How to fight COVID-19John Jacobs, 11 April 2020Expert opinionThis paper is an expert opinion.[1] It is neither just a story, nor the only vision that could be held. I wrote some blogs [2], that predicted the COVID-19 epidemic in the Netherlands, which match the actual events, more closely than the national official message. This does not imply that I know it better, only that my thoughts might be interesting enough to consider for future policies. We all aim for the same: beat this epidemic, while minimalizing costs of human lives, quality of life[3] and economy.
--- [1] https://hartblik.weebly.com/expert-opinion.html [2] Collected at http://hartblik.nl/ [3] Social isolation has a huge impact for people. |
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Know what you do!
We need data-driven decisions, I wrote many times.[1],[2],[3],[4] Without data we are lost, and will never be in control. This epidemic could last for years, and its impact for healthcare, wellbeing and the economy, should not be underestimated. We need policies based on extended testing to save lives, make life more pleasurable, which would also help the whole nation.[5]
Some countries, like South Korea, Germany and Iceland, use a testing-based strategy. This is the default strategy in the Netherlands, and our national institute, the RIVM, initially followed this strategy at the COVID-19 epidemic. Unfortunately, we were not well enough prepared to maintain this strategy. A lesson for the future is, that we should be prepared for epidemics.[6]
The RIVM states repeatedly that our national capacity for resting is insufficient.[7] When they first delivered this message, a local university hospital in Groningen (UMCG) drastically increased their testing.[8] Currently our national strategy is to test more,[9] and we should test even more. We have different types of tests,[10] all well-known in our laboratories. RNA detection (RT-PCR) has been routinely used for 30 years, [11] antibody detection (ELISA) for forty years,[12] and also to create apps could not be considered rocket science anymore. In short, technology is not stopping is, so if we really want to test, we could do so.
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[1] https://hartblik.weebly.com/versimpeld-model-corona-nl.html
[2] https://hartblik.weebly.com/rekenen-zonder-getallen.html
[3] https://hartblik.weebly.com/ontelbaar-op-waarde-geschat.html
[4] https://hartblik.weebly.com/verloren-door-te-weinig-kennis.html
[5] https://hartblik.weebly.com/model-leren-voor-beter-handelen-4.html
[6] https://hartblik.weebly.com/Voorkom-epidemie.html
[7] https://www.rivm.nl/coronavirus-covid-19/vragen-antwoorden#test
[8] https://www.groene.nl/artikel/noordelijke-provincies-laten-landelijk-beleid-los-en-testen-massaal-zorgmedewerkers
[9] https://www.ad.nl/binnenland/het-mocht-even-duren-maar-nu-gaat-ook-nederland-testen-testen-testen~af63560b/
[10] https://hartblik.weebly.com/model-leren-voor-beter-handelen-4.html
[11] See section 1 https://hartblik.weebly.com/ontelbaar-op-waarde-geschat.html
[12] https://en.wikipedia.org/wiki/ELISA
Some countries, like South Korea, Germany and Iceland, use a testing-based strategy. This is the default strategy in the Netherlands, and our national institute, the RIVM, initially followed this strategy at the COVID-19 epidemic. Unfortunately, we were not well enough prepared to maintain this strategy. A lesson for the future is, that we should be prepared for epidemics.[6]
The RIVM states repeatedly that our national capacity for resting is insufficient.[7] When they first delivered this message, a local university hospital in Groningen (UMCG) drastically increased their testing.[8] Currently our national strategy is to test more,[9] and we should test even more. We have different types of tests,[10] all well-known in our laboratories. RNA detection (RT-PCR) has been routinely used for 30 years, [11] antibody detection (ELISA) for forty years,[12] and also to create apps could not be considered rocket science anymore. In short, technology is not stopping is, so if we really want to test, we could do so.
---
[1] https://hartblik.weebly.com/versimpeld-model-corona-nl.html
[2] https://hartblik.weebly.com/rekenen-zonder-getallen.html
[3] https://hartblik.weebly.com/ontelbaar-op-waarde-geschat.html
[4] https://hartblik.weebly.com/verloren-door-te-weinig-kennis.html
[5] https://hartblik.weebly.com/model-leren-voor-beter-handelen-4.html
[6] https://hartblik.weebly.com/Voorkom-epidemie.html
[7] https://www.rivm.nl/coronavirus-covid-19/vragen-antwoorden#test
[8] https://www.groene.nl/artikel/noordelijke-provincies-laten-landelijk-beleid-los-en-testen-massaal-zorgmedewerkers
[9] https://www.ad.nl/binnenland/het-mocht-even-duren-maar-nu-gaat-ook-nederland-testen-testen-testen~af63560b/
[10] https://hartblik.weebly.com/model-leren-voor-beter-handelen-4.html
[11] See section 1 https://hartblik.weebly.com/ontelbaar-op-waarde-geschat.html
[12] https://en.wikipedia.org/wiki/ELISA
Ten reasons why testing is central:
1. Protect healthy people by detecting and isolating infected persons.
2. Monitor disease progression in infected persons
3. Optimize therapy for early stage, mild patients, to reduce sever cases.
4. Experimental trials to treat severe COVID-19
5. Match the need for healthcare workers
6. Monitor the number of infected people:
7. Adapt policy locally or regionally
8. Verify that cured people are virus free
9. Determine who is immune to SARS-2.
10. Measure how many people are immune.
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[1] https://hartblik.weebly.com/immuniteit-en-antistoffen.html
[2] Section 2 https://hartblik.weebly.com/ontelbaar-op-waarde-geschat.html
- To avoid new infections should be our main priority in population health.
- This implies quarantine for infected persons – at least two weeks, at most until recovered (this could be at home). This is much more friendly than a lockdown for months or years for the entire society.
- Most likely, people will adhere better to a temporary isolation for being infected than to a self-isolation for years.
2. Monitor disease progression in infected persons
- Different stages of the disease may need different interventions.
- Early interventions could avoid many severe cases.
3. Optimize therapy for early stage, mild patients, to reduce sever cases.
- Randomized controlled clinical trials (RCTs) should be performed with several medicines currently used to inhibit flulike symptoms.
- Population health will have most gain by treating people who are not yet seriously ill. This is common knowledge for physicians. To avoid disease progression by optimizing early treatment avoids both healthcare overload and high mortality of infected patients.
4. Experimental trials to treat severe COVID-19
- Start small studies using registered medicines that are likely to have a theoretical health gain in case of COVID-19. Exploration proceeds faster with small trials than with huge trials.
- After analysis of small studies, the best interventions could be compared in RCTs.
- After the RCTs every will receive the best therapy according to evidence-based medicine.
5. Match the need for healthcare workers
- It is essential to protect healthcare workers working with patients for these patients, the healthcare workers, and it is our moral duty when we send people on a dangerous mission.
- Test health care workers for both infection and immunity. Infected health care workers would spread the disease (see item 1)
6. Monitor the number of infected people:
- To predict how many patients will come to the hospital, and
- To predict how many patients will need intensive care.
- Healthcare could be planned and prepared for the forecasted patient flow.
7. Adapt policy locally or regionally
- If the patient flow forecasting threatens to overquest the medical capacities, prevention politics should be tightened. This would avoid surplus mortality related to insufficient care.
- Preventive measures could be loosened if healthcare capacity and forecasted patient flows allow this. This would be a relieve for society and economy.
- The disease spreads locally, so preventive policies should be adaptable per region.
8. Verify that cured people are virus free
- Some virus infections are known to allow a carrier state, people who transmit the virus afger being cured from the infection. We should investigate if SARS-2 also has a carrier state. This can be done by detecting viral RNA in cured patients that have developed antiviral immunity.
- A putative carrier state would be relevant for epidemiological models. The impact depends on how many of cured patients remain carrier for which period.
- In case herd immunity is a strategy, it is crucial to exclude a carrier state. A carrier state would invalidate the fundament of this concept.
9. Determine who is immune to SARS-2.
- Detect antibodies to determine who has been infected with SARS-2. If antibodies are not required for immunity, they still are an epiphenomena to show that the cured patient is immune.[1]
- People who are immune, cannot get corona virus disase-2019.
- If it could be shown that someone is immune, no medical reason exists to limit someone’s freedom, provided (s)he is virus free (see item 8). These people might receive a certificate of being immune to COVID-19.
- Immune people are ideally suited for critical functions related to infection, such as healthcare and surveillance.
10. Measure how many people are immune.
- A few weeks I estimated that it millions of people in the Netherlands could be immune.[2] IF this would be true, this would be great news for population health, because a major part of the epidemic would be behind us. However, we do not know this, since we do not measure immunity.
- Knowing the fraction of people who are immune is crucial for epidemiological predictions (see item 6) and prevention policies (see item 7).
- If sufficient people are immune, we might investigate herd immunity.
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[1] https://hartblik.weebly.com/immuniteit-en-antistoffen.html
[2] Section 2 https://hartblik.weebly.com/ontelbaar-op-waarde-geschat.html
Where there's a will there's a way
Many people in society have called for their need of support, because of lockdown damage. The Dutch government has often listened carefully to these people. However, compensation should not have the highest priority of the government. We should focus to limit the lockdown and its consequences. After all, only once the epidemic is stopped, the total balance can be drawn up. The sooner the epidemic is stopped, the less the total damage is. To stop the loss, is a common gain.
Investments in testing are much less expensive than a lockdown, much easier to understand, much more enjoyable and it saves more lives. [1]
Investments in testing are much less expensive than a lockdown, much easier to understand, much more enjoyable and it saves more lives. [1]
John Jacobs, 11th of April 2020.
In collaboration with Platform Betrouwbare Zorgcijfers. An independent platform of people working in different heathcare functions with a common interest in reliable data on healthcare.
In collaboration with Platform Betrouwbare Zorgcijfers. An independent platform of people working in different heathcare functions with a common interest in reliable data on healthcare.
Two ways to limit disease spreading added 17th of April
The epidemic could be slowed down using generic and specific measurements. Here I focussed at specific measurements, since these are more suitable for a prolonged strategy. Generic measurements have severe side effects for humans, economy and society.
Generic limitation of the virus epidemic could be achieved by social distancing, wearing regular face masks and washing your hands.[1]
Specific measurements to limit the viral spread consist of three interdependent steps: extensive testing, rigorous contact tracing, and strict isolation of infected persons. Countries should prepare themselves for an epidemic,[2] but not all countries, included the Netherlands, were sufficiently prepared.
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[1] https://www.thelancet.com/action/showPdf?pii=S0140-6736%2820%2930918-1
[2] https://hartblik.weebly.com/voorkom-epidemie.html
Generic limitation of the virus epidemic could be achieved by social distancing, wearing regular face masks and washing your hands.[1]
Specific measurements to limit the viral spread consist of three interdependent steps: extensive testing, rigorous contact tracing, and strict isolation of infected persons. Countries should prepare themselves for an epidemic,[2] but not all countries, included the Netherlands, were sufficiently prepared.
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[1] https://www.thelancet.com/action/showPdf?pii=S0140-6736%2820%2930918-1
[2] https://hartblik.weebly.com/voorkom-epidemie.html
