1. Is there remuneration?

Yes – remuneration is dependent on the age of the patient. Please ask your RCGP RSC contact for further details.

 2. I have a patient who would be suitable for HOCO and wants to participate. Can you recruit them into the surveillance?

Please email HOCO team/PHE nurses at: phe.covid19hoco@nhs.net

 3. Our practice does not have a phlebotomist/ we do not do bloods at our practice site however refer our patients to our local phlebotomy service. Is this OK?

We would greatly appreciate your assistance in organising the bloods for your patient(s) as serology is a critical component of this surveillance. If this is the only option you have for your patient, please discuss this directly with the RCGP RSC contact.

 4. What is in the blood kits?

Kits contain a vacutainer tube, a request form for the blood sample, an oral fluid kit (comprising a swab in a tube in a sealed packet) together with two specimen labels, two green topped outer tubes, a clear plastic specimen bag, BD Vacutainer One Use Holder, Blood Collection Set (Safetylok Sterile Closed), and a reply paid envelope for return of the samples to Porton Down. If a finger prick sample is needed safety lancets and alcohol swabs will be included.

5. A household member has since been diagnosed with COVID-19 and is in isolation. Do they come in for Day 35 bloods?

NO. Current PHE guidance (as of 7^th of May 2020 midday) states ‘if you live with others and you are the first in the household to have symptoms of coronavirus (COVID-19), then you must stay at home for 7 days, but all other household members who remain well must stay at home and not leave the house for 14 days. The 14-day period starts from the day when the first person in the house became ill’.

Therefore do not ask any household members to come in for blood sampling at Day 35 if they are still in the isolation period. Bloods should be rescheduled to take place after the end of the quarantine period – even if it is a fortnight or a month later.

It is very important that you always follow PHE guidance (available at: https://www.gov.uk/government/collections/coronavirus-covid-19-list-of-guidance)

 

WHO has recommended that follow up of household contacts of COVID-19 cases should be conducted in order to provide key epidemiological and virological information relevant to understanding the spread and morbidity associated with SARS-CoV-2 infection.[1] Since the WHO recommendation, the first contact study has been published reporting the clinical and virological follow up of contacts of COVID-19 cases in China[2]. Close contacts were defined as those who lived in the same apartment, shared a meal, travelled, or socially interacted with an index case during the period starting two days before symptom onset. Index cases and any contacts who were positive when initially swabbed were isolated in hospital or other centralised facility; other contacts were isolated at home. Release from isolation was conditional on a negative swab 14 days after the start of isolation. The secondary attack rate was 14.9% (95% CI 12.1,18.2) among the 699 household contacts, with a median serial interval between onsets of 6.3 days. Overall 20% of the swab positive contacts remained asymptomatic. No serological follow up was reported and the swabbing protocol would not have identified asymptomatic contacts[3] who shed virus in the 14 days between the first and second swab.

Currently, in England testing of suspected cases[4] of COVID-19 infection in the community is focussed on those admitted to hospital, or are aged 65+ years or working in essential non-home based occupations. Those testing positive are required to self-isolate in the home for 7 days with any household contacts required to self-isolate for 14 days from onset of symptoms in the initial case. Cases are only quarantined in hospital on grounds of clinical severity. There is therefore a need to assess transmission to household contacts from confirmed cases under the current self-isolation recommendations and to study virus shedding in relation to symptoms in those with serological evidence of infection.  Apart from the special population groups, swabbing of non-hospitalised cases in the community is also taking place in general practice as part of community-based surveillance, organised through the RCGP RSC sentinel practice network. This enhanced household contact surveillance will therefore be conducted through the cases confirmed by the RCGP surveillance network.

The aims are to measure

• The infection rate in household contacts by age
• The proportion of individuals infected who develop symptoms by age
• The proportion of infected individuals without symptoms with evidence of viral shedding
• The proportion of confirmed cases that are still swab positive 7 days after onset

[1] Available at https://www.who.int/publications-detail/household-transmission-investigation-protocol-for-2019-novel-coronavirus-(2019-ncov)-infection

[2] Epidemiology and Transmission of COVID-19 in Shenzhen China: Analysis of 391 cases and 1,286 of their close contacts. Qifang Bi et al. Non-peer reviewed pre-print available at https://www.medrxiv.org/content/10.1101/2020.03.03.20028423v2

[3] It is unclear from the paper whether contacts who were swab negative and asymptomatic at the time of the initial swab and subsequently developed symptoms were swabbed at the time of symptom onset.

[4] Suspected case defined as fever or new persistent cough as at 19/3/2020

Households with a confirmed index case identified through the RCGP RSC surveillance will be contacted by PHE nurses who will monitor household members for symptoms by regular phone calls. Swab kits will be sent by PHE to each household member (including the index case) who will be asked to take two nasal swabs, one on receipt of the kit and a second one a week later. Swab results will be sent to the practice(s) where the confirmed case and each household member is registered either by eLab or post according to practice preference. In addition, blood samples will be taken from the index cases and all household contacts at Day 35 after the initial contact made by the PHE nurse with the household to identify those who have serological evidence of infection irrespective of symptoms. A self-taken oral fluid (OF) sample will also be requested with the first nasal swab sample and the blood sample form all household contacts.

Individuals with an influenza-like-illness or lower respiratory tract infection who are identified as SARS-CoV-2 positive in one of the RCGP RSC practices taking part in the enhanced COVID-19 surveillance will be telephoned by a PHE nurse to identify those with at least one household contact. Households will be asked to take part in a prospective follow up involving swabbing, recording of clinical symptoms and blood testing of all family members. In consenting families, the nurse will record demographic and clinical information for the index case and their contact(s) on HOCO questionnaires 1A and 2A respectively. In non-consenting families only form 1A for the index case will be completed.

Serum samples will be tested in batches and results provided to GPs and household members once testing by the different assays is complete and there is consensus on the interpretation of the results.

Since this enhanced follow up will comprise an updated component of the FF100 protocol similar governance procedures should apply, namely that these procedures constitute essential surveillance during a pandemic and are therefore deemed outside the remit of research ethics committees. Confirmation of this position has been given by the PHE research ethics and governance group. No patient identifying information will be sent directly to the RCGP RSC contact.

The samples that are being taken are for diagnostic purposes for which the household has given verbal consent, including adults for any minors for whom they are parents/guardians, over the phone when asked to take part in the enhanced surveillance. Should parents/guardians subsequently not wish the minor to be bled then they are free to refuse this.

Consent is obtained verbally and can be withdrawn subsequently if the household member does not wish the blood sample to be taken. Since the nasal and OF swabs are self-taken then consent is not an issue.