26 March 2020

We still have time to implement more tests to halt the panddemic


All over the world, many people are starting their days with new information about the spread of the Covid-19 infection. This new virus, unknown to the world until only a few months ago, is shutting down schools and workplaces, causing queues to build up in supermarkets and leaving entire towns and cities on lockdown. Although it is only deadly in a small percentage of cases, the virus has unfortunately been tallying up a rather worrying death count over time. 

However, we are also receiving good news regarding the tireless battle being waged by healthcare and research professionals. The former are saving lives on a daily basis. The latter are coming up with treatments to halt and even cure the disease.

While many people across Spain were finishing up their first week on lockdown, we spoke to Antoni Plasència, the director of ISGlobal and a renowned epidemiologist. His research centre, the result of an innovative alliance between ”la Caixa” and academic and governmental organisations, has played a pioneering role in creating interdisciplinary teams to provide a 360 response to global healthcare. Research into infectious diseases is one of the main strategic focal points in their work.

Every day we’re getting more news about the virus spread curve. What point of the curve are we at in Spain as of now?

Right now, we’re in the rapid spread phase, and right now there are no signs that this trend is changing. It’s going to keep on rising for some time. How it develops will depend on how effective the recent mitigation measures taken by the Spanish government are.

Is there any way of predicting when the curve will start to change?

It’s still too early to make forecasts of that kind but the measures taken are aimed at bringing about a turning point in a couple of weeks and halting this growth. I can’t see it happening within two weeks, that would be an untimely prediction. It will be a matter of a few weeks, but we can't say how many. It’s only been a few days since we started social distancing en masse, since the decree was passed, so it's too early to assess how effective it’s been. 

Can we trust the statistics from other countries to predict what could happen here?

Everything will depend on the efforts made by each country and their capacity to confirm cases; this means how many tests are available and the criteria for testing. Moreover, a significant number of assumed cases depend on this, which otherwise would not have a confirmed diagnosis. Some countries have implemented a lot of tests and others haven’t. As such, comparing epidemic trends across countries is no easy feat. Here at ISGlobal, we’ve drawn up a document that compares the different strategies implemented by the countries. 

Right now, China and South Korea seem to have implemented successful strategies.

China has worked intensively and has really doubled down on strict social isolation, shouldering the negative economic impact of its measures, and this has been very effective. South Korea’s strategy was to identify the first cases, implementing more individual measures with less social disruption, and investing a lot of resources into their capacity for diagnosis and technology for identifying and monitoring people who have caught the virus and those with whom they have been in contact.

What has been going on in Italy and Spain?

We’re still on the warpath here. What’s happening in Europe is a result of what we thought might be the case, that infection could be asymptomatic; however, this was not taken into consideration as much as it should have. We have seen the virus being passed in the community beyond confirmed cases from overseas or associated with a case from overseas. This has led to the exponential growth that we are still dealing with now.

As such, each country has been faced with a different situation.

Not quite. The difference between the countries is in their response strategies, where they are adapting to the dynamic development of the disease to different extents. In line with WHO criteria, these strategies are gradual and progressive. Now we have to wait and see how these new measures turn the curve around. Sooner or later we’ll see success. However, right now we can’t be sure of when it will happen and the extent of the economic and social toll it will take on us. 

As of now in Spain, the basic measure is social isolation. Will testing, like in Korea, be useful, or are we already at a stage where the virus has spread too much?

They would be useful; it’s never too late to implement testing. It still makes perfect sense to identify and isolate confirmed cases and people with whom they have been in contact. However, this also depends on the logistical capacities for making tests available and putting people confirmed to have the virus into isolation. It was slightly easier in Korea from the outset because the epidemic started off in a very specific point, a religious congregation. In our case, both in Spain and in Italy, it's far more complex since it started off at different points, which weren't clearly identified and all developed simultaneously. I think there could be a halfway point and, if we can't do testing en masse, we could focus the testing on specific cases. 

Is there any other alternative strategy if transmissions don't start to come down in a month's time?

If the transmission rate doesn’t start to come down, we will have to start weighing up keeping the measures in place even longer, assessing what should be the limits of the socio-economic impact they might have. This seems to be what is behind the current strategy in the UK right now.

What does it involve?

Allowing the virus to spread to allow the population to develop herd immunity against it, focusing on detecting cases and people with whom they have been in contact and bolstering the NHS to treat them all as effectively as possible without any drastic social distancing measures. However, there are some risks involved. There’s still no evidence on what the immune response is in people who have been exposed to the virus and the protection generated against a possible return of the virus. Moreover, in the meantime this strategy could really overload the NHS, leading to many more people dying. 

That’s not an ideal scenario.

At the end of the day, their strategy is based on the idea that “health comes at a cost.” Do we set that price or do we decide that people’s health is more important than anything else? I think it is. It’s more important than the social and economic impact. I argue that we should stick to implementing the current measures: isolation and an increase in the number of tests conducted on the public, specifically on vulnerable groups. The question is what price Spanish society is willing to pay in order to keep up these efforts. 

What are the priorities as of now in the fight against coronavirus?

The first is to bolster the resources and equipment we need in order to ensure that our healthcare system has the capacity to treat people. The second is to keep tight social distancing measures. The third is to increase access to the diagnostic tests, especially in high-risk groups: vulnerable groups and social and healthcare workers, also in regions where the virus is spreading faster. 

Will this be enough?

We need to bear in mind that what we know about the pandemic isn’t changing every day but rather every minute. We are constantly seeing new results and we need to use this information so that, in practice, the public authorities can make good decisions. For example, it’s not a good idea to talk about fatality rates, which are the number of deaths out of the number of cases. At first, in China it was thought to be around 2-3%, but we are yet to find out in Europe since more cases that had gone undetected are being picked up. It’s too early to make any reliable estimates. That's why we should not lose sight of the fact that one of the main determining factors in the death rate is not the virology of COVID-19 itself but rather the response capacity of the healthcare system to treat severe cases. 

There’s still a lot to learn then.

In the coming weeks we are going to see how the spread of the pandemic will become more visible in Africa and the Americas. Right now, it would appear that there aren't many cases, but the problem is that they don’t have much scope to detect cases. Africa is a very worrying case since they also have other severe problems such as malaria, AIDS, tuberculosis and other infections with a high rate of diseases, as well as high blood pressure, obesity and heart disease, which are on the rise. Coronavirus will be added into the mix in a context where there is little scope for diagnosis and very fragile healthcare systems.

Are we still in the first stages of building up knowledge?

I wouldn’t say that. It’s been three months now. We have proof of success stories in China and South Korea. We also need to see how things develop in Japan and Singapore. We need to wait. However, in Europe, we are in a war zone. Drastic measures are being taken to a good extent and we need to wait for things to turn around to start adapting our responses. What is clear is that we will get through this but at a huge cost. 

Could COVID-19 become a seasonal virus?

We don't know, but it looks like it’s going to be circulating for an indefinite period of time and it will affect the entire world. We still don't know how it will behave seasonally, e.g. how it reacts to moisture and temperature. We also don't know what our immune response will be, whether it is a one-off response, meaning that we could catch the virus again, or if we could develop long-term immunity to it. There is still a lot for us to learn.

Could we learn anything from how we have managed the start of the crisis?

It’s still early days for interpreting what has happened. Most European countries have followed WHO guidelines, which stipulate a gradual response, adapted to how the epidemic develops. Could we have taken some of the current measures earlier within this model? It’s still too early to say. In any case, the other, more extreme approach involving intensive intervention when the first cases appear is not in the current protocol. So, the discussion is about how this gradual approach is implemented, even though the information we have is not complete and there is still a lot of uncertainty. However, we are clearly learning useful lessons for the future every day.

Is there a bright side to all of this?

With this new risk to public health, a lot of actions are being taken that will strengthen us as a global society. What has happened to us, the pandemic, shows how interdependent we always are on one another, almost every minute. It shows us how fragile we are and allows us to tackle this as a collective, through shared efforts and collective intelligence. The virus is creating a situation we have never experienced before and a response that all of us have to shape out in order to guarantee healthcare while keeping the economic and social impact to a minimum. In this respect, science is a crucial tool for understanding the infection dynamic and coming up with responses. It is still difficult to make predictions, but as of now we know more than last week, and in one week’s time we will know more that we do now in order to overcome this pandemic.