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MARCH 16, 2020 -- COVID-19 cases in France are rising but is the country heading for infections on the scale seen in Italy?
What measures have already been taken in hospitals? Are they enough? What advice can infectious disease specialists give to healthcare professionals?
Dr Benjamin Davido is an infectious disease specialist at Raymond-Poincaré hospital in Garches, on the outskirts of Paris. He is the lead referral for COVID-19 and clinical lead for their ‘Plan Blanc’, the planned response to exceptional healthcare situations, which became a requirement following the terror attacks in 2014.
He spoke to Medscape’s French Edition.
What is the situation in your hospital?
Since the beginning of [last] week, we have had a worrying and very significant increase in the number of cases. Currently, we receive one phone call for a screening request every 2 minutes, and one request to evaluate a patient suspected of having, or already tested positive for, COVID-19 every 10 minutes (and try to find a bed). We have had to assign two doctors full time to handle this.
In addition, today [13th March], outpatient screening of caregivers suspected of having the disease revealed that 40% tested positive for SARS-CoV-2. There is now a worrying degree of infection that shows the virus is circulating outside but also inside the hospital. This figure is all the more worrying because, 10 days ago, we were close to 0%. The increase did not happen by chance.
When we had only 40 cases in France, we relied on level 1 Health Referral Centres (établissements de santé de référence; HRCs), such as Bichat or Pitié-Salpêtrière hospitals in Paris, to absorb the flow of patients. Now we have more than 3000 infected individuals, it is obvious that the dozen level 1 HRCs across the country are no longer enough. Consequently, second line centres, like our hospital, are taking their turn, just in time.
We have had to adapt and put in place dedicated COVID-19 units. We have, as of today [13th March] a total of 11 beds, with a planned increase to 20 beds next week. Centres no longer have the time nor the space to receive and respond to the demand for screening. Fifteen days ago, the screening of suspected patients had to be done in the hospital with containment measures. Today, it is no longer possible as these places are taken by confirmed cases. Screening is therefore performed in the emergency department. This is stage 3 crisis management, although this has not yet been officially announced, which underlines the pressure from the flow of patients arriving in hospitals.
Are there annexes for screening?
Some hospitals have installed tents for urgent services, but you still need to have the capacity, to have the space and enough caregivers. And these tents only allow outpatient diagnoses, they don’t allow for patients considered fragile or severe cases requiring hospitalisation in a dedicated isolation facility.
Is France heading for a situation like Italy?
It is certain that the curves of the Italian and French epidemics can be superimposed; they are just separated in time by around 10 days. One difference between the two countries is that Italy has a particular set-up in which healthcare is organised separately by region, which may have led to a delay in the organisation of care.
Italy also organised the situation by geographic area; thinking, for example, that only the north of the country was affected, which was, in hindsight, probably a mistake. But in the same way, in France, in mid-February, we thought only in terms of clusters or people returning from at-risk zones, 10 km outside of which patients were not considered suspect, only for, the next day, those areas to become clusters.
Today, in France, we no longer talk of zones or foci of COVID-19, and we no longer take into account travel. On the contrary, we consider the severity of the illness, and it is the presence of unexplained pneumonia that makes us suspect a COVID-19 diagnosis, especially if it is serious straight away (in resuscitation, for example).
We are now in the middle of a major public health problem. We have stayed at stage 2 in terms of the health alert, in that we screen people with relevant symptoms, even if they are minor. But as we no longer include history of travel, and the relevant symptoms are flu-like, such as having a fever, a runny nose, or coughing, and that, chronologically, it is the peak of the flu epidemic, we have an enormous influx of patients who may have flu or seasonal viral infection (mainly rhinovirus). These are consistent with the new coronavirus and, as such, we cannot, for benign cases, make a clinical distinction between them. It becomes therefore impossible to screen everyone. In any case, we don’t have enough kits. We are at the stage of counting the number of cotton swabs to take samples…
Did France act too late to prevent shortages?
Yes. Personally, for 10 days, I and my colleagues have struggled with the healthcare teams to urgently set up a hospitalisation and screening structure to make the diagnoses, as some seemed doubtful due to the lack of anticipation by our local bodies. I don’t blame them, because bodies at the ministerial level have not given us the funds for taking the samples, as the laboratories themselves do not yet have the testing machines.
On the other hand, what should have been anticipated is the current situation where we find ourselves with questions over the supply of masks. There are general practitioners who cannot see patients in their office due to a lack of surgical masks (FFP2s [masks] only have demonstrated effectiveness in resuscitation and when obtaining the sample), while we are in a period of seasonalflu and colds…and coronavirus. There is also a lack of hydroalcoholic gels. For lack of a better option, it is necessary to rely on hand-washing, which is a backwards step in terms of hygiene practices. That’s why, there should be, from tomorrow, a national plan that fits with the pandemic, as declared by the WHO. Care, as set out in the current plan, is not tenable in the long-term because in the short-term we will no longer have the capacity to accept and regulate the flow of hospitalised patients, or even to screen them.
How did you set up your dedicated COVID-19 unit?
We opened our unit around 15 days ago in response to a call from level 1 HRCs. As with any new epidemic, there was a lot of apprehension at the outset, especially among caregivers and nurses. We anticipated that before opening the service. It’s what we saw with HIV in the 90s and with highly resistant bacteria in the 2010s. It’s a normal reaction. Once we had explained the issues and above all that we are capable of effectively protecting ourselves against transmission of the illness (in hospital) by using FFP2 masks in particular, everyone took part with extraordinary energy.
Is transmission really controlled in your unit?
Yes, in the hospital it is. Contaminated caregivers have been probably, in the main, in the community or hadn’t take sufficient precautions at the start of the epidemic by not wearing a mask when the patient had signs consistent with the illness (especially cough). Personally, I think I have more risk of catching the virus on public transport than in the hospital. We are working on a cohort of patients to determine the risk factors for infection specific to caregivers, to know precisely how much of a role is played by contamination outside the hospital, in meetings, or the non-application of precautions (wearing a mask or using hydroalcoholic gel).
It is certain that, in our infectious diseases service, there is a bias because we are used to protecting ourselves, so the risk is obviously and thankfully residual. What is dangerous is, for example, a patient hospitalised in orthopaedics for a hipfracture who coughs; we aren’t necessarily going to think about COVID-19, and in orthopaedics the policy outside theatre is to not wear a mask.
How anxious are you?
I am personally not afraid of being infected. I am, on the other hand, very preoccupied by the thought that the numbers are increasing exponentially; we are at the beginning of the epidemic, so that’s normal. But the question is: will we have the physical means (masks, hydroalcoholic gel…) and the people (who could work non-stop days, nights, the weekends…?) at a constant level and without additional help? If the epidemic lasts for 3 months, I think it will be very difficult.
Current health policy is to keep the epidemic at alert stage 2, flattening the curve to not saturate the health system, which may make the epidemic last longer. Hospitals in France have been in crisis for years; in January, healthcare professionals protested against the lack of healthcare personnel and to explain that the austerity policy, which would see hospital beds close and push outpatient care, was not viable. Today, we are reopening hospital beds and requisitioning them to hospitalise suspected coronavirus patients.
This morning, the regional health agencies asked us to cancel all scheduled non-urgent hospital admissions.
Doctors in Italy have had to make difficult ethical choices due to the lack of equipment (respirators, beds, etc). Will this happen in France?
We have discussed it among infectious disease specialists, and we think that it’s a question which will sadly arise when we have no more room for resuscitation, which is currently not the case. But COVID-19 patients with severe disease stay in hospital for a long time (around 3 to 6 weeks) so if the epidemic lasts, it may indeed happen. But this decision algorithm is sadly not rare in medicine. We decide not to resuscitate a patient when we know it will not save them. What is new is that this is a kind of illness for which we are not used to taking this type of decision.
In Italy, several doctors report that patients under 40 years old, without comorbidities, could also present with serious forms of COVID-19. Are we seeing the same thing in France?
Currently, a third of hospitalised patients in resuscitation in France don’t have risk factors, including some under 40 years of age. We don’t know why yet. There is probably a genetic factor to the illness. One hypothesis is that it causes an immune reconstitution inflammatory syndrome, which we see sometimes in infectious diseases like tuberculosis and HIV.
How do you explain there being fewer severe paediatric cases? Could children, in a second outbreak of the epidemic, be more susceptible?
There are currently two hypotheses. We know that children are exposed to a number of different coronaviruses; they could have therefore developed an immunity against this virus, and don’t develop the severe clinical form. The second hypothesis is that COVID-19 cannot attach itself to the respiratory epithelium in children. This immature epithelium has few if any receptors.
One could reasonably think that in the case of a second outbreak that children could still be protected. We know that the virus mutates relatively little, so the risk is probably small, even if it cannot be confirmed at this stage. We saw in Japan patients re-infected with coronavirus but it seems that there is nevertheless a partial immunity, contrary to what was said initially.
You will take part in a clinical trial in France for the treatment of COVID-19. Can you tell us more?
It is a large-scale clinical trial [with 3200 European patients, including 800 from France] conducted at Bichat hospital by Dr Yazdan Yazdanpanah, which will attempt to answer many questions. It will consist of four arms, testing the following treatments:
Remdesivir [GS-5734, Gilead], an antiviral that has already been tested on MERS-CoV. The first version was tested on SARS in 2003, but we have little data for SARS-CoV-2 because the illness has only been around for several months. The in vitro results were interesting; it could be effective against SARS-CoV-2.
Lopinavir/ritonavir [Kaletra, AbbVie]. It’s an old retroviral used against HIV. It’s a protease inhibitor which is said to be effective against sequences similar between SARS-CoV-2 and HIV. It could reduce the viral load. But the recent data showed, in vitro, that HIV, which is meant to be resistant to lopinavir, was paradoxically more sensitive than SARS-CoV2, calling into question its clinical effectiveness.
A combination of interferon beta and lopinavir/ritonavir.
A control arm of standard of care, with oxygen therapy, etc.
What message would you give to your colleagues?
When we are in stage 3, we should not see it as a nuisance. We will be able to take decisions that will allow general practitioners to be involved and manage outpatients, as these are mainly non-severe cases (80% of cases). And to properly care for these patients, it will be absolutely necessary to follow hygiene rules (masks, hand washing…) and monitor them well; in other words, see them again at 7 and 14 days to ensure that they don’t have complications of the illness.