After an initial inventory last week, Laurent Lagrost, Research Director at INSERM and Didier Payen, former head of the anesthesia-resuscitation service at Lariboisière Hospital in Paris, are continuing their analysis of the epidemiological situation. They believe that there are “several advantages to screening on a large scale”. And return to the usefulness of confinement: “Everyone must prepare mentally for a period of movement restriction and isolation,” they say.
We were concerned about the Covid-19 and we wanted to alert, without alarming, in our soul and conscience. Our initial article “The Covid-19 is a real danger”, published on the website of the “Quotidien du Médecin” on March 6, 2020, echoed, even beyond medical readership (> 400,000 views of the article on the “Daily Doctor” site in 4 days). Somehow spreading viral information! Many health actors and citizens have taken it up, very naturally and without panic. In confidence with this citizen approach, they are the first concerned and constitute the enlightening statistical and epidemiological cohorts.
Therefore, we decided to follow the evolution of the circumstances and data, methodically, day after day, to understand the proposed strategic changes. The situation is evolving in such a way that preventing the spread of the virus is no longer topical, now replaced by slowing it down, so as not to exceed health capacities. The strategic consequences lead to fewer and fewer people being screened, with the exception of severe cases and certain socio-professional categories, since there is no specific treatment. We wish to share our reflections on the basis of the published data and the current context.
Caregivers on the front line
Dr. Wenliang, the first whistleblower unjustly accused of spreading false rumors and disrupting social order, died at the age of 34, almost a month after being hospitalized for Covid-19. Thousands of healthcare workers in China have been infected with SARS-CoV-2, including nearly 15% of cases classified as severe or critical. Again, nothing to do with the flu for which a vaccine exists, even if not all health care workers get vaccinated. In our country, access to teleconsultation has recently been eased. This is an excellent measure and we have ourselves received the testimony of practitioners in recent days already putting this provision in place.
We cannot stress enough how much we are indebted to trained, efficient, dedicated and selfless medical and paramedical staff. Faced with an unprecedented situation and a pathology that is little known, they will be able to demonstrate composure, common sense and discernment, in a difficult structural and human context. And the exercise is not easy! For example, what about the poly-pathological patient who does not correspond to the standard clinical case but who, ultimately very classic, consults the daily doctor?
Covid-19 Mortality Assessment: What to Think?
The risks and severity of Covid-19 are assessed globally and taken seriously, leading the media to reduce comparative discourse to seasonal flu. As of this writing, Covid-19 virus SARS-CoV-2 has affected 128,000 people worldwide with 4,700 deaths and 68,000 patients who have recovered. It is necessary, on the published curves, to integrate the kinetic parameter of the phenomenon. China, the first country affected, is one month ahead of the rest of the world. Italy, Spain, and France have very similar and very steep growth curves, shifted in time with China. The slopes of these curves also depend on the quality of the reaction and the means available in the different countries.
But what about the reality behind the figures, the absolute values, the percentages? What significance? For some, the mortality rate of Covid-19 would be overstated due to the impossibility of carrying out systematic screening for the whole population and because many asymptomatic cases or deaths in intercurrent pathologies would go unnoticed. Consequently, the denominator of the fraction n deaths / n cases remains unknown. Others believe that the current assessment of mortality may be confirmed and even underestimated. Indeed, sick or very sick patients included in the studies may die beyond the short duration of the observational studies currently available and are therefore not counted at the time t when the counts are stopped. Watch for the publication of information about the cruise ship “Diamond Princess”, as it is in fact a quasi-experimental model of the epidemic, constituting a follow-up cohort.
Let us repeat it again, the Covid-19 has its own characteristics. Thus, the risk of recurrence appears much higher for Covid-19 than for influenza, infected patients can carry the virus several weeks before the appearance of the first symptoms (against one to two days for influenza), Covid- 19 can last several weeks (against only one on average for influenza), Covid-19 leads to severe forms requiring hospitalization in 15 to 20% of cases (order of magnitude 10 times that of influenza) and some patients may die several weeks after the first symptoms appear.
Finally, we must keep in mind that the Covid-19 could itself constitute a comorbidity and produce collateral damage 1) by weakening the general condition of the patients and 2) because, in the hypothesis of a system overwhelmed and degraded care, patients not infected but suffering from classic acute pathologies are likely to be less well taken care of. A hypothesis and a risk which nevertheless remains to be assessed with precision, on a case-by-case basis and for each of the geographic areas concerned.
There appears to be some geographic disparity in the severity of the Covid-19. The epidemiological maps show the strong East-West progression and the weak North-South progression. It is not related to a lack of monitoring or alarm. If there was an upsurge in serious cases, such as during the Ebola epidemic, the alarm would be raised. Only seven scientific articles published recently in the PubMed NIH relate to the African continent against a few hundred for China, Europe and the United States. It is therefore reasonable to think that the African continent is in fact little concerned, for the moment with few cases. This aspect is excellent news, reason for motivation to understand the specifics and subtleties of SARS-CoV-2 and the disease. For the contaminated countries west of China, the epidemiological curves are very similar for Italy, Spain, France, etc. We can therefore expect a comparable transmission. On the other hand, the mortality generated could be different depending on the health systems developed and the strategies implemented.
It will therefore be in retrospect, at the end of the crisis, that we will be able to know the famous numerator and denominator of the calculation of the mortality rate. For now, it seems useless to discuss, debate and worse, to worry about the mortality rate of 1 to 4% in the general population or 18% in our seniors. It is anyway, at the scale of nations, important enough to warrant action. This invites everyone to focus on what has now become essential: detect, treat and … save time!
Test: stop or not enough yet?
Vast debate, especially if we look at the choices made by different countries. The overall strategy can oscillate between taking into account the adequacy of disease / health capacity or the need to adapt decisions with a high economic impact to the reality of the disease or epidemic. In South Korea, tests are carried out very widely, when France limits tests to hospitalized patients and to so-called at-risk populations.
There are two reasons for opposition. The first is based on the argument that there is no specific antiviral treatment, which would make screening “de facto” unnecessary. In addition, we have gone from blocking the epidemic to slowing it down. So, testing widely would be pointless. The second, on the contrary, consists in indicating more widely the tests for a maximum of citizens like in South Korea, in priority those with or without symptoms who have been in contact with infected subjects. Children are a significant population in this regard. Sometimes carriers of the virus in large quantities, they have little or no symptoms, but can infect others.
Several advantages therefore to this screening on a large scale. If necessary, it would provide an objective answer to the delicate question of whether or not to close schools and universities and to the decision to contain them. It would help to know the famous denominator already mentioned. It would also help uncover invisible and unsuspected chains of transmission. It would make it possible to decide on appropriate measures, in particular for companies, in terms of containment, in an informed manner and on a case-by-case basis. Carriers without symptoms, or pauci-symptomatic, therefore identified, could be informed, monitored and confined. Finally, screening is of public health interest to assess the progression, trajectory and severity of the epidemic. With this reasoning, one should be warned that many results will be negative, necessarily but not unnecessarily. Thus, they will provide information on the geolocation of SARS-CoV-2.
Of course, such a change in scale of screening and paradigm would be ambitious, but fundamental, as evidenced by the February 16, 2020 Editorial published in the New England Journal of Medicine by Professor Lipsicht. It has proven effective in other countries such as Korea, Japan and Singapore. For it to be contributory, it is important that the human and technical means (sampling kits, standards and security) follow. This decision belongs to the public authorities. The more systematic identification of carrier subjects could significantly contribute to the crushing or stretching of the epidemic peak as sought today to avoid saturation of the health system.
Considering SARS-CoV-2 not very fatal in the general population with often little or no symptoms, one would be tempted to be content with limited measures. But, at the same time, the SARS-CoV-2 virus generates serious cases which fuel the engine of fear. SARS-CoV-2 paradox: many asymptomatic, but highly contagious cases, often traveling incognito, infecting a very large number of individuals (one patient in South Korea was able to infect 83 patients, exceptional case) and thus being able to lead to an absolute number of severe cases and high deaths.
According to models from Harvard University, SARS-CoV-2 will continue to progress and spread. The Americans had however put in place special measures to block the entry of the virus into their territory (ban on entry of Chinese nationals and quarantine on arrival for nationals from areas at risk). Nothing worked, and as estimated in an article in The Harvard Gazette of March 4, 2020, almost 2/3 of the incoming carriers passed through the detection device, however considerable, upon entry into the United States .
While some predict that SARS-CoV-2 will be difficult to stop, there is still room for action to contain and slow its progression. In other words, save time while waiting for better days, those of the arrival of a curative treatment, a vaccine or climatic conditions less favorable to SARS-CoV-2. Barrier gestures, simple but demanding, take their place and their importance here: wash your hands frequently and meticulously, maintain and disinfect the house with particular attention to toilets and bathrooms, leave shoes and city clothes in the vestibule for those who return from the outside, ventilate regularly by opening the windows when possible and, why not, when he knows how to be generous, expose to the sun and its UV radiation potentially contaminated objects and objects.
This is the good old sun and the dry air that we count on to help stop SARS-CoV-2. If the progression of the epidemic decreases with good weather, marking a halt to SARS-CoV-2, it will therefore be confirmed to have been perfectly indicated to have acted effectively and early, to limit the chains of transmission and cross the few months that separate us from the beautiful season.
The delicate question of containment
As Chinese measures have dramatically shown, “containment” is effective when the epidemic has not yet spread throughout the population. We wish the same result to our European partners who have implemented and are currently following this provision. Teleworking, which is possible today, is a considerable asset, and while many of our workers remain useful in the workplace, many also can work remotely. Why should we deprive ourselves of it? This would reduce the possibility of creating new chains of transmission.
However, confinement can be very restrictive and inevitably comes with social and economic damage. Beyond the precautions and barrier gestures, each and everyone must prepare mentally for a period of movement restriction and isolation. Without preparation, this episode can be experienced very painfully, like a confinement. Conversely, it can take a new turn, and why not educational and attractive, as a challenge that we accept to take up or an unprecedented experience that we will ultimately be proud to have gone through.
At the national level, could we not therefore advance the date of the Easter holidays, to allow the establishment of a fortnight with the family? The ideal for our fellow citizens would then be to be able to consider this episode as a unique opportunity to air his mind, reflect, take stock and take control of his life. Take advantage of it to settle all these little things that have accumulated and for which we never have enough time. Undertake a major cleaning at home, cleaning the garden paths, tidying up the cupboards, greasing the door which creaks and closes badly, replacing the bulb which we do not even remember when it burnt out, the sorting overdue papers for months, reading all these promising books accumulated in the tablet or on the bedside table and which have been waiting too long to be leafed through …
Also and above all, take advantage of them to find a little time to self, family and friends. Call loved ones to get news and share information. As we had vainly promised each morning on the way to work, write and finally send these famous emails to relatives and friends to remind them that we love them. Watch calmly the old family videos to realize how little the children have grown and travel without moderation in front of the beautiful images of the film of the last vacation in paradise. In summary, be inventive to multiply your activities at home while waiting … next summer!