New sub variant joins Covid vanguard as funds released to tackle hospital bed-blocking

The story of Covid-19 is currently one of the continual emergence of new sub variants within the Omicron family, of which the latest is the highly transmissible XBB.1.5, which looks set to drive an increase in infections. Flu has also made a come-back this winter. As hospitals in East Sussex and elsewhere resorted to emergency measures to cope with winter demand, the government has released emergency funds to tackle the chronic problem of bed-blocking. Text by Nick Terdre, research and graphics by Russell Hall.

This winter we were able to enjoy Christmas and New Year festivities properly for the first time since 2019/20, but, possibly boosted by all the social mixing, the number of Covid cases kept rising over the period.

According to the latest Office of National Statistics data, the estimated number of people testing positive in England on 28 December was 2,501,300, equivalent to 1 in 20 of the population, and in the South East 1 in 19. Back in mid November when the upturn began, the ratio for England was 1 in 60.

There is no current figure for East Sussex as the ONS only publishes such local data once a month, but cases recorded by the UK Health Security Agency indicate that both Hastings and East Sussex returned relatively strong growth in new infections in the week to 3 January, up 32.1% and 20.5% respectively, while growth in Rother was more muted at 6.2%.

While the reproductive rate – R value – of the virus calculated from case figures was above one for Hastings, Rother and East Sussex, for England on 1 January, it was 0.9 for England, suggesting that growth across the country had peaked. This was consistent with data from the Zoe Health Study showing a decline in cases to 7 January. There may therefore be an imminent dip in cases.

However, this is likely to be short-lived, given the emergence of the XBB.1.5 sub-variant, a so-called recombinant combining the features of two other sub-variants BJ.1 and BM.1.1.1 that makes it the most immune-evasive Covid-19 sub-variant yet, plus a key mutation that that makes it more infectious. XBB.1.5 has advanced furthest in the US, where the first known sample was identified on 22 October. A month later, on 24 November, it was identified in England.

Growth advantage

XBB.1.5’s main growth advantage over other sub lineages is its much enhanced transmissibility – roughly about a 50% increase on other sub variants. According to the World Health Organisation Covid-19 technical lead Maria van Kerkhove, “It is the most transmissible sub-variant that has been detected yet.” However, early lab data shows no change in disease severity compared with BQ.1 and associated sub lineages.

According to the Centers for Disease Control and Prevention, XBB.1.5 was estimated to account for 27.6% of all new infections in the US in the week ending 7 January. In New York and New Jersey where it was first found, it has already become the dominant strain, accounting for 72.7% of new infections.

In the UK its progress may be hindered by a much higher rate of vaccination – 78.4% of those aged 65 or more have had the autumn booster, against 38.1% in the US. On the other hand the Omicron component of the bivalent vaccines now being administered in the US for the autumn booster targets the BA.5 sub-lineage while in the UK it targets BA.1 – as BA.5 is more closely related to XBB.1.5 than BA.1, the US version may be more effective against XBB.1.5.

Warning note

But a warning note has been sounded by Adam Kucharski, professor of Infectious Disease Epidemiology at the London School of Hygiene and Tropical Medicine, who suggests that a 50% increase in transmissibility causes five times more deaths than a 50% increase in mortality, due to the much greater number of people being infected, among them more vulnerable people.

The latest data on the ‘variant landscape’ in the UK, showing the relative performance of the most prominent sub-lineages, shows XBB.1.5 to be the fastest-growing. In the week to 31 December it accounted for 4.7% of new infections among all those genomically sequenced, more than doubling its share on the previous week. BQ.1.1 was found in 18.8% of new infections, though this was down 3.9% on the week, and CH.1.1 in 13.1%, up 2.9%.

With its greater transmissibility, XBB.1.5 looks set to become dominant in the UK over the next month or so.

Flu is back

But influenza is also making a strong comeback after a quiet period last winter. The chart below of the proportion of samples testing positive for flu, an indication of its incidence in the population, shows a rapid increase to a peak in week 51, similar to or greater than the peaks in 2018/19 and 2019/20. By contrast, the winter of 2021/22 was a quiet one for flu, though not for Covid.

In late December the NHS reported a seven-fold increase in hospital patients with flu, from 520 in the week ending 27 November to 3,746 in the week ending 24 December, with 267 in critical care beds.

Precautions advised

Health authorities have seen fit to warn the public about the threat from these viruses. Citing high numbers of Covid, flu and scarlet fever caused by group A streptococcus, Prof Susan Hopkins, chief medical adviser at the UKHSA, advised adults feeling unwell to stay at home, wear a face covering if having to go out and avoid healthcare settings and vulnerable people.

A “surge” of Covid and flu cases was also blamed when NHS Sussex Health & Care on 30 December declared a Sussex-wide Critical Incident, a status allowing a series of emergency measures to focus care on the most serious cases while postponing appointments and treatment for less urgent cases.

In a follow-up announcement on 4 January East Sussex Healthcare pointed out that delays in discharging patients were limiting the number of beds available to new admissions. A discharge intervention team had been set up to improve patient flow, it said. Separately restrictions on visitors were also imposed.

The Critical Incident in Sussex was stepped down on Friday 6 January though many of the emergency measures remain in place. It is questionable, however, whether the sorry state of the NHS in Sussex and the country as a whole is due to rapidly rising numbers of Covid and flu cases.

Although the number of flu cases in East Sussex hospitals went from zero on 1 December to 87 on 30 December, by the following day the number was back to zero. Meanwhile the number of beds occupied by Covid patients on 4 January was 74, down from 82 a week before.

So the inability of the NHS to cope with the current situation appears to be primarily down to the long-standing problem of bed-blocking caused by the failure of the social care system to provide care home places for patients needing step-down care on the way from hospital to home. At the weekend prime minister Rishi Sunak referred to bed-blocking as the NHS’s “number one problem.”

Data on hospital discharge delays shows that on 1 January there were 216 patients in East Sussex hospitals who could not be moved despite being medically fit to leave. At the same time there were no flu patients and 61 Covid patients. The chart of East Sussex bed occupancy shows the small proportion of Covid patients and zero proportion of flu patients, while the proportion of beds occupied by dischargeable patients was around one quarter.

When East Sussex Healthcare NHS Trust chief medical officer Dr Simon Merrit was asked by BBC South East what was needed by way of a quick fix, he replied: “I think it would be looking at the funding for social care.”

Funding boost

And he seems to be getting his wish, as the government has released funds from the £500m adult social care discharge fund announced in the autumn budget to tackle the problem, with East Sussex County Council receiving £2.15m for social care and the NHS Sussex Integrated Care Board £10.5m to be spent by 31 March - a welcome funding boost although it is expected to take several weeks before it produces practical effects.

And today the government announced emergency funding of £200m to pay for short-term placements in care homes for patients ready to leave hospital but requiring further care before returning home - there are some 13,000 beds occupied by patients who are ready for discharge. A further £50m is to be made available to expand hospital discharge lounges and ambulance hubs.

New ideas for facilitating discharge are also to be trialled by six regional trusts, including NHS Sussex Health & Care.

Another welcome piece of news is that last week the East Sussex director of Adult Social Services, Mark Stainton, reported to an NHS Sussex board meeting that he had recruited 200 social care staff from abroad using part of the ESCC discharge fund allocation.

 

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