Covid-19: Was the confinement really unavoidable and what have we learned?

As many countries are initiating their deconfinement, 2 essential questions arise:

1. Could infection control through general population confinement have been avoided ?

2. What can we learn from it ?  

To answer the above questions, several virus defining facts need to be reemphasized:

The first fact is the current, well documented, worldwide spread of this pandemic, and its profound patient and healthcare impact over the last 4 months (see chart below)

The second resides in COVID-19’s characteristics and associated clinical implications:

1. SARS-CoV-2 rapid transmission mode, including during asymptomatic incubation period, with currently estimated R0 level at 2-3

2. ARDS clinical pulmonary complications occurring at a late infection response stage, especially in higher risk patients (65% men, >60 years, associated comorbidities)

3. Consequent significant ICU admission of above ARDS patients with particularly long ICU stay duration (3-5 weeks) associated with an enhanced need for mechanical ventilation

Such a high level of ICU-admissions, as well as the extended duration of stay, generated an overwhelming pressure on our healthcare professionals and ICU resources. This was a major defining factor in the level of stringent infection control strategies, and observed differences between countries.

The 2 other important healthcare capability related data points:

1. The availability/number of ventilators and
2. The SARS-CoV-2 RT-PCR diagnostic test access

Interestingly, the below data suggests that while enhanced healthcare capabilities are directly correlated to a positive impact on Covid-19 death toll, this fact alone does not fully explain the differences in number of deaths between countries. These differences appear to be also correlated to other factors, including large immediate supplies of protective masks for general population, cultural behaviours and demographics.

The 3rd fundamental fact is the absence, at this stage, of proven efficacy treatment or prevention measures (prophylactic treatment or vaccination). This reduced our primary options to non-pharmaceutical, general population infection control measures, including population confinement. 

The above translated into confinement strategies ranging from targeted risk population confinement, as in Sweden, to more generalized ones, as in several European countries and US states. The differences in the scale and strictness of general population confinement strategies between countries, were significantly impacted by all the above fundamental facts.

These measures led to an unprecedented lockdown impacting up to 40% of worldwide population. This resulted in social and economic costs estimated at $1 trillion during 2020, according to the UN Trade Agency. Such a downside strongly challenged the sustainability of these confinement measures on the long run.

One positive side, is the triggered unprecedented accelerated gap closing collaborative efforts focused on diagnosis, treatment and prevention initiatives with the launch of 373 advanced therapeutic projects.

Based on above reviewed fundamental facts, the short answer to our 1st question, “could such an infection control through general population confinement have been avoided”, is a highly conditional yes.

In fact, this could only have been possible if we had been able to successfully contain the pandemic spread and contamination speed of SARS-CoV-2 infection beyond China’s borders.

The above obviously prompts the question “why were we not able to do so?”  

First and foremost, it is our failure to create a more efficient, accurate and transparent global alert system to allow early detection and trigger immediate containment measures of such infectious disease threats. The early detection could have critically supported our efforts to mitigate both the speed and level of Covid-19 spread. This would have also allowed immediate initiation of currently ongoing focused R&D activities, aiming at providing diagnostic, treatment and vaccine prevention options at an earlier stage 

Unfortunately, once SARS-CoV-2 new virus became pandemic, and owing to its fast spreading and ARDS clinical implication, we had to face an unprecedented pressure on ICU capabilities. This context led to the need for an immediate measures to protect the general population and avoid total saturation of our ICU-settings capabilities.

Consequently, the use of non-pharmaceutical infection control measures, became unavoidable, at this stage.

However, it is also worth reminding that, as previously outlined, the extent and strictness of such confinement measures ranged from a targeted/focused population measures to most strict general population confinement.

It is mostly the dramatic projected social and economic implication of a strict general confinement measures that led several countries to opt for less stringent confinement. However, the feasibility of such less stringent confinement, was highly conditioned by country’s appropriate ICU capabilities, large skill RT-PCR diagnostic testing and general population protective mask availability.

Prior to answering our 2nd question of “What can we learn from the Covid-19 pandemic“, we need to start by emphasizing the recent WHO 2019 report, indicating current 10 global health threats, of which 6 are related to infectious diseases and their management. Specifically, these included Global influenza pandemic, Vaccine hesitancy and Antimicrobial resistance. To that last threat, several specific reports including the WHO one published in 2018, stressed the extremely alarming projection of antimicrobial resistance across the world (see below)

This report rightfully highlighted that, if not acted on and mitigated, antimicrobial resistance could also threaten the success of major surgery and cancer chemotherapy.

Therefore answering our 2nd question of what learnings can be made, and with the above in mind, the first learning is a simple yet critical one:

• To best mitigate global infectious diseases threats, anticipation is the name of the game. In the context of Covid-19 pandemic crisis, our current struggle is definitely unsettling, considering the number of published alarming reports, including the ones by WHO. Such recent reports robustly identified and recognized infectious diseases as 6 of the 10 global health threats    

Specifically to our current situation, the general population strict confinement measures avoidance was directly conditioned by our ability to immediately detect, alert and act on such global infectious pandemic threat. This would have allowed us to collectively and preemptively act on containing or at least slowing down its global spreading. This would have also bought us precious time to allow the ramp up of individual countries healthcare capabilities and readiness, including enhanced ICU capabilities, large skill RT-PCR diagnostic testing and general population protective mask availability

• Secondly, the current suboptimal healthcare systems and ICU capabilities in many geographies including western countries, left us vulnerable in facing such a sudden and massive number of patient’s ICU admissions and extended duration of stay 
• Thirdly, we need a larger countries autonomy and sources diversification of materials needed in such infectious diseases pandemic crisis. Specifically to our current convid-19 pandemic, the global massive needs and excessive concentration in, mechanical ventilators, large skill RT-PCR diagnostic testing, as well as, general population protective masks, created a huge tension and often a supply shortage. This was aggravated by the shutdown of main production sites of such materials    
• The fourth learning, is that the need and expected contribution of treatment and vaccines prevention options are definitely and eagerly expected to help us win this battle in the most impactful, cost-effective and sustainable way.
• The fifth learning is a whistle-blower to the fact that, failure to better acknowledge and diligently act on other identified infectious diseases global health threats, particularly Vaccine hesitancy and Antimicrobial resistance, could results in a similar and imminent healthcare crisis 
• Finally, as recently published, cancer as well as other critical diseases diagnostics and management have been significantly disrupted by our response to the COVID-19 pandemic. This could worryingly compromise patient long-term survival. Also, keeping “Patients First” in mind, should remind us that diabetes, cancer, heart and respiratory diseases are associated with over 41 million deaths worldwide and remain part of the top 10 Global health threats identified in 2019 

Last, but most definitely not least, I’d like to personally thank all my colleagues, clinicians, experts and pharma peers for their time and precious contribution to these thoughts about Covid-19 management and learnings so far.