Also, on average most of the patient’s time in the clinic (70%) is spent waiting for review by members of the multidisciplinary team, with only 30% of time spent with members of the multidisciplinary team.

Interviews with patients and their families suggest that a more flexible and responsive system is required to meet patient needs, and that will help improve the efficiency of how we provide care.

The research team will implement, evaluate and modify a new patient/caregiver-oriented telemedicine system developed by its collaborators in Sheffield University, to provide immediate virtual support for those with Motor Neuron Disease (MND) and Frontotemporal Dementia (FTD) and related conditions. The study will examine the strengths and opportunities for modification of this system, tailoring it to enhance care for Irish patients and their families.

Speaking on the importance of this research, Professor Hardiman said:

The COVID-19 pandemic has made patients and their families reluctant to attend their GPs or visit the hospital, creating a high risk of patients experiencing untreated complications of their condition, and breakdown of care that is usually provided by family members and community-based services. Remote and accurate tracking of person’s clinical symptoms, early recognition of new symptoms and timely home-based visits are very important. The telemedicine system will allow us to efficiently monitor people in real time, and deploy team members to those most in need, allowing continuation of high quality patient centred care despite the limitations posed by Covid-19.

In the longer term, this telemedicine system will be adjusted to improve how care is provided between the hospital and the community services to improve the experience of patients and their families.

Professor Orla Hardiman BSc, MD, FRCPI, FTCD, MRIA. Professor of Neurology, School of Medicine, Trinity College Dublin, Consultant Neurologist, Beaumont Hospital, HSE Clinical Lead in Neurology.

Studying the impact of rescheduled radiation on cancer patients

Radiotherapy is a key component of cancer treatment. Approximately 50% of all cancer patients should receive radiotherapy as part of their cancer treatment regimen and radiotherapy, either on its own or in combination with other modalities, is responsible for 40% of all cancer cures. Therefore, deviations from evidence-based regimes must be collated to analyse changes in standard practice and outcome.

During the Covid-19 pandemic, deviations in standard radiotherapy treatments are inevitable due to the immunocompromised status of patients, the potential for patients to be Covid-19 positive as well as the Covid-19 status of specialised radiotherapy professionals involved in the planning and delivery of treatment.

Michelle Leech, Head of the Discipline of Radiation Therapy, School of Medicine, has been funded under TCD’s “Harnessing Trinity’s Collective Expertise for the Greater Good”, initiative to conduct a comprehensive, national report on radiation oncology practice over the course of the pandemic. Her study will cover radiation activities over the full range of cancer sites and analyse the potential impact of these deviations. These will include changes in fractionation (the number of treatments and size of radiation dose given to the patient), deviations in treatment technique ( e.g. from complicated methods of radiation therapy delivery to simpler methods) and changes in imaging of the patient (e.g. changing from imaging daily to imaging a defined number of times per week).

 

Exploring the contrasting responses to COVID-19 on both sides of the Irish border

Trinity College is leading a major research project to explore the implications of COVID-19 on the public health jurisdictions of the Republic of Ireland (ROI) and Northern Ireland (NI). The research team is led by Professor Catherine Darker, Associate Professor of Health Services Research, Public Health and Primary Care, Institute of Population Health at the School of Medicine.

Professor Darker has brought together a group of experts from University College Dublin, Queens University Belfast and University of Bristol in the UK; those academics are working in tandem with public health leaders in the Health Service Executive (HSE).

The team will produce an evidence-based toolbox for targeting of public health and political leadership in terms of messaging and measures for any further waves of COVID-19, and subsequently for future epidemics/pandemics. Professor Darker was one of six projects at Trinity College who received government funding for her research through the ‘Covid-19 Rapid Response Call’ announced on April 29th, 2020.

Explaining the project, Professor Darker said:

COVID-19 is one of the biggest threats to public health in a generation. On the island of Ireland there are two different governments and public health jurisdictions. This represents a unique opportunity to explore the implications of different measures and messaging across these two jurisdictions as they relate to this virus on two similar populations. Arising from this research we will produce a public health toolbox that will guide both public health and political leaders for any further surges of COVID-19 or indeed for future epidemics or pandemics.

The team will:

  • talk to people through both surveys and focus groups to assess key behavioural, social and psychological factors of the disease.
  • investigate social media messaging and formal media responses in both jurisdictions to investigate the spread of (mis)information.
  • model data to plot the psychosocial/behavioural and media messaging information with incidence and mortality data.
  • conduct an assessment of health policy in terms of the most significant public health and political insights from each jurisdiction.

Professor Darker concluded:

COVID-19 represents a serious challenge to governments and healthcare systems.

In addition to testing and contact tracing; behavioural responses, like hand-washing and social responses, such as social distancing and cocooning are the most effective tools for stopping the spread of the disease. Psychological factors, that is; how likely you believe it is that you will contract the disease and contextual factors, like government and public health messaging are likely to drive these behaviours.

Professor Darker’s team at Trinity includes: Professor Lina Zgaga, Dr Nicola O’Connell, Dr Ann Nolan, Dr Katy Tobin, Ms Niamh Brennan, Ms Emma Burke, Ms Gail Nicolson.

Institutions involved: Trinity College (lead); University College Dublin; Queens University Belfast; University of Bristol, UK; Health Service Executive.

Defining the course of the COVID-19 disease in the immunosuppressed patient

COVID-19 is a severe, highly contagious condition that has forced the government to issue strict stay-at-home orders to reduce its spread. This advice is particularly important to protect vulnerable groups such as those with autoimmune conditions taking medications that suppress the immune system, who are more susceptible to infections. However, these people may have an advantage against the disease. Early evidence indicates that the overreaction of the immune system – the “cytokine storm”– is particularly damaging in COVID-19, which means that people receiving immunosuppressive therapies could in fact be protected.

A new research project, the DeCOmPRESS Study, (Defining the disease course and immune profile of COVID-19 in the immunosuppressed patient) will allow the team to better understand the disease and how it effects those who are medically compromised in our community.

Professor Mark Little, Clinical Medicine at the School of Medicine, was recently awarded government funding through the ‘Rapid Response Covid-19 Call’ for an important research project which will define the course of SARS-CoV-2 infection in patients with systemic autoimmune disease. Professor Little’s team will also determine if COVID-19 is severe in these immunosuppressed patients.

Using ANCA vasculitis (an autoimmune disease affecting small blood vessels in the body) as a model autoimmune disease, the team will characterise the immune response in COVID-19 in these patients. Through the Rare Kidney Disease Biobank, we have access to an engaged and well-connected network of patients, eager to help us understand more about the disease. Vasculitis patients who test positive for COVID-19 will provide blood samples and clinical information to allow us to measure the types of immune cells that are impacted during SARS-CoV-2 infection.

This will allow the team to better understand how the immune system responds to the virus and assess whether immunosuppressive therapies could be used to treat COVID-19. It will also assist in providing clear guidance to patients with respect to cocooning and current use of immunosuppressant medication.

Speaking on the importance of this research project, Professor Mark Little said:

The DECOMPRESS project will determine the outcome of patients taking immunosuppressive medication who contract SARS-Cov2. This will allow us to target accurate advice regarding cocooning to these patients, and to inform development of new therapies and biomarkers. Conventionally, we assume that, when the immune system is suppressed, the ability to fight infection is impaired. While this is certainly true generally, these medications may actually protect against the “cytokine storm” that characterises severe COVID-19. The project will build on work in the Irish Rare Kidney Disease registry and biobank, and will incorporate six clinical research facilities around Ireland, a dedicated smartphone

app developed by patientMpower, the immunology expertise of St James’s Hospital and the data integration capability of the ADAPT SFI centre.

The study will rapidly deliver critical information on how patients with autoimmune and chronic inflammatory diseases should be managed during this pandemic.

The team will deliver its first report within three months (from April 2020).

Five innovative School of Medicine projects to wage war on COVID-19

Five School of Medicine researchers secure HRB funding for vital research into COVID-19 and the implications of the disease on the health and well-being of our nation.

The successful projects awarded are:

1: Title: SABS-TILDA: SARS-CoV-2 specific AntiBodieS in The Irish LongituDinal Study on Ageing (TILDA): an opportunity to assess COVID-19 rates and phenotypes in older adults in Ireland

Principal Investigator: Dr Nollaig Bourke, Dept of Medical Gerontology, School of Medicine

Trinity Translational Medicine Institute (TTMI), St. James’s Hospital

Watch: You can view Dr Bourke’s synopsis of her research here: https://youtu.be/c9VpexgItcQ

Dr Bourke and her team will investigate the ‘who’ and ‘why’ of COVID-19 in older people in Ireland. They will investigate which participants of the Irish Longitudinal Study on Ageing (TILDA) were infected with the disease by measuring virus specific antibody levels and will explore what risk factors are associated with disease, including analysis of how the immune system is activated in these individuals.

Dr Nollaig Bourke said:

“Older people in Ireland are disproportionally affected by COVID-19, so it is really important that we have accurate national rates of infection in this population (including asymptomatic individuals). It is also very important that we understand who got sick and why, so by doing our proposed in-depth research into risk factors associated with COVID-19 disease in older people in Ireland, including detailed analysis of their immune system, we will potentially be able to explain why someone might be more likely to experience severe COVID-19 disease. This would potentially help us identify high risk individuals, as well as reveal what parts of the immune system would be best to target therapeutically in individuals.”

2.Title: Creating an evidence-based toolbox for targeted public health interventions during COVID-19: a cross-border analysis to disentangle psychological, behavioural, media and governmental responses.

Principal Investigator: Professor Catherine Darker, Associate Professor of Health Services Research, (interim) Head of Discipline, Public Health & Primary Care, Trinity.

Watch: You can view Professor Darker’s synopsis of her research here: https://youtu.be/bgPiPhWsoho

Professor Darker and her team will produce an evidence-based toolbox for targeting of public health and political leadership in terms of messaging and measures for any further waves of COVID-19, and subsequently for future epidemics/pandemics. The team will explore the implications of COVID-19 on two very similar populations in two different governments and public health jurisdictions (Republic of Ireland (ROI) and Northern Ireland (NI)). As part of the research the team will investigate the spread of (mis)information and the key behavioural, social and psychological factors of the disease.

Professor Catherine Darker said:

“COVID-19 is one of the biggest threats to public health in a generation. On the island of Ireland there are two different governments and public health jurisdictions. This represents a unique opportunity to explore the implications of different measures and messaging across these two jurisdictions as they relate to this virus on two similar populations. Arising from this research we will produce a public health toolbox that will guide both public health and political leaders for any further surges of COVID-19 or indeed for future epidemics or pandemics.”

3.Title: Using Telehealth to enhance management of vulnerable groups during the COVID-19 pandemic.

Principal Investigator: Professor Orla Hardiman BSc, MD, FRCPI, FTCD, MRIA. Professor of Neurology, Trinity College Dublin, Consultant Neurologist, Beaumont Hospital, HSE Clinical Lead in Neurology.

Professor Hardiman and her research team will implement, evaluate and modify a new patient/caregiver-oriented telemedicine system developed by their collaborators in Sheffield University, to provide immediate virtual support for those with Motor Neuron Disease (MND) and Frontotemporal Dementia (FTD) and related conditions. They will examine the strengths and opportunities for modification of this system, tailoring it to enhance care for Irish patients and their families.

Professor Hardiman said:

“The COVID-19 pandemic has made patients and their families reluctant to attend their GPs or visit the hospital, creating a high risk of patients experiencing untreated complications of their condition, and breakdown of care that is usually provided by family members and community-based services. Remote and accurate tracking of clinical symptoms, early recognition of new symptoms and timely home-based visits are very important. The telemedicine system will allow us to efficiently monitor people in real time, and deploy team members to those most in need, allowing continuation of high-quality patient centred care despite the limitations posed by COVID-19.

In the longer term, this telemedicine system will be adjusted to improve how care is provided between the hospital and the community services to improve the experience of patients and their families. “

4.Title: Defining the disease course and immune profile of COVID-19 in the immunosuppressed patient (DeCOmPRESS study)

Principal Investigator: Professor Mark Little, Professor/Consultant of Nephrology, Clinical Medicine, School of Medicine, Trinity.

The aim of the research project is to define the course of SARS-CoV-2 infection in patients with systemic autoimmune disease, and to determine if COVID-19 is more or less severe in these immunosuppressed patients.

Professor Little and his team will better understand how the immune system responds to the virus and assess whether immunosuppressive therapies could be used to treat COVID-19. It will also assist in providing clear guidance to patients with respect to cocooning and current use of immunosuppressant medication.

Professor Mark Little said:

“The DECOMPRESS project will determine the outcome of patients taking immunosuppressive medication who contract SARS-CoV2. This will allow us to target accurate advice regarding cocooning to these patients, and to inform development of new therapies and biomarkers. Conventionally, we assume that, when the immune system is suppressed, the ability to fight infection is impaired. While this is certainly true generally, these medications may actually protect against the “cytokine storm” that characterises severe COVID-19. The project will build on work in the Irish Rare Kidney Disease registry and biobank, and will incorporate six clinical research facilities around Ireland, a dedicated smartphone app developed by patientMpower, the immunology expertise of St James’s Hospital and the data integration capability of the ADAPT SFI centre.”

Photo Caption: Julie Power, a patient with systemic vasculitis (and patient lead on the DeCOmPRESS project), displaying her smartphone app (which will be a cornerstone of patient reported outcomes aspect of the DeCOmPRESS study).

5.Title: Altered lives in a time of crisis: Preparing for recovery from the impact of the COVID-19 pandemic on the lives of older adults.

Principal Investigator: Professor Rose-Anne Kenny, The Irish Longitudinal Study on Ageing (TILDA), Trinity College Dublin.

Watch: You can view Professor Kenny’s synopsis of this research project here: https://youtu.be/py9SafZcqAM

Older persons are most likely to experience severe and critical consequences of COVID-19 including death. The ability to mount an immune response declines with age. Understanding immunosenescence (the gradual deterioration of the immune system brought on by natural age advancement), its relationship to COVID-19 and therefore its impact on future vaccination responsiveness is a priority. Because TILDA has comprehensive data collected at regular periods for the past 10 years the research team can explore how immune profiles and other biological and social factors change over time and which changes enhance an individual’s vulnerability to infection.

Professor Rose-Anne Kenny said:

“The measures which have been introduced as a result of COVID-19 have particularly impacted on the lives of people over 70. The research will further enquire about the impact of these policies on mental and physical health and hear the voice and views of those most affected. This is important if we are to understand and manage the collateral damage from COVID-19.”

Title: The role of physiotherapy throughout the COVID-19 recovery trajectory

From information available so far it appears the majority of people who get COVID-19 will suffer a mild to moderate disease and will recover. A smaller number (13.8%) will have severe disease and 6.1% are critical (https://www.who.int/publications-detail/report-of-the-who-china-joint-mission-on-coronavirus-disease-2019-(covid-19). Physiotherapists have a role throughout the COVID-19 disease trajectory from initial acute illness to recovery.

In the acute hospital setting, physiotherapists remotely screen referred patients using electronic records where possible and available medical information. This is to minimise unnecessary exposure to COVID-19 patients. They also link in with the health care team and access tests such as x-rays and arterial blood gases and will weigh up on a case-by-case basis if there is an indication or a need for physiotherapy treatment at this stage. Their skills in relation to the acute management of COVID-19 are mainly focussed on the following two areas;

(1) Respiratory focussed treatments in the critical care setting where specialised care is delivered and constant monitoring takes place

About one third of patients with COVID-19 in the critical care setting will have excess secretions or mucus which the physiotherapist will help to clear using a variety of methods. Techniques will be adapted to prevent spread of the virus, for instance the physiotherapist will position him/herself out of the path of expelled air if a patient coughs or huffs (exhalation though an open mouth) as part of treatment. Where necessary, suctioning (removing mucus secretions using a small tube or catheter) will be conducted as part of a closed circuit if possible rather than ‘open’ suctioning which involves temporarily disconnecting the person from the ventilator and thereby increasing the risk of air droplets spreading. A number of techniques to improve oxygenation can also be applied in this setting, such as ventilator hyperinflation or machine generated ventilator ‘big breaths’. They can also assist with prone positioning or placing the patient ‘face down’ to improve oxygen levels in the lungs.

(2) Physical focussed treatments in the critical care and ward settings

Physiotherapists will also help manage the complex physical rehabilitation needs of patients with COVID-19 in the critical care setting to try and prevent physical aspects of the ‘post intensive care syndrome’ or PICS.

Anecdotally, physiotherapists are finding many people recovering from COVID-19 in the critical care setting are extremely deconditioned or weak. Some need assistance with very basic tasks such as sitting up and need to progressively develop their strength and endurance with the assistance of a physiotherapist and the wider health care team. They can de-saturate or their oxygen levels can drop with the slightest physical effort. Some are confused and disorientated in this setting which can influence their ability to comply with treatment at times.

‘Early rehabilitation’ (or getting patients moving as soon as possible) is the aim where possible. Some patients can be complex, for instance many can be older and suffer from other comorbidities or conditions which need to be considered in terms of rehabilitation planning. Also they may have developed other complications such as kidney, liver and cardiac problems which makes treatment decisions complex and requires close collaboration with the multidisciplinary team such as intensive care doctors, other medical specialities, critical care nurses and other allied health professionals among others.

When it is safe, physiotherapists will deliver a progressive rehabilitation programme which may start at a very low level such as moving the limbs in bed and then sitting at the edge of the bed with assistance. Where possible, this will progress to standing, potentially with the use of electronic equipment and then walking based on the condition and endurance of the patient. These treatments will minimise the physical decline which can result from a critical care stay and help facilitate ‘weaning’ or coming off the ventilator and early discharge to less intensive settings.

Not all patients with COVID-19 will need to be admitted to the critical care setting. Many patients will be managed on a hospital ward where physiotherapists will also help manage respiratory and physical rehabilitation needs of patients. They will also continue treatment of patients who have been stepped down from the critical care to the ward setting to facilitate discharge home. Ideally, once home, patients should continue to exercise as building back muscle mass and restoring fitness is expected to take time.

Physiotherapists can also advise the following categories of people:

(1) People who have COVID-19 and don’t need hospitalisation who are self-isolating at home; for those that are physically vulnerable, it appears that low intensity exercise can be performed in the home environment, based on tolerance levels. People without any prior disease are likely to recover their physical capacity quicker but robust data is lacking on recovery profiles at this time.

(2) People who don’t have COVID-19 but who are vulnerable as well as those >70 years who are ‘cocooning’ at home should try to remain physically active and ideally do some strengthening exercises to prevent declines in muscle mass and endurance. For exercise advice while cocooning see this information from the Irish Society of Chartered Physiotherapists (ISCP), Health Service Executive (HSE) and gov.ie website.

https://www.iscp.ie/sites/default/files/documents/HSE%20COMMUNITY%20PHYSIO%20LEAFLET.pdf

https://www.gov.ie/en/publication/5a4293-staying-active-during-covid-19/

Exercise during the COVID-19 pandemic - a lifeline, a privilege, an opportunity

The COVID-19 pandemic has changed the way we live and brings challenges for everyone on a daily basis. One such challenge is keeping physically fit. From the very outset of this pandemic, the importance of keeping fit was mentioned by the government, but with gyms, clubs, swimming pools and other such amenities closed, many people cannot get the exercise they’re used to. On the other hand, some people who may have been “time poor” due to work or long commutes may now find the time, but are out of practice. If you are lucky enough not to be sick, then whether you are self-isolating, cocooning or working from home, it’s important to stay healthy.

A lifeline

The benefits of exercise on your health are undisputed. If we stay moving during this pandemic we have a better chance of bouncing back to our pre-pandemic selves when this is over. People who exercise regularly are less likely to get ill and end up in hospital. Yes, keeping yourself healthy now will help our front-line health workers during and after this pandemic. As well as that, being active helps reduce stress and has proven benefits for our mental health, something many of us will be struggling with in these trying times.

A privilege and opportunity

Being able to exercise outdoors daily is a privilege during this crisis. It is something we should respect and use wisely. Exercise safely and alone or with members of your household. For many people, exercise is a social activity but learning to exercise alone is a skill that will stand to you. Those who can self-motivate to exercise are more likely to stay physically active over time. Challenge yourself to self-motivate and reap the benefits for a lifetime.

What can you do to keep fit?

It is important that we exercise safely. Those who do not usually engage in regular physical activity may choose to begin with walking or jogging. Healthy Ireland guidelines recommend at least 30 minutes of moderate activity a day, 5 days a week. That’s 2 and a half hours a week.To find out if you’re exercising at the correct rate for you, take the “talk test”. While exercising try to sing, if you are not able to sing properly but you are able to talk, then you are exercising at a moderate intensity. Keep it up! Another way to see if you are exercising at the right intensity is to count your steps. Taking 100 steps or more per minute when walking is moderate exercise for a healthy adult. Walking also helps your mental health, helping to reduce stress and anxiety. Perhaps the most interesting thing that all the research shows is that moderate exercise, like walking and jogging, has no negative effects. Walking may seem like a mundane activity, but evidence continues to mount in support of Hippocrates’s claim that it is in fact “man’s best medicine”.

Add an extra layer to your shield

For those who are cocooning or shielding it is also still possible to stay fit. There are safe exercise options you can do using little or no equipment that do not require much space. If you are not used to being active try marching on the spot for 30 seconds and gradually increasing the time to several minutes. You can do this while standing or sitting. Try exercising to music to keep movements rhythmical and help you to stay motivated. Going from a seated position to a standing position several times in a row with your arms crossed across your chest is a great exercise to strengthen your legs. It may sound, easy but even healthy young adults will feel their legs burn after three minutes of this exercise– try it!

Exercise isn’t just about being strong, it is also important to maintain flexibility, coordination and balance and these types of exercise can easily be done in the home. Challenge your balance by standing on one leg (touch a solid surface like the kitchen table to steady yourself if needed) or walk along a line (the join between floorboards for example). For more examples of exercises you can do while cocooning, PCC Physiotherapists in Cork along with the ISCP have published a brochure which is free to download here.

Think of being active today as a lifeline, a privilege and an opportunity. Imagine yourself looking back at your time well spent stacking health odds in your favour during the pandemic by keeping active. The take-home message? Keep moving, at a distance from others.

Impact of COVID-19 on ECT Electroconvulsive therapy (ECT)

A newly released paper authored by Trinity College Dublin and St. Patrick’s University Hospital entitled “Images in Clinical ECT: Immediate impact of COVID-19 on ECT Electroconvulsive therapy (ECT)” outlines the impact of COVID-19 on the provision of ECT.

It is universally accepted that Health care workers are at higher risk of exposure and use of Personal Protective Equipment (PPE) is a key component in mitigating this risk. Current efforts to secure PPE in nearly every world region affected by COVID 19 are well documented. However, less documented, are the risks to ECT practitioners, who are continuing to treat critically ill patients with this critical form of therapy.

The authors forcefully make the case that ECT practitioners need to liaise with their senior anaesthetic colleagues to optimise a safe environment for ECT and determine the most appropriate PPE to be used.  This may include protective eyewear, body gowns, headwear, facemasks, shoe covers and gloves.

Electroconvulsive therapy ECT is an important medical procedure for patients with severe and sometimes life-threatening illness.  It is important during the current crisis that we don’t forget the healthcare needs of the more vulnerable in our society.  As with all medical procedures at the moment, practice is a balance of risks and benefits.
This paper is one of 3 papers featured in the Journal of ECT providing very early reactions to how ECT services respond to the impact of COVID-19 on the provision of ECT.

Paper Ref: Colbert SA, McCarron S, Ryan G, McLoughlin DM (2020) Images in Clinical ECT: Immediate impact of COVID-19 on ECT Practice. J ECT Mar 31. doi: 10.1097/YCT.0000000000000688. [Epub ahead of print]

Article by Prof Declan Mc Loughlin, Research Professor of Psychiatry, School of Medicine, Trinity Inst. of Neurosciences (TCIN) and St. Patrick’s St. Patrick’s University Hospital.

Derek Doherty - The Science behind the COVID-19 Virus

Coronavirus disease 2019 (COVID-19) is here. Confirmed cases in Ireland and deaths in Europe offer the grim forecast that we are almost certain to experience a coronavirus epidemic and the lifestyle changes that will accompany it. Being a new virus to affect humans, we don’t know the magnitude of the problem or how long will it last. Will it be a seasonal epidemic that wanes in the summer months? Will we acquire immunity against the virus and can this immunity be exploited to develop a protective or therapeutic vaccine?

COVID-19 is the disease caused by the novel 2019 coronavirus (2019-nCoV), the seventh member of the coronavirus family that infects humans. Other members include four prevalent strains that typically cause common cold symptoms, the severe acute respiratory syndrome coronavirus (SARS-CoV) and the Middle East respiratory syndrome coronavirus (MERS-CoV), the latter two which caused respiratory disease outbreaks in 2002 and 2012. Because 2019-nCoV has only been known for 3 months, our knowledge of the biology and pathology of this virus is mostly based on research on SARS-CoV and MERS-CoV.

In the three months since COVID-19 emerged in China, causing fever, coughing and pneumonia, it has swept into 72 countries, infecting nearly 93,000 people and killing more than 3,000. The majority (about 80%) of hospitalised COVID-19 cases were asymptomatic or with mild symptoms, but the current fatality rate is estimated to be about 3.4% globally, which is lower than those of SARS and MERS, but higher than that of flu. 2019-nCoV is very contagious. It is spreading with an R0 of more than 2.2, meaning that each individual has the potential to spread the infection to an average of 2.2 other people. This number must be reduced to less than 1 before the epidemic can be halted. This can only be achieved by the implementation of public health measures involving travel restrictions, public lockdowns and isolation of confirmed cases. Indeed, China’s aggressive measures have slowed the spread of 2019-nCoV, showing us that this is possible.

Can we make a vaccine that protects us against 2019-nCoV? Most likely. Coronaviruses induce immediate and long-lasting immune responses in most people. However, the virus can dampen these anti-viral responses in some people resulting in uncontrolled viral replication. They can also cause the immune system to over-react, resulting in inflammation in the lungs and pneumonia. An effective vaccine against 2019-nCoV will have to stimulate the anti-viral immunity while avoiding unwanted inflammation. Within two months of the 2019-nCoV outbreak, over 37 biopharmaceutical companies or academic sectors had joined the race to develop this vaccine. However, the development and testing of this vaccine is likely to take at least 1.5 years. Meanwhile, we must focus on avoiding exposure to the virus and bring the R0 for 2019-nCoV down to less than 1, through continued social restrictions and surveillance

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By Derek G. Doherty School of Medicine, TCD