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Introduction

Dr Tom Wingfield is Senior Clinical Lecturer and Honorary Consultant Physician at the Liverpool School of Tropical Medicine. He is part of the COVID-19 response in Liverpool and the UK. He has previously worked in informal settlements in Peru, Nepal and Mozambique. Here are short answers to questions put to him from Slum/Shack Dwellers International and the wider ARISE Consortium. There is a YouTube video which develops these responses further.

What is COVID-19?

• COVID-19 or Sars-CoV-2 is a novel (new) coronavirus
• Corona means crown and these viruses have crown-like spikes on their surface
• There are seven known coronaviruses that can infect people
• After COVID-19, the most well-known are SARS (Severe Acute Respiratory Syndrome) and MERS (Middle Eastern Respiratory Syndrome), both of which have caused much smaller outbreaks
• COVID-19 was first identified in Wuhan, Hubei province, in December 2019
• It originated in a seafood market in Wuhan that sold wild animals
• It is thought that infected bats may have been the source
• It is spread through the air via droplets and also, to a far lesser extent, on surfaces
• In the vast majority of people, COVID-19 causes mild flu-like illness with cough, fever, and shortness of breath

Are there people who are MORE vulnerable to COVID-19?

• It is difficult to know who is more at risk of getting the infection
• We do know who is more vulnerable to severe disease
• Early data from China showed that people over 70 years old and/or those with chronic medical conditions (including diabetes, hypertension, heart disease, lung disease, chronic kidney disease, and some cancers) or suppressed immune systems were at greater risk of more severe disease. It looks like the more of these conditions you have together the more vulnerable you are to severe disease
• There is still only limited evidence on the effect of HIV on vulnerability to severe COVID-19 but it would be likely that if you have HIV, were on treatment, and had an undetectable viral load with a good immune system, you are unlikely to be at any significantly greater risk than a similar person to you without HIV
• Unlike avian flu, the evidence we currently have suggests that women who are pregnant are not more vulnerable to severe disease, but UK advice is that they should take extra care
• It should be stressed though that even of those people who are vulnerable, the majority will recover to full health

What do I do if I live where there is malaria and I experience some of these symptoms?

If you have a fever without necessarily having other COVID-19 symptoms (e.g. cough/shortness of breath) you should seek advice and care. Your government should have a number you can call to ask for this help or you could go to your local health facility screening point if this is the advice provided. Remember to ask a health worker what to do before entering the busy clinic area if you are presenting at the facility. This could be done at a temperature check point or hand washing station if the facility has one.

What measures should we take in our households and communities to prevent the spread of the disease? Many of us live and work in informal settlements. We do not have ready access to soap or water. Social distancing is also going to be challenging as our communities have a high population density. What would you advise in terms of prevention?

General personal advice

• Common-sense: simple measures to avoid and prevent infection similar to those for a cold or the flu
• Clean hands: Try to keep your hands as clean as possible. Soap and water is fine as is alcohol gel. These may not be available in many settings so where you don’t have soap or alcohol gel, just use water and try to follow the other guidance in this section as much as possible
• Avoid touch: If you don’t have access to soap/gel/water then avoid shaking hands and touching surfaces especially those that are in most communal use (e.g. door handles). Avoid touching your nose, mouth, and eyes (all portals of entry for the virus)
• Catch it, bin it, kill it: If you have tissues or a bin. If you don’t try to cough into the crook of your arm to avoid spreading droplets to others

Household advice

• Clean surfaces: Keep surfaces cleaned regularly, ideally with alcohol-based cleaner, sodium hypochlorite, or hydrogen peroxide, which will kill the virus
• Ventilation: Try and keep a good flow of air through your home if possible. If you have doors/windows, leave them open where possible (weather and security willing). This protects against other airborne infections too
• Sunlight: Try and allow sunlight into the home where possible. Although the evidence is limited in the real-world setting, we do know that UV rays kill some organisms and might help to dry out and kill viruses (as might heat)
• Isolation of ill person: If someone is sick with flu-like illness/COVID-19 symptoms then, where possible, they should temporarily eat and sleep in a separate room and use separate toilet/shower facilities. Clearly, in most urban informal settlements, this won’t be possible so you’ll have to adapt. Don’t share cutlery, don’t eat from the same bowl. Make sure the person knows this is not to punish them, this is to try and have the best health for the whole family

Physical distancing measures

• Avoid contact with someone who is displaying symptoms of coronavirus (COVID-19). These symptoms include high temperature and/or new and continuous cough
• Avoid non-essential use of public transport, varying your travel times to avoid rush hour, when possible. Could you walk/cycle to work rather than use a small bus or shared car?
• Work from home, where possible. It is appreciated that for many people this may not be possible but consider alternative options and, if formally employed, talk it through with your employer
• Avoid large and small gatherings, including in smaller public spaces such as (in the UK) pubs, cinemas, restaurants, theatres, bars, clubs. We know that working age adults (20-50) make most of their contacts in workplaces and people over 70 make over half of their contacts in other settings (not home, school or work), such as shops, restaurants and leisure centres
• Each community or person will have to consider where its major public places/points of contact are and these may include markets, church, mosque, other religious place of congregation, or shabeens
• Avoid gatherings with friends and family
• Keep in touch using remote technology such as phone, internet, and social media if available

How do you treat COVID 19 at home? Are there any low-cost measures we can take?

• There are many simple things you can do to try and get better from COVID-19 at home
  Keep up your fluids
• Eat a balanced diet
• Don’t drink or smoke
• Try to rest and get as much sleep as possible
• Avoid buying unproven remedies or “vitabiotics” which are a waste of your money
• Take paracetamol if available for fever or reduce fever with cool compresses (e.g. flannel/towel with cool water)
• There are no direct treatments available for COVID-19
• Antibiotics do not work against COVID-19 and are only used in rare cases that have bacterial chest infection on top of COVID-19 or are severe – this would usually be on the advice of a doctor/nurse
• Ask family and friends to help you to get food/water

I think the “5 things you can do to help your community” by Public Health England on Public Health Matters blogs are excellent:

1. Wash your hands frequently and catch coughs and sneezes in a tissue
2. Be prepared to self-isolate (as best as possible)
3. Plan ahead (travel/visitors/work/health services/social distancing/help from friends and relatives/support with shopping etc)
4. Use health services wisely (e.g. stay at home if only mild symptoms / remember antibiotics don’t work for COVID-19)
5. Keep up to date with trusted sources of information (see below)

We know there is a lot of misinformation circulating. What are your recommendations for reliable sources of information on COVID 19?

In the UK, the Public Health England “Public Health Matters” blogs are clear and written for the public and there is also PHE’s specific advice pages for the public.
https://publichealthmatters.blog.gov.uk/

The Lancet and British Medical Journal both have open-access COVID-19 resource centres aimed at health workers and researchers. This is less information for the public and more about ongoing research or new evidence, but they still have some useful summary documents.
https://www.thelancet.com/coronavirus

https://www.bmj.com/coronavirus

US CDC advice is also clear
https://www.cdc.gov/coronavirus/2019-ncov/index.html

The above are predominantly UK/US orientated, for more global advice, I would suggest WHO and the World Economic Forum webpages. WHO’s pages include a helpful “Myth Busters” section and the World Economic Forum seems to have some good advice for all, including a focus on the global south.
https://www.who.int/emergencies/diseases/novel-coronavirus-2019/advice-for-public
https://www.weforum.org/agenda/2020/03/coronavirus-COVID-19-advice-health-virus-disease

There are patient groups that are developing websites and ministries of health in each country so keep abreast of these too. Look for local sources of information too that don’t require internet (e.g. radio/TV/newspapers/healthcare providers and clinics/posters) but I can’t vouch for reliability of these sources.

What should our research teams do to protect themselves and to contribute to the prevention of the spread of the illness?

The advice for the research teams isn’t any different to that for the public above. We are all in this together and need to work in concert to control this pandemic. Each research team should have contingency measures in place to avoid contact/promote social distance/work from home policies. Many funders and agencies are allowing extensions (sometimes paid) for existing grants. Ultimately, our health now is more important than any single research project and we have to look after each other.

How can we help people maintain good mental health in the face of COVID 19?

• COVID-19 outbreak may be stressful for people
• Coping and overcoming our own stress and helping others to do the same can make us and our communities stronger
• People at risk of stress
  o Vulnerable
  o Children/teens
  o Healthcare workers/responders
  o People with pre-existing mental health problems
  o Substance use
  o Difficult social circumstances
• Stress during outbreak can include
  o Fear and worry about your health or health of your loved ones or individual/household finances
  o Changes in sleeping/eating patterns
  o Difficulty sleeping/concentrating
  o Worsening of chronic health problems
  o Increased alcohol/tobacco/drug use
  o Boredom/anger/frustration/stress/worry/fear during isolation
  o Post-isolation/quarantine feelings of the above plus guilt/mixed emotions (including relief)
• Things you can do to support yourself
  o While we all should try to keep up to date with the latest COVID-19 guidance, it is also important to switch off from the news/social media/conversations about it to give yourself a break
  o Take care of your body: deep breaths, stretch, meditation for some, exercise, sleep, healthy eating, avoid alcohol and drugs
  o Do things you enjoy/take time for leisure (especially outdoor activities, walks etc. It is appreciated that this will be setting dependent)
  o Communicate/tell people you trust how you are feeling

• For parents
  o The calmer you are, the calmer your children will be. Be a role model.
  o Take time to talk to your children about COVID-19 in a way they can understand
  o Answer their questions and arm them with the facts
  o Keep regular routines where possible
• As a community
  o Collective responsibility, we are all in this together
  o Support not stigma, especially for the most vulnerable
  o Share the facts about COVID-19 with others, spread knowledge and empower
  o There are mutual support groups (including in person/What’s App/Facebook being set up all over the world)
  o Consider adapting existing civil society, cooperative, or women’s groups to focus on COVID-19 temporarily if this is felt to be appropriate

How should we support people who have pre-existing health conditions? Who are currently taking medication?

• You can support your friends, neighbours and other community members who are living with TB, HIV, diabetes or other chronic conditions by offering to go to the local clinic to pick up medications. Remember these conditions are not easily contractible and so interacting with these people in your community to pick up and drop off medicines won’t place you at higher risk.
• You might support elderly people in the local community by offering to collect medicines for them too.
• Try to think about people in your community who might be vulnerable to infections if they have to spend time sitting in a queue at the health facility or having to collect water or go for food from the shop or market. You can support all these people by offering to help with these things.

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