In the looming epidemic, French hospitals will have to be reserved for patients who need them most. Social distancing measures should be able to slow the spread and home care will take care of the majority of the less serious cases. General practitioners must therefore absolutely be helped.
Already, it is possible to say that we are faced with a health crisis very disturbing. Over the past few weeks, Covid-19 has started acting like a rather menacing pathogen, maybe not the dreaded “plague” that only happens once a century, but maybe not far off.
In any case, the spread of the virus is inevitably accelerating, the social and economic consequences are already being felt and France is moving towards a change of strategy in the management of this epidemic which cannot be based on the “all hospital”.
7th human coronavirus
This novel coronavirus is the 7th known in humans (4 seasonal HCov, SARS) – severe acute respiratory syndrome – and MERS – Middle East respiratory syndrome). It can kill healthy adults, not just old or sick people. The data available so far suggests that the virus has a lethality risk between 1.4% at 2.3% in China (but 8% after 70 years).
This rate would make it much more severe than seasonal flu (0.1%), placing it somewhere between the 1957 flu pandemic (0.6%) and that of 1918-1919 (2%), but not like SARS or MERS, which had case fatality rates of 10% and 36%, respectively.
A majority of mild cases
Covid-19 is mild in more than 80% of cases (a common infection of the upper respiratory tract), and in particular in children it seems (very few symptomatic cases among children under 15 in China), which is not without posing problems of dissemination and contagion.
But it is also responsible for nearly 15% of pneumonia requiring hospitalization and 5% of patients in intensive care (pneumonia, acute respiratory distress syndrome), including nearly half die (from respiratory, cardiac, renal and hepatic failure during the outbreak in Wuhan, China).
If the spread of this virus grows exponentially, we will therefore be quickly overwhelmed, both in terms of hospitalization capacities and resuscitation possibilities.
Slow transmission
The Covid-19 is transmitted rather effectively. The incubation period appears to be 5 days on average (2 to 12 days), with some patients showing little or no symptoms (1.2 to 1.8%) that could transmit the disease, at least 24 hours before the first signs.
An infected person would transmit the disease on average to two or three other people, which represents with a doubling time of the epidemic of 6.4 to 7.5 days: an exponential growth rate therefore.
This means, in practice, that Covid-19 will be much more difficult to contain than Middle East respiratory syndrome (MERS) or severe acute respiratory syndrome (SARS), transmitted only by symptomatic patients. In fact, Covid-19 has already caused ten times more cases than SARS in roughly a quarter of the time of this outbreak.
Slowing the epidemic without slowing down the economy
The efficiency of transmission of any respiratory virus has important implications for containment strategies. We have seen that the current studies indicate a basic reproduction number (R0) estimated at 2.2 (each infected person transmits the infection to at least two other people). As long as this number is not less than 1, it is likely that the epidemic continue to to spread. However, reports Recent reports of high virus titers in the oropharynx early in the disease reinforce concerns of increased infectiousness during the period when symptoms are minimal.
China and several other countries have introduced dramatic travel restrictions in an effort to slow the spread of this new disease. At least temporarily, these restrictions may have helped slow the spread of the virus, but the Chinese economy will have to restart to feed its population. It is therefore necessary to find strategies for slowing down the epidemic that are compatible with economic functioning.
An international scientific collaboration
A remarkable research effort is currently underway to develop a vaccine against Covid-19 and the first candidates will enter phase 1 trials in early spring with at best the availability of a possible vaccine effective in large quantities not before 2021.
Current treatment essentially consists of supportive care, while various experimental approaches are based on the use of existing drugs in other directions. Among these, we note the interest of an antiviral combination, lopinavir-ritonavir, and especially an inhibitor of RNA polymerase, remdesivir. Chloroquine has recently made the buzz but we have to wait for more precise scientific data.
Once available, ultra-specific immunoglobulins from cured patients and monoclonal antibodies will be studied in scientific studies.
It should be noted that researchers are very interested in the time limit 9.1 to 12.5 days which elapses on average between the first symptoms and a hospitalization, if this should occur, which militates in favor of a window of opportunity for early therapeutic interventions intended to reduce the frequency of severe forms.
Social distancing
The spread of Covid-19 is therefore inevitable and the therapeutic strategies are still unclear, but it is necessary to slow down the epidemic as much as possible in order to be able to manage it as well as possible and reserve hospitals for the patients who need them the most.
The French strategy is therefore likely to move towards a shift from confinement to mitigation strategies such as social distancing in order to reduce transmission (avoiding physical contact, no more handshakes or hugs, teleworking, etc.) .
These strategies could include isolating sick people at home, closing schools and banning public gatherings as recommended on February 29 by the French government, which notably warned of gatherings of more than 5,000 people. causing the cancellation of many sporting or cultural events, … and therefore home care for the majority of patients.,
Importance of general medicine
Only the most severe patients would therefore go to the hospital and the majority of patients would be treated at home, with their families of course (since they will also be confined), but also with general practitioners.
Because this is one of the great advantages we have over China where there are no general practitioners: the hospitals there were immediately overwhelmed and many patients were infected in the hospital.
In France, we have city medicine that suffers but is efficient (1 million consultations per day). With appropriate aid, and state support in the event of contamination and quarantine, general medicine could avoid the over-catastrophe announced by “overflow” of hospitals.
Really helping general medicine
On the other hand, general medicine must be able to benefit from massive help, both in terms of reception of patients (separation of coughing patients from others, provision of masks for coughers), and in terms of examination of these (gowns, glasses, non-sterile single-use gloves, FFP2 masks and decontamination by SHA – hydro-alcoholic solution – which currently seem to be lacking for many practitioners), and also at the level of home monitoring of infected people, the majority of which, although contagious, will be moderately ill (telemedicine with assistance from platforms that will help GPs to monitor their patients remotely).
In particular, knowing that patients who worsen would do so within 9.1 to 12.5 days after the initial symptoms, they should be monitored on a daily basis with relevant indicators so that patients who must be hospitalized, are in due time.
Telemedicine is there, it’s a solution that should help doctors save time on home monitoring, but that won’t be enough. We would need real-time monitoring platforms for the symptoms of homebound patients to sort out those who will need GPs or the hospital.
Don’t forget the less fortunate
Bill Gates recently recalled this in a item of the New England Journal of Medicine, it will also be essential to help countries which do not have our health capacities, or which are in situations of war or major economic constraint. So far sub-Saharan Africa seems relatively spared, let’s hope it lasts.
On the other hand, the Middle East, with Iran, Iraq and Syria, and the millions of refugees who live in precarious conditions in the surrounding countries, represent a problem which will quickly become uncontrollable for Europe (immigration mass, including infected patients) if the international community does not organize itself, both medically, politically and economically.
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