When every cough and snuffle are possibly due to covid, how are patients and GPs supposed to handle people with these once typically innocuous symptoms?
For all the volumes written about covid to date, here are some ticklish problems and questions that remain unanswered.
Respiratory disease not due to SARS-CoV-2 (novid?) is an appropriate subject for study in the context of the pandemic’s impact on people’s health and on the delivery of healthcare.
During the pandemic, some people have become pariahs in the Australian community and medical system: people with respiratory symptoms who have chronic respiratory disease or acute respiratory symptoms.
Coughing or sneezing in public can elicit hostile responses from bystanders. Excluding voluntary coughs – and who would release a voluntary cough in public now? – coughs and sneezes are reflexes. They are not deliberate acts of sabotage to put others at risk of infection, but the perception may be: “If you have symptoms, you are supposed to be at home.”
Some of these pariahs have had multiple covid-19 tests.
Some are children with serial viral respiratory infections, post-infectious cough and upper airway cough syndrome, who attend childcare or school with respiratory symptoms, contravening instructions to stay at home until symptoms have resolved. This is difficult for parents and children.
Some patients may feel rebuffed by their GP clinic.
Our practice is probably not unique in that space, and staff issues adversely affect our capacity to manage potential covid patients. We have two consulting rooms, a small waiting room and no treatment room. Several staff are medically vulnerable to getting covid-19 and its complications. We do not wear full PPE.
So, we do not see patients who have respiratory symptoms in person at our clinic. Contrary to patient expectation, a negative covid-19 test result is not a talisman for getting an in-person consultation, even if the test was taken less than 24 hours previously. Could the result be a false negative? If the test were repeated at the time of consultation, would the result be positive?
Patients with respiratory symptoms can have telehealth consultations with the GPs at our clinic. However, we are aware that their care may be suboptimal and discriminatory.
When a person with respiratory symptoms (or their carer) contacts their GP clinic, they may be informed that they cannot be seen in person and instead may be:
- offered a telehealth consultation;
- advised to phone the state covid-19 hotline;
- told to go to one of the following:
- a covid testing centre,
- a GP-led respiratory clinic,
- another GP clinic, or
- the emergency department.
Emergency department attendance is not appropriate for mild respiratory illness. It increases the demand on the ED and places the patient and carers in a high-risk setting for transmission of infection. In the crowded waiting room and treatment areas, they can pass on infection or become infected.
The Department of Health has funded GP-led respiratory clinics to assess and manage patients with mild or moderate respiratory symptoms. There are more than 100 of them in Australia, but there is no central directory.
Only some of these clinics provide a full respiratory service: in-person assessment and management of patients, SARS-CoV-2 testing and vaccination.
There is considerable overlap between the symptoms of chronic respiratory diseases, non-covid-19 respiratory infections and covid-19. In the current situation, the clinical and social assumption – appropriately – is that it’s covid until proven otherwise.
But patients with non-covid-19 respiratory illnesses need medical care and support. They need assessment and management, perhaps over video consultation. But the number of differential diagnoses is high, as anyone who has attempted Murtagh’s “safe diagnostic strategy” for respiratory symptoms will attest.
GPs need to recognise which patients with acute respiratory symptoms are “safe” or “unsafe’ for community management. The acute “unsafe” patient needs to be discussed with an emergency department physician or referred to an emergency department. The subacute “unsafe” patient needs an in-person assessment – somewhere. Clinical red flags for the “unsafe” patient may be determined by the individual GP but would probably include chest pain, lethargy, high fever, tachycardia, increased work of breathing, tachypnoea, and “looks unwell”.
It is relatively easy to miss pulmonary embolus, the chameleon of respiratory disease. There is also the risk of delayed diagnosis for chronic respiratory disease – for example, asthma and chronic obstructive pulmonary disease – particularly with the reduced availability of spirometry “due to covid”.
Patients with respiratory symptoms also need public health advice: stay at home, do not go to work, school or childcare (obtain a certificate), and if out of home, wear a surgical mask or fabric face covering, and practise hand hygiene, cough and sneeze hygiene, and physical distancing.
Some patients may not get this medical care and support. They may be dismissed with “it’s not covid”. No wonder some patients feel frustrated, abandoned and frightened.
It can seem as if the public health imperative takes precedence over the individual’s medical care and support. In protecting patients, let us not inadvertently exclude patients from care.
Anecdotally, some patients are bypassing the system using deception. When booking in-person appointments online, they click ‘No’ to the triage question about symptoms of covid-19. When booking in-person appointments by phone – or in person – they respond ‘No’ to the triage questions from the receptionist or practice nurse.
Typically, the triage question is “Do you (or your child) have one or more of the following symptoms: fever, cough, sore throat, shortness of breath, runny nose, and change or loss of sense of smell and/or taste?”. Typically, this is followed by the statement “If you have one or more of these symptoms, you must not attend the clinic in person, but you may have a telehealth consultation”.
The trickster books an appointment for an in-person consultation, at which the trickster discloses to the GP (who is wearing a surgical mask, not full PPE) that they have one or more of sore throat, cough, other respiratory symptoms or fever.
Patients who have otalgia or sinus pain can also inadvertently bypass the triage system, as their symptoms may not be included in the triage questions.
General practice clinics that are not set up for managing respiratory patients need to reinforce that it is vital that patients do not attend general practices if they have respiratory symptoms, and that there are alternatives (including telehealth).
Uncertainties about testing for SARS-CoV-2 and other respiratory pathogens
People with respiratory symptoms must get a covid-19 test and isolate until both asymptomatic and notified of a negative result. This is essential.
Patients who are contacts of a covid-19 case, and travellers from orange zones and red zones, whether symptomatic or asymptomatic, must follow the Department of Health advice on testing and quarantine.
What proportion of patients who get respiratory symptoms will get a covid-19 test? This is not known. Flutracking data indicate that only 42% of people with cough and fever will get a covid-19 test, but these data do not include other respiratory symptoms. Many people who have respiratory symptoms may not be getting tested for covid-19. It is possible that there is unrecognised and undiagnosed SARS-CoV-2 (in one or more of its variant guises) “out there” in the community.
Patients with respiratory symptoms may be less likely to consult their GP during the pandemic than before the pandemic. GPs and pathology services may be taking fewer upper airway swabs for respiratory pathogen testing during the pandemic than before the pandemic. Fewer patients presenting with respiratory disease; fewer tests for respiratory disease.
There is likely to be under-reporting of non-covid-19 respiratory virus diseases, including influenza. Anecdotally, GPs have the impression based on clinical assessment (without microbiological confirmation) that the incidence of URTIs and influenza-like illnesses is higher than reported in Department of Health statistics (Victoria, Australia).
Does a negative covid-19 test result mean that the patient is “clear”? The result may be a false negative, particularly if there has been poor sample collection technique, which may occur with self-collection of swabs. Is the patient with respiratory symptoms and a negative covid-19 test result safe to attend a GP Clinic, 24 hours after the test, 48 hours after the test, one week after the test? This information is not known.
If a patient’s respiratory symptoms persist and/or change, should the covid-19 test be repeated, and if so, how often should the test be repeated? This information is not known.
Fully vaccinated patients and in-person consultations?
The patient has respiratory symptoms, is fully vaccinated and requests an in-person consultation at their GP clinic. Should the patient be exempt from the GP clinic’s policy of excluding patients with respiratory symptoms from in-person consultations? If the patient is permitted to attend the clinic in person, then their vaccination status must be verified before their attendance. How? A vaccine “passport”? The Australian Immunisation Register?
And there are more questions about this question. How long after the second dose of covid-19 vaccine is the patient deemed to be “safe” to attend the GP clinic? One week? One month? Never?
And it is not yet known if vaccination prevents asymptomatic and/or symptomatic transmission of SARS-CoV-2, so patients and staff at the GP clinic may indeed be at risk of covid-19 when the fully vaccinated “respiratory” patient attends the clinic in person.
The pandemic raises many questions related to patients with respiratory symptoms:
- How many patients with respiratory symptoms get a covid-19 test?
- Is there undiagnosed covid-19 in our communities?
- Is there under-reporting of non-covid-19 respiratory diseases, including influenza?
- Should throat and nose swabs taken from people with respiratory symptoms for SARS-CoV-2 PCR testing also get tested for the respiratory virus PCR panel and pertussis PCR?
- What is the true false-negative rate for covid-19 tests results?
- If a patient has a negative covid-19 test result today, could the patient have covid-19 tomorrow?
- Has telehealth affected GPs’ prescribing of antibiotics and corticosteroids for acute respiratory illnesses?
- For symptoms that persist and/or change, how frequently should covid-19 tests be repeated?
- Are GPs missing serious and de novo chronic respiratory diseases?
- Are spirometry and the use of nebulisers safe in general practice?
- Has the pandemic affected the management of smoking cessation in general practicw?
- Should patients who have had two doses of a covid-19 vaccine be exempt from the exclusion of patients with respiratory symptoms from GP clinics?
- Can respiratory disease be diagnosed using a cough analysis app and a smartphone?
- Is it COVID, Covid or covid?
Dr Andrew Baird is a GP at the Elwood Family Clinic in Victoria.