The COVID-19 pandemic has transformed lives across the world. In the UK there has been a public health driven policy of population ‘lockdown’ that had enormous personal and economic impact. We compare UK response/outcomes including excess deaths with European countries with similar levels of income/healthcare resources. We calibrate estimates of the economic costs as different %loss in GDP against possible benefits of avoiding life years lost, for different scenarios where local COVID-19 mortality/comorbidity rates were used to calculate the loss in life expectancy. We apply quality-adjusted life years (QALY) value of £30,000 (maximum under NICE guidelines). The implications for future lockdown easing policy in the UK are also evaluated. The spread of cases across European countries was extremely rapid. There was significant variation both in severity and timing of both implementation and subsequent reductions in social restrictions. There was less variation in the trajectory of mortality rates and excess deaths, which have fallen across all countries during May/June 2020. The average age at death and life expectancy loss for non-COVID-19 was 79.1 and 11.4years respectively while COVID-19 were 80.4 and 10.1years; including for life-shortening comorbidities and quality of life reduced this to 5QALY for each COVID-19 death. The lowest estimate for lockdown costs incurred was 50% higher than highest benefits from avoiding the worst mortality case scenario at full life expectancy tariff and in more realistic estimation they were over 50 times higher. Application to potential future scenarios showed in the best case a QALY value of £220k (7xNICE guideline) and in the worst-case £3.7m (125xNICE guideline) was needed to justify the continuation of the lockdown. The evidence suggests that the costs of continuing severe restrictions in the UK are so great relative to likely benefits in numbers of lives saved so that a substantial easing in restrictions is now warranted.

The worldwide outbreak of coronavirus disease-19 (COVID-19) has already put healthcare workers (HCWs) at a high risk of infection. The question of how to give HCWs the best protection against infection is a priority. Our literature review has indicated that the degree of protection required in looking after people with COVID-19 infection, is dependent on the particular environment to which the HCW is exposed. Covering more of the body could provide better protection for HCWs. Of importance, it is not just the provision of PPE but the skills in donning and doffing of PPE that are important, this being a key time for potential transmission of pathogen to the HCW and in due time from them to others. In relation to face masks, the evidence indicates that a higher-level specification of face masks (N95) seems to be essential to protect HCWs from Coronavirus infection. Evidence specifically around PPE and protection from the COVID-19 virus is minimal and at the level of anecdotal reports only.

The Facts COVID-19 is the disease associated with the 2019 novel coronavirus Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2). The pandemic related to this virus has transformed life for billions of people across the globe. Using population based data from England, we recently showed a strong independent relation over time between our calculated R value for COVID-19 transmission and the number of cases identified as definitely positive in the population. We determined that 26.8% of the population of the United Kingdom (UK) possibly had been infected by late April 2020 approximating to 18.2 million people. Reflection Different modelling approaches give different answers to the question of how many people in the UK and elsewhere have actually been infected by COVID-19, which all would agree in epidemiological terms is behaving very differently from other Coronaviruses that we have seen in the past. We are learning more and more about this virus. National policy is changing rapidly and COIVD-19 antibody testing is increasingly being applied. This will facilitate better datasets from population based studies. The picture will become clearer as more data accrues over time.

At the date of writing this editorial, there is growing agreement amongst experts that the first wave of the COVID-19 pandemic is in decline. The number of deaths reported each day is now around 1% of the cumulative total and falling. In general, the approach to predicting pandemic policy has been through a comparison of inter-country performance in managing this crisis. While all countries are paying a high price in economic slowdown and lives lost, the health consequences in terms of cases and deaths have varied considerably. Countries with lower relative mortality and infection numbers have shown a more structured logical approach to pandemic management. There is a very real urgency to learn lessons immediately given the pressure to reduce the home confinement policy as soon as possible. While this is clearly a challenging time for policy makers, public health messaging is often emotive around concepts such ‘being at war’ with the virus, and other similar statements. We propose that a more rational approach to moving forward is required to avoid a second wave. Understanding this rational approach can be found through an evaluation of not only how other countries are approaching this challenge, but also from history.

We are writing to highlight the potential for a post-viral syndrome to manifest following COVID-19 infection as previously reported following Severe Acute Respiratory Syndrome (SARS) infection, also a coronavirus. After the acute SARS episode some patients, many of whom were healthcare workers went on to develop a Chronic Fatigue Syndrome / Myalgic Encephalomyelitis (CFS/ME) - like illness which nearly 20 months on prevented them returning to work. We propose that once an acute COVID-19 infection has been overcome, a subgroup of remitted patients are likely to experience long-term adverse effects resembling CFS/ME symptomatology such as persistent fatigue, diffuse myalgia, depressive symptoms, and non-restorative sleep. In a contracted future economy, managing likely Post COVID-19 syndrome cases, in addition to existing CFS/ME cases will put additional burden on our already hard pressed healthcare system. We suggest that priority is given to exploration of pragmatic relatively low cost techniques to treat post-viral fatigue, to alleviate symptoms and improve quality of life for those affected by the longer term sequelae of COVID-19.

Introduction Erectile Dysfunction (ED) is common in older age and in diabetes (DM). Phosphodiesterase type 5-inhibitors (PDE5-is) are the first-line for ED. We investigated how type of diabetes and age of males affects the PDE5-i use in the primary care setting. Methods 2018-19 general practice level quantity of all PDE5-i agents were taken from the GP Prescribing Data set in England. The variation in outcomes across practices was examined across one year, and for the same practice against the previous year. Results We included 5,761 larger practices supporting 25.8million men of whom 4.2million≥65 years old. Of these, 1.4million had T2DM, with 0.8million of these>65. 137,000 people had T1DM. 28.8million tablets of PDE5-i were prescribed within the 12 months (2018-19) period in 3.7million prescriptions (7.7 tablets/prescription), at total costs of £15.8million (£0.55/tablet). The NHS ED limit of 1 tablet/user/week suggests that 540,000 males are being prescribed a PDE5-i at a cost of £29/year each. With approximately 30,000 GPs practising, this is equivalent to one GP providing 2.5 prescriptions/week to overall 18 males. There was a 3x variation between the highest decile of practices (2.6 tablets/male/year) and lowest decile (0.96 tablets/male/year). The statistical model captured 14% of this variation and showed T1DM males were the largest users, while men age<65 with T2DM were being prescribed 4 times as much as non-DM. Those T2DM>65 were prescribed 80% of the non-DM amount. Conclusion There is wide variation in use of PDE5-is. With only 14% variance capture, other factors including wide variation in patient awareness, prescribing rules of local health providers, and recognition of the importance of male sexual health by GP prescribers might have significant impact.

Background The COVID-19 pandemic has led to radical political control of social behaviour. The purpose of this paper is to explore data trends from the pandemic regarding infection rates/policy impact, and draw learning points for informing the unlocking process. Methods The daily published cases in England in each of 149 Upper Tier Local Authority (UTLA) areas were converted to Average Daily Infection Rate(ADIR), an R-value - the number of further people infected by one infected person during their infectious phase with Rate of Change of Infection Rate(RCIR) also calculated. Stepwise regression was carried out to see what local factors could be linked to differences in local infection rates. Results By the 19th April 2020 the infection R has fallen from 2.8 on 23rd March before the lockdown and has stabilised at about 0.8 sufficient for suppression. However there remain significant variations between England regions. Regression analysis across UTLAs found that the only factor relating to reduction in ADIR was the historic number of confirmed number infection/000 population, There is however wide variation between Upper Tier Local Authorities (UTLA) areas. Extrapolation of these results showed that unreported community infection may be >200 times higher than reported cases, providing evidence that by the end of the second week in April, 29% of the population may already have had the disease and so have increased immunity. Conclusion Analysis of current case data using infectious ratio has provided novel insight into the current national state and can be used to make better-informed decisions about future management of restricted social behaviour and movement.