20th APRIL 2020
GRADUAL EXIT FROM CONTAINMENT PREREQUISITES AND MEASURES
Members of the Scientific Council associated with this opinion:
Jean-François Delfraissy, President
Laetitia Atlani-Duault, Anthropologist
Daniel Benamouzig, Sociologist
Lila Bouadma, ICU
Jean-Laurent Casanova, Immunology/Pediatrics*
Simon Cauchemez, Modeller
Franck Chauvin, High Council of Public Health
Pierre Louis Druais, City Medicine
Arnaud Fontanet, Epidemiologist
Marie-Aleth Grard, Association
Aymeril Hoang, Digital Specialist
Bruno Lina, Virologist
Denis Malvy, Infectious Disease Specialist
Yazdan Yazdanpanah, Infectious Disease Specialist
French Public Health Correspondent: Jean-Claude Desenclos
The document is dated 20 April 2020. The opinion was finalised on 16 April 2020 and the technical data sheets and the international point on 20 April 2020. This opinion was sent to the national authorities on 20 April 2020 at 20H. Like the other opinions of the Scientific Council, this opinion is intended to be made public.The purpose of this Notice is to indicate the minimum conditions necessary to prepare consistently and effectively for the phase-out and controlled release of containment. This notice is organized in 2 parts:
(i) Minimum containment exit requirements, and (ii) containment exit scenarios. It is completed by a set of annexes.Jean-Laurent Casanova disagreed on the nature of the recommended masks for caregivers and the nature of the recommendations for digital tracing. His opinion is mentioned at the bottom of these points.
*Jean-Laurent Casanova disagreed on the nature of the recommended masks for caregivers and the nature of the recommendations for digital tracing. His opinion is mentioned at the bottom of these points.
This notice shall cover the two months following release from confinement.
Progressive and controlled relief does not mean lifting control measures
The Scientific Council would first like to clarify that preparing the conditions for the gradual release from containment does not mean announcing that the control measures against COVID-19 must be lifted. These measures must remain strong because too sudden a relaxation of control measures could result in a rapid increase in the number of cases and a return of serious cases in hospitalization and resuscitation.Thanks to containment, the transmission rate of SARS-Cov-2 in the French population has been reduced by at least 70%. This extremely large reduction in transmission has allowed the expansion dynamics of SARS-Cov-2 to be broken. It must be maintained over time in order to be able to largely reduce the number of resuscitation admissions for COVID-19 and more generally, the number of cases of COVID-19 in the national territory.At the time of release from containment, if all control measures are lifted at once, a second epidemic wave of COVID-19 is expected. Indeed, for a virus as transmissible as SARS-Cov-2, it is estimated that at least 70% of the population should be immunized to avoid an epidemic recurrence. Even if significant uncertainties persist on the current level of immunity in the French population, in any case, this level is much less than 70%, as it is between 5% and 20% depending on the more or less affected regions, with all the necessary caution.
The society’s adherence to strict containment measures that are difficult to tolerate in the long term
Considering the conditions for phasing out of containment must take into account not only the economic burden of containment, which is considerable but also the weight that containment places on society as a whole. For example, difficulties in monitoring other pathologies making it more difficult to manage in the epidemic context, or the increase of psychic disorders, sleep disorders, forms of violence as well as the consumption of drugs and alcohol, etc. Confinement weighs heavily on the general condition of the population and causes suffering for many of our fellow citizens, as has been pointed out
in previous opinions.
Objectives for a gradual and controlled release from containment
Release from containment should be seen as a continuation of the epidemic control strategy that was previously adopted, not as a break or a new strategy.
In the current state of knowledge, two main objectives must be pursued:
•Control of the epidemic: the virus will continue to circulate with different levels depending on the region. It is imperative to limit the appearance of new infections.
•Limiting the number of serious cases and deaths: The detected cases must have optimal management to avoid aggravation and death. It must also be ensured that the measures put in place are not accompanied by an increase in deaths due to causes other than COVID-19 due to a lack of prevention or management.In addition to these objectives, social and economic objectives must be integrated into strategic thinking.
Prerequisites and measures to be put in place before any progressive and controlled release from containment
In order to achieve these objectives and to gradually and partially relieve the constraints of containment while maintaining a low level of SARS-Cov-2 transmission, a series of prerequisites and measures to be implemented is proposed in this notice. It must be made possible to identify suspect cases on national territory as quickly and as comprehensively as possible to test them and isolate them if they are positive. Case contacts must also be identified, tested and, in turn, isolated.At the outset, the Scientific Council wishes to highlight the many challenges associated with the implementation of such measures. They must be backed up by extremely important technological, logistical and human resources, enabling them to cover the entire national territory efficiently and quickly. Digital tools also have an important role to play in enhancing effectiveness.
Given the characteristics of SARS-Cov-2, these measures will have to be complemented by other strong control measures, including the maintenance of significant barriers and social distancing measures and the protection of the most vulnerable populations. These measures may be strengthened or relaxed depending on the evolution of the epidemic.At this stage, given the many uncertainties, the great transmissibility of the virus, the unknown proportion of asymptomatic forms, the logistical and technological challenges, and the heterogeneity of the population’s adherence, the resurgence of the epidemic after containment remains possible. In such a case, a new containment cannot be excluded. Everything must be implemented to avoid such a scenario.Data available to date indicate that containment since March 17 has reduced virus transmission by 84%, with an estimated reproduction of 0.5 during containment, up from 3.3 before containment initiation. This resulted in a significant decrease in the number of ICU admissions from approximately 700 cases per day at the end of March to 220 cases per day on April 14. If this trend continues, it is expected to observe 10-50 ICU admissions per day on May 11. Given the length of stay observed, the number of beds occupied in the ICU could then be of the order of 1400-1900. This could be 1000-3000 people newly infected with SARS-Cov-2 per day on May 11. These assessments are likely to change significantly, particularly if there is a relaxation, even partial, of the application of containment (Salje et al, 2020). The proportion of asymptomatic carriers is still poorly known, estimated at around 20% or more, with all the prudence that this figure imposes (see Sheet 1).
MINIMUM REQUIREMENTS FOR RELEASE FROM CONTAINMENT
In this context, the Scientific Council wishes to emphasize that an exit strategy must ensure six distinct minimum prerequisites:
Prerequisite 1. Implementation of governance in charge of containment exit
• A unified and coherent national governance, including cases of regional variations.
• Impartial consideration of ethical issues, including digital tools, which should not stop the fight against the epidemic.
• Governance coordinated with other European strategies and taking into account the stakes of national or European sovereignty, in particular concerning the deployment of digital tools.
• Governance that is supported by the population.Phasing out containment requires consistent national governance. It aims to avoid or control the occurrence of new epidemics. In view of the strong territorial interdependencies, a clear national system must make it possible to implement a coherent strategy at the national level, including in the event of possible regional variations. In addition, a link with the measures taken in other countries, particularly in Europe, is also essential. Finally, the lifting of containment must be welcomed by our fellow citizens, who are called upon to take an active part in it. The governance chosen should ensure an impartial observance of ethical principles and involve the participation of citizens. The Scientific Council appreciates the establishment of the team with the Prime Minister which is responsible for preparing and conducting the release from containment.
Prerequisite 2. Hospitals and reconstituted health services
• Relieving resuscitation and hospitalization services, ensuring nursing teams are rested, stock of equipment, treatments and reconstituting protective equipment
• Intermediary facilities for the management of dependent elderly patients
• Urban medicine repositioned on the front line, with integrated digital patient tracking tools COVID-19 consolidated
The short-term objective of the confinement was to reduce the burden on French ICU services, by decreasing the arrival in ICU of patients with serious and critical symptoms. The exit from confinement can therefore only be done when the indicators of monitoring the hospital load in the resuscitation of hospitals located in epidemic areas show a return to an acceptable routine functioning. It will be necessary to ensure that hospital and non-hospital care teams have been provided with a sufficient recovery period to overcome the considerable effort made in the past few weeks.
Prerequisite 3. Ability to quickly identify cases, their contacts, and isolate patients and all contagious healthy carriers (see Sheet 4)
•Diagnostic capacity of new cases based on reliable and accessible RT-PCR tests throughout the territory, following a medical prescription.
•An effective system based on urban medicine, digital platforms, and mobile teams to identify suspected cases and direct them to test structures.
• Dedicated locations for the rapid diagnosis of suspected cases, with rapid transmission of test results to individuals, their doctors and surveillance systems for the follow-up of the epidemic.
• Telephone platforms complemented by mobile teams for the management of diagnosed cases and their contacts.
• Mobile teams and digital tools for efficient contact tracing.
• Accommodation facilities for people suffering from benign forms of the disease.
The availability of these tools is essential to consider a containment exit.
A rendering of the individual results of RT-PCR or serology should be implemented with real-time data transfer to epidemiological surveillance systems. These are essentially RT-PCR COVID tests that allow the diagnosis of infected people. The place of serology (search for anti-COVID antibodies) will probably have a more targeted role than hoped at the level of individual management.
Prerequisite 4. An epidemiological surveillance system capable of detecting new cases and a resumption of the epidemic (see Sheet 5)
• National coverage of surveillance of new cases, hospitalizations, and ICU admissions
allowing the production of regional, departmental and even territorial indicators (large
• Monitoring of COVID-19 mortality and other causes.
• Serological surveys allowing the monitoring of the acquisition of immunity in the population (serological test looking for anti-COVID antibodies).
The system of collecting the most sensitive indicators, such as the number of new cases on the national territory and the number of new hospital admissions, must be consolidated in order to ensure extremely strict control of the epidemic. Surveillance must make it possible to identify places at risk of transmission or even epidemic.
Finally, it is urgent to build a database in a first-time hospital, allowing to have, in real-time, characteristics of patients hospitalized for COVID-19. This database, which is linked to the SNDS, will be used to describe patient trajectories and to identify risk factors for serious cases, as well as to assess the possible poor management of other pathologies.
Prerequisite 5. Epidemiological criteria
Containment removal must be managed by monitoring epidemiological parameters to assess the performance of the new case identification system, the epidemic risk and the health risk. For containment removal to be carried out in good conditions, it is necessary that:the daily number of hospitalizations and admissions to resuscitation for COVID-19 must be low;
• The daily number of hospitalizations and admissions to resuscitation for COVID-19 must be low;
• The number of breeding on the territory must be less than 1 (R<1);the number of occupied and available resuscitation beds allows for the management of COVID-19 cases, especially if there is an epidemic recurrence, as well as for other serious pathologies.
The first set of indicators makes it possible to measure the level of circulation of the SARS-Cov-2 virus in France. If there are too many people infected with SARS-Cov-2 on the national territory, the capacities may be insufficient to quickly identify, test and isolate these people and investigate their contacts. The exact level of circulation for successful containment removal will depend on the ability to quickly identify cases, their contacts, and isolation at the time of containment removal. For example, while we wait for 10-50 COVID-19 admissions in resuscitation per day, there could be 1000-3000 people infected with SARS-Cov-2 per day on the national territory. When containment is lifted, the government must ensure that it has the means to detect the significant proportion of people infected with SARS-Cov-2, in a context where other respiratory viruses can circulate. One criterion could be that the number of confirmed cases per day is relatively close to the number of infections expected per day. The latter number can be estimated based on mathematical modelling. The second indicator, the number of breeding on the territory, makes it possible to understand the impact of control measures on the epidemic dynamics and to anticipate a resumption of the epidemic. The latest indicators, the number of occupied and available ICU beds, are essential to ensure that ICU resources are sufficient to manage COVID-19 cases but also other serious conditions.
Prerequisite 6. Availability of physical protection gear stock for the entire population
•¹FFP2 and/or surgical masks be made available and accessible to caregivers and people at risk of contamination depending on the context(WHO, 2020; recommendations from different learned societies and/or health agencies)
• alternative masks of industrial or artisanal anti-projection production available for the whole population and distributed in priority to people in regular contact with the public.
• education on the use of masks to the general population.
All these elements constitute this prerequisite for the containment exit. It should be noted that we do not currently have solid data on the effectiveness of alternative masks; the results of the effectiveness of alternative masks evaluated by health agencies will be available soon. Stockpiles of equipment, specific resuscitation treatments, and protective equipment (masks, etc.) will need to be adequately replenished, both for the target individuals (hospital and non-hospital care staff, people with increased exposure to the virus as a result of their work), then for the general population, according to their needs. The whole population must wear a mask in spaces welcoming the public (closed spaces, especially in transport, shops, etc.). This reduces the transmission of droplets and possibly aerosols. In the most affected areas, beds, 2 trained staff and dedicated equipment, including respirators, must be available in sufficient numbers. For the general population, the reinforcement of barrier measures is dependent on the availability of hydro-alcoholic solutions in public places and handwashing points in places that do not. The availability of masks is an additional measure compared to the barrier measures that remain the key element.
SCENARIOS FOR CONTAINMENT EXIT (THE FIRST TWO MONTHS)
The government will have to ensure that all the prerequisites as detailed above are operational at the time of release from containment. In terms of timing, it seems difficult to envisage, in the current state of knowledge that these prerequisites can be fulfilled before, at best, May 2020. Available epidemiological data suggest that containment since 17 March has reduced virus transmission by 84%. This resulted in a significant decrease in the number of emergency room admissions for suspected COVID-19, the number of COVID-19 hospitalizations, and finally the number of COVID-19 resuscitation admissions. The saturation of the resuscitation beds by COVID-19 patients will nevertheless continue for a few weeks, as patients with severe forms of inflammatory pneumonia require prolonged ventilation.
Three scenarios are possible:
i. Strict containment continued until the number of new cases is extinguished;
ii. The total exit from containment to acquire collective immunity but with an unacceptable risk of extremely high mortality;
iii. The continuation of the strategy with a gradual, cautious and monitored removal of containment and adaptation of measures according to epidemiological results.
Only the latter scenario was chosen by the Scientific Council and it is presented below.
This scenario is proposed for the two months following release from containment. The Scientific Council considers that it is impossible at this stage to estimate the evolution of the epidemic beyond this period. Only strict and regular monitoring of the spread of the epidemic will make it possible to adapt the proposed measures. The Scientific Council assumes that for this period there will be no curative or preventive treatment or vaccine.
The Scientific Council proposes the first draft of a containment exit scenario, based on the current state of knowledge. This scenario shows the big trade-offs that must be made for a successful exit from containment.This scenario will evolve in the coming weeks as
i) the operational aspects of its implementation will be implemented and the performance of the new control systems will be evaluated,
ii) the exact level of immunity in the population will be better known,
iii) new studies will refine our understanding of the impact of the various control measures,
iv) the adherence of the French population to the control strategy will be known.Moreover, in the coming months, the control strategy will have to remain very flexible and adapt rapidly to the evolution of the epidemic and the latest advances in research. The impact of the various control measures will have to be assessed in order to gradually optimize the control strategy.
The Scientific Council proposes a containment exit strategy based on:
1. Identification of the broadest possible cases allowing for early diagnosis and the implementation of isolation measures;
2. Identification of contacts of diagnosed cases to allow for systematic detection of the presence of the virus, and isolation in case of positivity, including for asymptomatic persons;
3. Systematic measures to reduce the risk of transmission in the general population applied for several months depending on the kinetics of the epidemic, the wearing of a mask in public places and the maintenance of the rules of hygiene and social distancing;
4. Specific measures to control the epidemic by sub-populations taking into account the age and social situation;
5. Regular interval surveys to estimate immunization in the population. These measurements can be located if a cluster is detected.
The Scientific Council recommends that the exit from containment be carried out throughout the national territory. An exit of containment by regions does not appear realistic as an instrument of control of the epidemic because it would imply a very fine sanitary and epidemiological monitoring at the regional level. This does not exclude regional or even departmental variations, depending on the level of circulation of the virus. It should be noted that the restart of the epidemic will require a strengthening of measures to control the epidemic or a new territorial or national containment. In this sense, particular attention should be paid to regions with high population density and/or high viral circulation.
1. Case and Contact Identification and Isolation: Test and Isolation Strategy (see Sheet 3 and Sheet 4)
This is essential to maintain control of the outbreak during the containment period. Its strict application is essential.
This measure is based on:
•Voluntary reporting by any person presenting a suspicion of cases to the health authorities (call from the general practitioner, digital diagnostic aid system, telephone platforms, etc.).
•Referral of any potentially infected person to an RT-PCR COVID diagnostic location or a rapid diagnostic point when available on medical prescription.
•The fastest possible alert for people diagnosed positive by phone or SMS.
•Isolation of suspect cases at home until results are available
•The immediate isolation of confirmed cases under conditions adapted to the environment of the person concerned, which can range from hotel-type places to strict confinement in the habitual residence.
The process for monitoring and isolating contacts must be based on: •The earliest possible identification of contacts of detected cases.
•The combination of two complementary approaches: intensive investigation around all new cases and mobilization of digital tools under development.
•A diagnosis of the presence of the virus by RT-PCR COVID. Rapid tests that have been validated would probably only be available in a second time.
•If the contacts prove to be positive, then they are cases and the above process is again engaged for their contacts.
•If the close contacts (cf. the definition of cases and contacts given by Public Health France) are negative, about 14 days quarantine at home must be respected.
a) Principles of Implementation
The application of such a device has made it possible to control epidemics such as SARS, MERS-COV and Ebola. For SARS-Cov-2, which has particularly high transmissibility and can be done in the absence of symptoms or before the onset of symptoms, such a device is theoretically likely to significantly reduce transmission of the virus only if it is able to affect a high proportion of cases and their contact (Hellewell J. et al., 2020). To date, it has shown its effectiveness on the ground in Korea and Norway at the cost of a very strong mobilization, not only digital but also human and societal. The high level of coverage, responsiveness and buy-in of the people concerned means mobilising a transparent organisation with proactive communication, technological resources, logistical, and humane, which is particularly important at all stages of the process. Perfect integration between the steps of the process will be a key element, in particular with the production of the results of the COVID RT-PCR tests and the availability of the contact details of the people tested positive. The digital tool can be decisive to strengthen the overall effectiveness of the system, by complementing the actions carried out elsewhere in the field. In practice, this involves implementing a professional public health service to detect, monitor, isolate cases and their contacts. This service will have to be created on the basis of a clear expression of objectives and needs and meet a specification whose principles are indicated above.This service would be based on:
•Regional and/or territorial professionalized platforms linked to the results of the tests and with the information to call the listed cases and their contacts and to propose for each of the identified persons an effective and adapted isolation solution. The issues of protection of the identity of individuals and confidentiality of data concerning them must be controlled with the highest level of security as for any activity of a medical nature.
•Mobile contact tracing and isolation teams, in particular to target isolated or precarious
populations or in case of outbreaks of transmission (clusters). These teams are complementary to the aforementioned platforms and would be coordinated directly with them.
•Digital tools under development (see below). The two approaches (digital tools, platforms and mobile teams) are complementary and potentially affect different audiences. The combination of the two approaches should make it possible to reach all residents on the national territory even those who do not have a smartphone.
These infrastructures and teams will have to be put in place, coordinated and animated at the different regional and territorial levels closest to the population. They will mobilise the public health resources of the state, local authorities and municipalities. They may be formed by the mobilization of doctors, paramedics, volunteers and personnel to be recruited. Operational training providing the data confidentiality requirements must be formalised and provided to each of the components of this service
in terms of contact tracing, risk assessment based on reference systems, conduct delivery to be maintained in terms of isolation and orientation towards diagnostic and clinical care of proximity (general medicine, etc.).
This service must be known and understood by the population as a whole, especially by those who are least socially privileged. There will be a need for transparent and appropriate communication, particularly in the area of literacy. It will have to use multiple complementary approaches including the active involvement, as early as possible, of the entire medical community, in particular of the urban medicine.
b) A specific place for digital tools (see Sheet 6)²
At the same time, digital tools provide the public with simple ways to determine whether one is a probable case, in this case being oriented towards test sites, quickly obtaining the result of one’s test, being followed medically if one is positive, learn if you have been in contact with a case and more generally assess the risk of infection to which you have been exposed. Digital tools also have a key role to play in supporting logistics, including testing, rendering test results, managing hospital resources
The Scientific Council sees digital tools as a very useful part of the epidemic control strategy. In support of the other recommendations, given the significant risk of a second epidemic wave and new containment, the Scientific Council considers that the digital tools to improve the effectiveness of health control should be deployed in France, in consultation with the European institutions and European countries if possible. These tools must be part of a comprehensive health control strategy, of which they are only one element. It will be necessary for people using these digital tools to be able to contact a telephone platform (see above) whose function will be to respond in a personalized way on the conduct of isolation and to accompany and support them in this perspective.
These tools are not technologically neutral, especially since they use a variety of instruments (mobile applications, platforms, algorithms, software, extremely varied datasets) that can give rise to a wide variety of organizational uses, clinics or public health. They can raise acute legal and ethical issues that need to be addressed to strengthen public and health staff buy-in for their use. In this regard, the Council insists on the importance of working on devices that are also designed to benefit the millions of
our remote citizens. Health effectiveness is achieved through adherence, inclusion and transparency. In view of their sensitive nature, the Council considers that these tools should be put into service and managed by public health authorities and that their deployment should be limited to the period of the state of health emergency and be framed by clear governance, open and transparent to encourage our fellow citizens to support their public health goals.
2. The general rules of containment lifting: maintaining social distancing and reinforcing barrier gestures
Only compliance with rules strictly limiting the circulation of the virus makes it possible to consider lifting the containment.
a) Strict compliance with barrier measures
This respect is essential in controlling the epidemic. This will include maintaining the social distancing rules developed and implemented in recent weeks (maintain a physical distance of at least one metre on each side, do not shake hands, do not kiss, do not hug, telework, school closures, the prohibition of gatherings, closures of gathering places, closure of certain types of trade…).
The principle is the respect of the minimum distances (at least 1 meter on each side) to avoid respiratory and manual contamination by droplets. This principle must be respected in all public places, businesses and public transport. Hydro-alcoholic gels and masks for the use of health care personnel, people exposed to the virus, and more generally of the population will have to be available without risk of supply disruption. In particular, it is necessary to provide a sufficient number of physical protection material accessible to the whole population.
Places receiving the public must offer protective equipment for customers or residents: protective masks and hydro-alcoholic solution. Failure to comply with these rules must lead to administrative closure of these premises.
The wearing of an individual mask in places receiving the public must be systematic during the post-confinement period. Only a continuation of the low-level epidemic monitoring indicators for several weeks could lift this measure. The Scientific Council wishes to emphasize the feeling of security wrongly given by wearing a mask. It is effective when coupled with strict respect for the confinement measures and social distancing and the respect of the instructions of use.
(b) Places that are in confined spaces
It is suitable for each to strictly respect the physical distance rule of one meter on both sides in all places outside his home, including in closed or confined places if he is close to persons outside his intra-family home. Confined places correspond in particular to workplaces and all establishments receiving the public. In the absence of compliance with these rules, the risk of transmission of the virus between people remains very high.The Scientific Council considers that strict compliance with all rules is mandatory (social distancing, mask, gel, etc.) for a careful and progressive opening of businesses. With regard to the places remaining open, the control of the measures implemented by their operators and their effective respect (display of information on barrier gestures and physical distance rule of one meter on each side and another maximum density rule of people in these different places, etc.) is the responsibility of the authorities who must consider conditions for their application.The Scientific Council calls the attention of the authorities to the particular issue of public transport. Failure to comply with distance rules a metre on both sides whether or not users wear a mask of protection (is an important vector of virus transmission, both in terms of speed than volume) which could lead to the uncontrollable recovery of the epidemic.
c) Continued closure of public assembly sites
The Scientific Council considers it necessary to keep closed or banned all places and events that have as their object or consequence to bring the public together in numbers, whether they are in closed rooms or outdoor spaces.
3. General Travel Rules
The movement of individuals is a potential source of circulation of the virus and therefore of reappearance in areas with high circulation. This opinion concerns, as a reminder, the strategy for the two months following the release of the containment.
a) Urban and peri-urban transport
It is proposed to allow urban and peri-urban travel as long as the above-mentioned barrier measures and social distancing rules are respected. If the resumption of work is contained by telework-type measures (see below), maintaining the usual transport rates will limit the concentrations of passengers in confined spaces at high risk of viral transmission.
b) Inter-regional transport
It is proposed to allow interregional travel by public transport once again, as long as the barrier measures and social distancing rules are respected (cf. supra.). The occurrence of a regional epidemic outbreak can lead to a resumption of local containment rules and the suspension of inter-regional transport.
c) Transport between the metropolitan area and the ultra-marine territories and departments
The Scientific Council delivered a specific opinion on these territories and departments. It stresses the need to protect these territories and departments by applying strict rules of fourteen and diagnostic at the arrival of travellers.
d) International transport until summer 2020
The aim is to reduce the risk of reintroduction of the virus on national territory.
These movements are strongly discouraged during the months following the release period. Travelers are exposed to a risk of quarantine upon arrival in the destination country, a risk of contamination during the stay and the application of quarantine measures upon return to France. This policy should particularly target people coming from areas (EU or non-EU) with a high circulation of SARS-Cov-2, as well as from areas or countries (EU or non-EU) according to the degree of strict health control at their borders. Several intensities of controls can be considered, up to the systematic quarantine of people from areas with a high circulation of SARS-Cov-2 and/or without strict health control of their bordersConcerning mobility in the euro area, measures to diagnose and isolate people from outside the euro area. The European Union must first be harmonised on a sufficiently high standard to allow sufficient control of the epidemic within the intra-European area before it can be envisaged to allow movement without health checks at the entry of the national territory.
Travel abroad will in all circumstances have to respect the rules regarding travel abroad during the period of COVID-19 stipulated by the Ministry of Foreign Affairs.
Upon return, persons arriving on French territory must be subject to:
•A COVID RT-PCR diagnosis;
•Strict isolation if the diagnostic test is positive;
•Voluntary isolation at home if the diagnostic test is negative.
4. Rules applicable to specific populations at risk of serious forms and/or risk of transmission (see Form 2)
The different populations involved present different risks that make it possible to propose differentiated provisions:
a) People over 65 and/or with chronic conditions
Some of our fellow citizens are at higher risk of serious illness and death due to age or health (chronic at-risk conditions such as high blood pressure, diabetes, coronary heart disease or cancer being treated, etc.). 82% of deaths were observed in hospital in patients over 70 years of age. The population at risk of severe forms requiring hospitalization or ICU care is for people over 65 years of age, 800,000 of whom live in accommodation facilities for dependent elderly people. People with long-term illnesses and 160,000 people with disabilities living in community housing facilities. In total, this population is estimated at nearly 18 million people.
In the exit phase of containment, many people carry the virus and are therefore potentially contaminating, even when they show no clinical signs. These individuals are at a very high individual risk of developing serious symptoms. They need to be informed. However, this population does not have a higher risk of transmission of SARS-Cov-2 to other citizens. The Scientific Council advises these people to respect a strict and voluntary containment, which protects them from contamination risks. Unlike mandatory confinement, voluntary confinement is not intended to curb the epidemic; it allows people to protect themselves on the basis of an informed personal choice. This choice must be available to those at risk who are working.
The situation of persons residing in collective accommodation facilities must also be carefully considered because the risks are not only individual but also linked to the organisation of the establishments. In collective hosting structures, the diagnostic strategy of cases and contacts must be strictly applied. Upon diagnosis of a contaminated person, he/she must be isolated in an ad hoc structure until recovery. In this case, all persons in the structure must be diagnosed by an RT-PCR test, including caregivers and
administrative staff.For older people residing in facilities with dependent elderly people (EHPAD), the risk of transmission is significantly higher for both residents and caregivers. In view of this factor and the risk of serious forms, it is necessary to continue to confine the residents, although they must urgently find means of social liaison between the residents and their families (visual visit, RT-PCR COVID diagnostic tests before a physical visit, etc.). Strict adherence to barrier measures must be maintained to minimize the risk of virus intrusion into still healthy institutions. A minimum number of visits is likely to reduce the suffering of residents and to avoid very harmful or even fatal "slips", at least in regions where this is possible.
b) Populations under 25 years of age
In the current state of epidemic knowledge, the risk of serious symptoms is low in this population. The risk of individual contagiousness in young children is uncertain but appears to be low. On the other hand, the risk of transmission is high in places where schools and universities form a large group, with measures that are particularly difficult to implement among the youngest.
As a result, the Scientific Council proposes to keep nurseries, schools, colleges, high schools and universities closed until September. Societal issues also exist, particularly for children who, as a lack of school can lead to situations of abuse.
The Scientific Council takes note of the political decision taking into account the health issues but also societal and economic, of the progressive and prudent reopening of nurseries, schools, colleges and high schools. For nurseries, schools, colleges and high schools alternative solutions allowing reception and learning while respecting the measures barriers and distance can be considered. In this case:1) These establishments must imperatively put in place the necessary conditions for their reopening: compliance of sanitary facilities in schools, provision of hydro-alcoholic solutions, the arrangement of rooms allowing the respect of interindividual distances etc., and 2) the measures barriers will have to be pursued in a reasonable and individualized way at the home of the children to avoid the risk of contagion in the context of the family home.
In addition, the Council calls for special vigilance to maintain the continuity of all child welfare services. This continuity must be accompanied by a clear reference of the persons and services or structures that can be reached. This listing will be communicated to all children, families and professionals concerned. It will be accessible online.
The Scientific Council proposes that epidemiological and virological pilot surveys (RT-PCR and serology) be carried out urgently and iteratively on this population. A more precise note on the procedures for reopening schools and colleges is being prepared.
c) Persons aged 25 to 65 years with no chronic diseases
This is a normal working population. These people have a limited risk of serious form but sufficient to succeed in case of massive contamination like the one known before the confinement period in some regions (Grand Est, Ile de France), a new saturation of hospital services and consequent mortality. It is, therefore, possible to consider lifting the containment subject to the general rules outlined above.For administrations, it is proposed to maintain Business Continuity Plans allowing for teleworking for a significant proportion of staff.
For companies, it is proposed to maintain teleworking where possible, on all or more than half of the working time. For shops, craftsmen, etc., it is proposed to resume an activity scrupulously respecting the rules of social distancing and the use of masks in shops, workshops etc. which must be organized accordingly.
The aim is to gradually resume a face-to-face activity involving, if possible, only half of the workers.
d) Precarious or homeless persons
The Council has already stressed the fragility of these people in epidemic situations. In addition to the consequences of their personal health, their living conditions reinforce their vulnerability to contamination and thus to the recovery of epidemic outbreaks. It is necessary to protect the populations most at risk of the epidemic due to their habitat situation with targeted efforts (e.g.: in situations of great insecurity, prisons, people in institutions).
e) People who developed COVID-19
In the absence of scientific certainty at this stage on the acquisition of protective immunity in people who have developed COVID-19, it is proposed that the general measures be applied including to those immunized people.
5. Regular interval surveys to estimate immunization in the population including children
It is essential to have an estimate of the proportion of the population that has acquired immunity to the consequences of the first epidemic phase according to the regions. Serological tests are currently being validated, for some already existing and likely to be deployed on a large scale within a few weeks.
Knowledge of the level of immunity of individuals and the population is essential to follow a strategy of phasing out containment. These tests are a tool for epidemiologists and have a reduced utility for individual management.
6. The implementation of targeted communication for different target audiences
All the measures proposed above must be accompanied by appropriate and renewed communication in order to strengthen the support of our fellow citizens. This communication should be based on repeated assessments of the public’s knowledge, perceptions, attitudes and practices, and use available communication and public health knowledge. It must be stable and in the long term, corresponding to the prospects of returning to normal, even if it is to be shortened later, rather than the reverse, each extension representing a significant cost in an emotionally sensitive context. It must make use, in a differentiated manner according to the target groups, of the available knowledge on communication and public health.
The Scientific Council identified six prerequisites for mobilizing sufficient resources to implement a strategy to exit containment. These epidemiological and operational requirements must be met before a release of containment can be authorized. Otherwise, significant risks would be taken. Other parameters such as the incidence of diseases other than COVID-19, but also the economic and social impact of the health crisis, must be taken into account in this period.
The Scientific Council proposes a scenario of phase-out of containment for the next two months based on the application of measures whose intensity can be modulated over time according to the monitoring indicators. All these six measures must be implemented and followed up so that such a strategy is not only coherent but also effective. Specific data sheets on tools, instruments and measures are proposed in the Annex. The implementation of these measures and the longer-term perspective will be reviewed in future notices.
The risk of release from containment is that of a second epidemic wave, particularly if, as is likely, collective immunity remains low. If the early epidemiological indicators based on extensive diagnostic testing (RT-PCR) showed a resumption of the epidemic, it would be necessary to apply stricter social distancing measures up to a new containment. It could be partial or generalized. It could be regional or implemented in a specific territory. This scenario must be avoided, both from a health and economic point of view.
In the current state of knowledge, the only possible strategy is a gradual exit from the containment taking into account the risks of the different populations to adapt the protective measures.
3 key points
1. The Scientific Council stresses the importance of implementing the necessary actions to ensure that the 6 prerequisites are met, and the 6 key measures of the recommended scenario are operational before considering an exit from containment.
2. The Scientific Council highlights measures such as case screening, the possibility of screening for hospital and non-hospital caregivers, expanded screening in EHPAD-type containment sites, etc. can and should be implemented now, without waiting until mid-May. This will allow for a gradual increase in load and facilitate steering.
3. The Commission considers it essential that civil society is involved in this process and its implementation, with the creation of a Community Liaison Committee. “Trust to maintain trust”
INSTRUMENTS AND STRATEGIES FOR THE CONTROL OF EPIDEMICS/COVID-19
I. THE INSTRUMENTS
3 instruments contribute to the non-targeted limitation of the number of new cases:
1. Social distancing. The strategies of individual distancing (restriction of inter-individual contacts) or collective (restriction of social life, more or less strict forms of containment) make it possible to fight effectively against the transmission of the virus. It is possible to scale the intensity of these social distancing measures.
2. Material protection. These include public health measures, barrier gestures, the use of hydro-alcoholic solutions, or the deployment of protective equipment, including masks of various types.
3. Immunization. Immunization can be acquired naturally through direct contact with the virus or through vaccination. There are currently no vaccines available for COVID-19. Serological tests are used to detect immunization acquired after exposure to the virus. These tests can be used on a large scale after the qualification of the solutions under development.
4 instruments allow a targeted limitation of new cases by identifying cases and their contacts:
1. Virological tests for diagnosis of acute forms, making it possible to make the diagnosis of people carrying the virus and therefore contagious (existing PCR tests and possibly rapid antigenic tests to come)
2. Contact survey technologies. These investigations are an important part of controlling an outbreak when it is either at its beginning or at its end to identify and control residual cases.
3. Digital technologies for probable case diagnosis and contact identification. Digital tools downloadable on smartphones offer diagnostic help to relieve congestion in call numbers like the 15. Other tools allow the identification and alert of contacts of a confirmed case.
4. Isolation of contacts or COVID+ patients. The use of the solutions described above is of interest only if a proactive policy of containment of cases and contacts is applied, the only one capable of allowing control of the epidemic.
2 instruments to limit the impact in terms of mortality:
1. Hospital-based care and resuscitation capabilities directly impact the number of deaths. In addition to this hospital capacity, extra-hospital courses using ancillary units (COVID-Anciens SSR) are being set up in certain regions.
2. Drugs. There is currently no effective drug for COVID-19. Once available, a more or less active drug may play a decisive role in limiting the impact of the epidemic (i) by avoiding the evolution of benign cases to serious forms requiring hospitalization and (ii) by rapidly decreasing the viral load, certain anti-viral treatments that also reduce the contagiousness of cases.
Different strategies can be adapted to control an epidemic. These strategies are not exclusive and are adapted according to the evolution of this epidemic assessed by its transmissibility, the number of new cases and its geographical distribution.The ultimate goal of these strategies is to completely suppress circulation and lead to the absence of new cases.
The natural evolution of the epidemic
A strategy to control an epidemic must be compared with the evolution that would be observed in the absence of intervention. For COVID-19, the natural evolution of the disease implies a spread of the epidemic until the development of a collective immunity preventing the spread of the virus in the population. Given what we know about COVID-19, only immunity of at least 60% of the population would allow protection that could stop the epidemic (cf. previous opinions of the Scientific Council).
To date, no country has maintained a strategy based solely on the development of collective immunity when the number of hospitalized and deceased has increased substantially. The rate of spread of the disease and its lethality rate close to 1% prevents this option from being considered. Faced with this natural evolution of the disease, two approaches were proposed: the Chinese strategy in Wuhan and the strategy implemented in Korea.
The strategy of extinction of the epidemic
This strategy consists in stopping the spread of the virus until no more transmission of benign cases or complicated hospital cases. The objective is to flatten the appearance curve of new cases. The protection of the population is not achieved by the development of collective immunity but by the suppression of circulation in the population. This risk suppression involves drastic measures to prevent the virus from circulating outside a nearby family environment. This strategy is therefore based on strict containment (without exit for any reason), important control measures and systematic detection and
management of cases.
To be effective, this strategy presupposes that the measures are maintained for a long enough period of time to virtually stop the circulation of the virus. Wuhan’s Chinese experience shows that 10 weeks of confinement seems necessary to achieve this goal (Fineberg, 2020) and to find that the virus is not circulating. Finally, when the measures are lifted, it is necessary to maintain a very strict device preventing any new circulation of the virus.
Often used at the beginning of the epidemic, this strategy involves implementing very important means of control by reducing individual freedoms (freedom to come and go in particular) and by very strongly restricting the activity of a region or a country.
The epidemic risk control strategy
This strategy aims to slow the progression of the virus, without the objective of stopping it completely. It is based on the activation of the different measures (cf. supra) according to the speed of circulation of the virus. This reduces the pressure on the health system and allows research teams to develop preventive (vaccines or drugs), therapeutic (drugs) or diagnostic solutions (tests, digital solutions, etc.).
This strategy implies accepting, in the current state of knowledge, that a number of serious forms of death occur as a result of the low-noise progression of the epidemic. The intensity of control exerted on the circulation of the virus will condition the observed results.
In summary, only China in the Hubei region and specifically in Wuhan has chosen a strategy of extinction of the epidemic from the outset. This strategy was based on a very strict, controlled and prolonged containment until the disappearance of the virus transmission measured by the disappearance of new cases, that is 10 weeks before a gradual lifting.
Many other countries have implemented a strategy to control the epidemic with the eventual goal of extinction. Several countries, such as Korea, Singapore, Hong Kong and Taiwan, have so far managed to contain the COVID-19 epidemic without resorting to containment. These countries rely on the combination of strong control measures accompanied by a significant deployment of technological and human resources. New digital tools strengthen epidemic control performance. These examples suggest that an epidemic control objective can be achieved with very restrictive measures but without general containment of the population.
THE DIFFERENT POPULATIONS CONCERNED IN FRANCE
Epidemic control tools can be targeted differently depending on the risk of developing serious forms of the disease.
Populations at high risk of serious forms and death
Age appears to be a risk factor for severe forms of COVID-19 with lethality rates for clinical forms of infection close to 15% in people over the age of 80, compared to 3/1000 (0.3%) in people under the age of 60 (Verity et al, 2020).
The presence of comorbidities is another risk factor for severe forms. The main comorbidities are high blood pressure, diabetes, coronary heart disease, and overweight. It should be noted that there is no French data to establish risk scores at this stage.
In France, 82% of patients who died in hospital were 70 years of age. Moreover, only 10% of the people who died in France were under 70 and 4% under 60. The proportion of patients admitted to resuscitation was as follows: 1% in the under 15 years: 1%, 15-44 years: 8%, 45-64 years: 29%, 65-74 years: 36%, and over 75 years: 26%. The average age of people admitted to ICU was 65. Age is therefore a major risk factor for death and serious forms, many of which are not managed in ICU in people over the age of 70.
Among 1099 infected patients documented in the Chinese study, the frequency of comorbidities was 39% in severe forms. An unfavourable trend (defined by a composite criterion: admission to resuscitation/ assisted ventilation/ death) was noted in 58.2% of cases in the presence of comorbidity, compared to 21.5% in the absence of comorbidity. The main comorbidities are high blood pressure, diabetes and coronary heart disease.
In the absence of reliable data in France, it can be noted that 5 million people under the age of 65 are carriers of long-term conditions. Add all people treated for high blood pressure who do not fall under ALD 30, especially for medium and severe forms.
In France, for example, 18 million people are at higher risk of serious forms or death. Of these, 14 million people are over the age of 65. In addition, 700,000 seniors live in accommodation facilities for dependent elderly people.
Active and low risk or moderate risk population
People aged 20 to 65 (43 million people) without comorbidities have a low or moderate risk of serious forms of death. Moreover, they have no particular risk of contamination and carry out an activity that can be completely or partially dematerialised.
Some of this population is not or is only very little affected by the current containment. This is the case for hospital and city caregivers and auxiliary workers, especially in public places that are exposed to high viral load environments and therefore to a high contagious risk.
Others work in strategic areas that cannot be dematerialised.
School and University Youth
This population (15 million people) is at little risk of serious forms but is exposed to a high risk of contamination and can be a vector of contamination to older people. Schools and universities are places at significant risk of contamination.
The immunised populations
In the absence of a vaccine, only contact with the virus can lead to immunisation that can protect individuals. Based on the surveys carried out in late March and early April 2020 in the regions most affected by the epidemic, it can be estimated that the proportion of subjects carrying antibodies is less than 15% in these regions. Therefore, we can think that the collective immunity, which should be of the order of 60% of the population to be effective, will not contribute or little to the control of the epidemic when leaving confinement.
Principles for a successful exit from containment for people at risk of severe forms
It is important to recall the severity of COVID19 for people at risk as previously defined. Exit from containment must therefore be considered according to the following principles:
-If the first phase of containment was to reduce the circulation of the virus by decreasing the inter-personal relations, the exit from containment raises the question of the protection of the people most at risk.
– The protection of fragile people at risk of serious forms requires the reduction of the risk of contamination, in particular by carriers of the virus presenting no symptoms.
– This protection can only be a voluntary attitude on the part of the people concerned.
– Collective housing conditions that may promote the risk of contamination of people at risk of serious forms may require maintaining significant barrier measures.
Proposals for containment exit conditions
The Scientific Council wishes to reiterate that the following proposals are valid for the two months following the release from containment. At the end, they will have to be reconsidered according to the circulation of the virus.
Persons in employment with risk factorsThe Scientific Council recommends that an individual risk assessment be carried out by the treating physician before 11 May for people with ALD, receiving long-term treatment, over 65 years of age or who consider themselves at risk. This assessment should take into account the pathology and treatment received, the work situation and the geographical situation (active or not circulation of the virus).
The Scientific Council considers that, in the current state of knowledge, teleworking must be promoted for this category of persons but that it is possible, depending on the individual risk assessment, to consider either a work stoppage or a face-to-face work, the occupational doctor must then ensure that the barrier measures are strictly observed at the workplace.
Persons over 65 years of age or who have risk factors but do not work
The Scientific Council recommends that, in the state of knowledge, these people avoid the risk of contamination, in particular by asymptomatic carriers, by adopting a ‘containment’ voluntary during the weeks following release from confinement and close contact with children potentially presenting a particular risk due to the frequency of asymptomatic forms. This voluntary confinement therefore consists in limiting to the maximum the risk of contagion in places with high frequentation.
People at risk of serious forms in collective accommodation
The Scientific Council considers that in the state of knowledge these establishments must avoid the risk of contamination of residents by detecting positive people as quickly as possible by extensive practice of diagnostic tests by RT-PCR according to the rapid investigation methods proposed upon release of containment, and by immediate isolation of cases of COVID-19 confirmed by these tests.
Persons residing in care facilities for dependent elderly persons (EHPAD)
The Scientific Council considers that, in the state of knowledge, these establishments must maintain containment measures to protect the residents of these establishments from contamination. However, the Scientific Council considers that prolonged confinement in these establishments can be a source of long-term deleterious effects (social isolation which can lead to sliding syndromes in the elderly and a mobi-mortality unrelated to COVID-19). From 11 May, the resumption of visits should be considered. The arrangements for the organization of visits must be done on a case-by- case basis and in conjunction with the supervisory authorities (ARS and departmental councils) and under sanitary conditions that allow strict respect for social distancing and barrier measures.
The extensive practice of diagnostic tests by RT-PCR at the first signs suggestive of COVID19 impairment in both a staff member and one of the residents must allow for any significant risk of contamination.
SEROLOGICAL TESTS: LIMITS AND USEFULNESS
At the beginning of a pandemic, the entire population is “immunologically naive” to the pandemic virus. This means that no one has protective antibodies, which allows the virus to spread massively throughout the population. The detection by serological testing of specific antibodies to the circulating virus makes it possible to confirm retrospectively the diagnosis of infection in an individual, Igg antibodies are detectable 15 days after infection in the vast majority of patients with severe forms of COVID-19. For those who have made benign, even asymptomatic forms of the disease, the detection of antibodies may be later and requires more sensitive tests.
The current data available does not yet allow to know the duration of protection conferred by antibodies developed by people infected with SARS-Cov-2. Experience from other seasonal coronaviruses (OC43, 228E, NL63 and HKU1) suggests that infected individuals will benefit from short-term protective immunity (at least a few months). The measurement of antibody titers and the analysis of their neutralizing capacities, will allow to better estimate the duration of protection. The exact protective value of these antibodies is not yet known.
The ability of a serological test to detect antibodies in an individual carrying antibodies is called test sensitivity. The ability of a serological test to declare an antibody-free individual when it does not have one is the specificity of the test. The tests now available and intended to be widely used are field unit tests and automated laboratory tests of the ELISA type. The sensitivity and specificity of field unit tests will likely be lower than that of ELISA tests, making them less accurate and informative.
Two uses of serological tests are possible: individual and collective. The individual tests will allow a subject to know if he has been infected with the new coronavirus. Group tests will be carried out in the context of population epidemiological investigations to determine the degree of collective immunity acquired by a given population.
For the individual use of the tests, one of the main limitations today to their practice is the lack of sensitivity and specificity of the tests, estimated overall at 90% and 95%, respectively. This means that one in 10 antibody carriers can be falsely declared negative by the test. And that one in 20 non antibody carriers can be falsely declared positive by the test. In a context of low prevalence of carrying antibodies in population at the end of the first epidemic wave (estimated around 5% for France), 5% of false positives from the test mean that only half of people with a positive HIV test will actually carry antibodies. Finally, in the absence of reliable data on the protective or non-protective nature of antibodies, the recommendation given to people with a positive HIV test result will be to continue to practice barrier gestures and social distancing measures. For all these reasons, the interest of antibody screening for individuals is limited and will be reserved for specific situations (e.g., health care personnel, especially those working in accommodation facilities for dependent elderly people).
In this context, serological tests will be used primarily not for the determination of an individual status, but rather for epidemiological investigations in order to determine the level of collective immunity reached in populations more or less exposed during the first epidemic wave. These surveys will need to be conducted regionally and nationally, and will be repeated regularly to monitor the evolution of immunity in populations. This information is essential to accurately assess the risk of re-circulation of the virus from containment release, and therefore the risk of a second outbreak. The collective immunity necessary to protect the population from a restart of the epidemic is estimated at 60%.The collective immunity acquired during the first epidemic wave in the most affected regions is estimated at around 10%. When the containment is released in mid-May 2020, serological tests can be performed on a large scale using ELISA or similar techniques (possible flow of more than 100 000 tests per day). The usefulness of TROD at the individual level is relative, but there will likely be strong demand. It should be recalled that these tests can be performed on medical prescription only.
Thus, the priority of the coming weeks will focus instead on the wide-scale availability of diagnostic tests RT-PCR, carried out on medical prescription, the main tool of diagnosis of infection in front of a symptomatic patient and control of the epidemic. The realisation of large quantities of this test will make it possible to accompany the lifting of the containment and to minimize the risks of recovery of the epidemic. Serological tests should be performed in addition to RT-PCR tests. They will make it possible to carry out targeted surveys (using the most efficient TROD), and especially repeated sero-epidemiological surveys (using ELISA tests) to determine the level of population immunity, a major and complementary element of RT-PCR for the determination of the risk of resumption of the epidemic.
IDENTIFICATION, ISOLATION OF CASES AND FOLLOW-UP OF CONTACTS
In order to be able to gradually and partially release the constraints of containment while maintaining a low level of transmission of SARS-Cov-2, an extremely ambitious program of control of the epidemic must be developed. This programme should make it possible to identify the likely cases on the national territory as quickly and as comprehensively as possible in order to test them and isolate them if they are positive. Case contacts should also be identified, tested and isolated if necessary. Such a strategy, advocated by the WHO, draws on the experience of countries such as Korea, Taiwan, Singapore, or regions such as Hong Kong, which have so far managed to control the COVID-19 epidemic.
The Scientific Council would like to begin by highlighting the many challenges associated with the implementation of such a program. Indeed, a strategy based on identification, case isolation and contact tracking can be very effective in fighting viruses such as SARS where the majority of infected people have severe symptoms and are therefore easily identifiable. For a virus such as SARS-Cov-2, the effectiveness of the device is reduced because many cases with little symptoms may not be identified. In addition, isolated cases may have transmitted the virus before becoming symptomatic. Despite this reduced effectiveness, it is clear that the use of this strategy has produced very interesting results in several countries. In order for such a strategy to produce similar results in France, the system put in place must be extremely effective. It must be based on extremely important technological, logistical and human resources, enabling it to cover the entire national territory efficiently and quickly. Digital tools have an important role to play in enhancing its effectiveness. Ultimately, the level of containment release will depend on the effectiveness of this new device.In order for this strategy to be used, the following elements must be brought together:
Detection and referral of suspect cases
The Professional Public Health Service, which relies on regional professionalised platforms, mobile teams and digital tools (see Main Notice), must make it possible to detect suspicious cases as quickly as possible. In case of suspicion of SARS-Cov-2 infection, the person is referred to a test facility near his home for testing.
A network of infrastructures to test cases
Suspect cases should be easily tested and receive their results quickly. This requires a large network of infrastructures on the national territory, as well as a very efficient logistics organization. France can draw inspiration from the Korean model where patients can be tested in hundreds of clinics and in dedicated drive-in screening stations, very well organized throughout the country.
It is essential to have adequate “digital tools” so that patients can receive their results as soon as they are generated, for example by SMS. These results should be able to be used to inform other parts of the response, for example by initiating epidemiological investigations to find the contacts of cases. It is therefore necessary to ensure good interoperability between digital systems supporting the different
aspects of the response.
Case Isolation Measures
To reduce the risk of community transmission, suspected cases should be isolated at home until the test result is known or for a period of two weeks after the onset of symptoms. Positive cases should be isolated for a period of two weeks after the onset of symptoms. For cases with mild symptoms, two approaches can be considered: the person isolates himself in the family home; or he is quarantined in a dedicated structure.
Isolation within the family home increases the risk of intra-family transmission. This risk varies from one household to another depending on the characteristics of the household (housing size, number of people, presence of vulnerable people). This risk can be more easily controlled in some family settings, and more difficult in others.
The reception of the case in a dedicated structure limits the intra-family transmission but raises other important problems both in maintaining the relational links (between adults, children, etc.) and in terms, once isolated, of protection of the rights of the infected people. The effectiveness of such a measure of isolation in structures dedicated to infected persons may also be limited when isolation is delayed and intra-family transmissions may already have taken place.
When a positive case is detected, all members of the focus are tested to assess the extent of intra-focus transmissions. A risk assessment of intra-family transmission is then conducted by a physician or a member of the local COVID-19 team to determine with the family the most appropriate isolation strategy given the family context. Isolation in a dedicated structure should be preferred where possible.
If isolation within the household is decided, the other members of the household must also isolate themselves. The duration of this isolation should be extended if other cases are detected in the household.
Epidemiological investigations around cases
Given the possibility of transmission through asymptomatic or pre-symptomatic cases, it is essential to have particularly effective tools to quickly identify case contacts. Two complementary approaches must be considered:
Epidemiological surveys: Investigative work is traditionally carried out by teams of
epidemiologists who interview the identified cases to establish their contact list. The latter shall be informed individually of their status. The procedure can be lengthy, laborious and imperfect (a case does not necessarily declare all its contacts). Due to these delays, the contacts identified have already been able to transmit the virus themselves. Given the significant resources mobilized by this type of investigation, a large scale transition seems impossible in this form if it were to be based solely on the ARS teams. The creation of local control teams COVID-19, spread across the territory, is an important tool to contribute to this effort (see main notice).
Digital tool: The digital tool can be extremely valuable in enhancing the effectiveness of this device. Asian countries that have contained the COVID-19 epidemic to date have used strategies that combine field investigations involving large teams using digital tools. These approaches may have been criticized when they did not comply with the rules on the protection of personal data, in terms of consent or anonymity in particular. However, we note the emergence of an alternative European model, which ensures respect for the
protection of personal data. For example, a pan-European consortium is currently working on a tool that complies with the General Data Protection Regulation (GDPR). This tool is developed in partnership by several public research centres in conjunction with German cyber security and data protection agencies. An App is installed on mobile phones based on volunteering. It encrypts contacts between users, based on criteria such as distance between phones and contact duration. If a person is diagnosed positive, the contact list is extracted from the phone and decrypted. Contacts are invited to be tested and isolated if necessary (see above). Each contact does not know who was found positive among their own contacts. It could be a close acquaintance or a crossed stranger in a public place. This approach makes it possible to obtain for each case a list of contacts who have consented to use the application. This information can be obtained instantaneously and for all cases detected on a given day, which is impossible to envisage with more traditional approaches.
Several European countries have announced that they want to use this type of tool. A pan-European solution would allow cross-border transmission cases to be taken into account. Modelling work suggests that this type of approach can significantly enhance the effectiveness of epidemic health control. To avoid duplication of effort, it is essential that these two complementary contact tracking systems (mobile teams and digital tools) be as integrated as possible.
Follow-up of contacts
Once identified, case contacts are immediately notified of their status. They are encouraged to be tested by RT-PCR ideally five days after the date of contact to maximize the chance that the test will be positive if the person was infected during contact. A serological test can also be performed concurrently to determine if they have been previously infected. Contacts should isolate themselves at home until they are confirmed not to be infected with Sars-Cov-2, for a maximum of 15 days. If they are tested positive, they are considered cases. If they develop symptoms within 15 days of contact, they are also considered cases, even in the absence of diagnostic testing.
AN OPERATIONAL EPIDEMIOLOGICAL SURVEILLANCE SYSTEM
Exit from containment shall be based on an operational, reactive and reliable epidemiological surveillance system that:
1. Identification of new cases and their contacts for immediate management
2. Measuring severe morbidity related to COVID-19 through hospitalisations and ICU admissions
3. The detection of a recovery of the epidemic, local or general, with in particular the estimation of the effective R.
4. Estimation of the impact on mortality related or not to COVID-19
5. The estimation of the acquisition of collective immunity against SARS-Cov-2 and its tracking in time and space
1. Identification of new cases and their contacts for immediate management
Identification of new cases in community for immediate care
Diagnoses of infection must be communicated in real time to the ARS and France Public Health whose role is to update the available data on new cases, to estimate the temporo-spatial dynamics at a fine territorial level (e.g. department) and the identification of clusters that may require special support.
Case identification and home control in social and medico-social institutions
These include accommodation facilities for dependent elderly people, medical and social facilities, accommodation for disabled people, other facilities for children, Institutes for hearing and visual impairment), other institutions for adults (home of life, shelter), social assistance for children (departmental centres of children, children’s homes) and other institutions. A reporting system has been set up in the accommodation facilities for dependent elderly people and medical and social facilities, and is being extended to other institutions. The priority objective is to identify the outbreaks early and in a very reactive way by the ARS to intervene, implement the control measures. It should also be used to assess the number of people affected (residents and staff
affected) and deaths in these establishments by region and at national level.
Surveillance of COVID-19 among Infected Health Care Professionals
Health professionals are particularly exposed to SARS-Cov-2 and it is important that the
surveillance system be able to account for the impact of CODIV-19 in this population at national and regional level. France Public Health is currently implementing a surveillance system in this field involving field actors and ARS.
2. Measuring severe morbidity related to COVID-19 through hospitalisations and ICU admissions
The measure of severe morbidity will be based on the number of patients hospitalized for COVID-19 (SI-VIC data) and the number of patients admitted to resuscitation (data from a network of 194 sentinel resuscitation services).
3. The detection of a recovery of the epidemic, local or general and the prediction of the evolution of the epidemic
The monitoring of the epidemic will also rely on a set of surveillance networks already in place such as the network of general practitioners Sentinels, the number of medical acts for suspicion of COVID-19 in the associations SOS doctors, and the number of emergency room visits for suspected COVID-19 (OSCUR data).
Monitoring of diagnostic activity will be essential. The current increase in RT-PCR virological diagnostic capacity will achieve this objective. The return in real time of the results of all diagnostic sources (public and private) including age, sex, place of diagnosis and residence (municipality of residence) to France Public Health is essential to be able to produce indicators (proxy) the incidence at territorial, regional and national level for short time units (week or less). This comprehensive report will allow us to closely monitor the dynamics and detect early transmission repeats and grouped cases (clusters).
New surveillance systems based on internet sites or smartphone triage applications, as well as callbots installed upstream of the emergency numbers on the 15th, will complement the surveillance systems already in place at France Public Health, which are both centralised and regionalised.All these data (case detection, monitoring of severe morbidity, and population-based surveillance systems) allow to feed mathematical models, one of whose objectives is to anticipate the trajectory of the epidemic in the coming weeks, including the daily number of hospitalizations or ICU admissions, the number of beds occupied by COVID-19 patients in conventional hospitalisation or ICU. These models also measure the effective reproduction number R (average number of people infected with a case) at national and regional level. This number must remain below 1 for the epidemic to remain under control.
4. Monitoring of mortality related or not to COVID-19
The number of deaths related to COVID-19 is available daily in hospitals (SI-VIC data) and EHPAD, EMS and other social institutions (see above). The electronic certification of deaths allows a daily count of certified deaths with mentions of causes of death suggestive of COVID-19 infection (pneumopathy, respiratory failure, ARDS, COVID-19). This system, which covered only 20% of national mortality, with a high heterogeneity according to the regions before the epidemic of COVID-19, is in the phase of rapid rise in load requiring, in particular, for city medicine, increase the connection of municipalities to the Exchange and Trust Platform (PEC), allowing doctors to use a mobile application to report death.
The all-cause mortality is estimated on a sample of 3000 communes allowing a surveillance of 77% of the national mortality with a delay of two weeks. This tool allows France Public Health to identify excess mortality at the departmental, regional and national level and according to age by comparison with historical data over several years. These data can also be compared at European level via the Euromomo website.
5. Estimation of the acquisition of collective immunity against SARS-Cov-2
The availability of serological tests for the detection of anti-SARS-Cov-2 antibodies should allow the carrying out of epidemiological investigations to estimate population immunity to the consequences of the first epidemic wave. Studies should focus on the areas most affected by the epidemic to determine whether the immunity acquired in these populations can contribute to the control of the epidemic. The first available results suggest that this will not be the case (around 10%). Other surveys will need to be among the most exposed (caregivers) and most at risk (dependent elderly population).Population surveys based on existing large cohorts (e.g., Constancy) or representative samples of the general population are being prepared. Finally, the system will be supplemented by a system of regular collection in blood banks to follow the major evolutionary trends of the epidemic throughout the national territory.
The completion of these surveys will depend on the validity of the tests used (being confirmed) and their availability. It will also be important to have an estimate of whether or not the antibodies detected are protective.
ETHICAL AND STRATEGIC IMPLICATIONS OF DIGITAL OPTIONS
The exit from containment involves epidemiological, biological and digital technologies. These uses are based on well-established methods in public health, particularly in an infectious context. The use of digital technologies can significantly increase the effectiveness of these measures, which must be implemented in the epidemic context (Ferretti et al., 2020). They may comply with the principles of personal data protection, but may also be more derogatory in case of obligation. If voluntary uses are preferred, mandatory options cannot be ruled out. They raise a number of ethical issues (Heard, 2020). These uses are also part of a broader digital ecology that needs to take into account strategic and sometimes normative issues.
It is not for the Scientific Council to decide on the normative choices at stake or on the technological options chosen. It would, however, like to stress their importance, particularly with a view to promoting broad acceptance, which is essential to the effectiveness of the solutions implemented.
1. Digital strategies, ethics and public health principles
From the point of view of the Scientific Council, the debate is not to choose between the use and non-use of personalised epidemiological surveillance, traditionally implemented in an epidemic context, but to make the best possible choices, including technological ones. Various bodies have examined the ethical and civil liberties implications of such strategies. They make strong arguments in their favour when saving lives (WHO, 2017). The European Data Protection Committee recently stressed the importance of compliance with the General Data Protection Regulation (EDPB, 2020). The National Digital Steering Committee, attached to the CCNE, has issued ethical recommendations (CCNE-CNPEN, 2020).
In general, health measures to protect the population are a duty of a State. If the principles of consent and anonymity can be lifted in an epidemic situation, this derogatory situation must be limited and proportionate to the expected effects, which can be considerable here. While being technically able to dispense with consent, digital tools also make it possible to collect it through voluntary uses. In the absence of consent, a high degree of transparency must be accompanied by intelligible information, including for people far away from digital.
In the epidemic context, public expectations of technological options are evolving. They are also socially differentiated according to age, relationship to digital, trust in public authorities or socio- educational profile. Possible uses of derogations present real risks, which must not be obscured.
A waiver of anonymity does not imply a waiver of confidentiality. The collection of anonymous information, which can be encrypted, does not imply their open retrieval. These data must not give rise to any uses other than public health related to the resolution of the health crisis, whether these uses are judicial, media, sensationalist («horror stories») or commercial, including in the field of health. These abuses can be detrimental to people as well as to the fight against the epidemic.
The deployment of digital options raises important questions in terms of social justice for our citizens who are far from digital because of their condition, age or geographic location. The deployment of digital solutions cannot dispense with considering the entire population, which is also entitled to the benefits of the intervention. Options adapted to different situations must be proposed using appropriate human, material or digital means.
These elements lead the Scientific Council to formulate some principles that meet the public health objectives of these tools. The technological options envisaged must be informed not only by science and technology, but also by legal, ethical and democratic considerations. The competent public authorities may be asked to make a decision (CNIL, CCNE, CNTR, ARCEP, Agence des données de santé, etc.). The adherence of our fellow citizens to the chosen options, especially digital ones, can be favoured by participatory approaches and by the choice of operators presenting guarantees in terms of ethics and sovereignty.
-General principles and good governance
– A transparent intervention preceded by a period of debate.
-Clear governance and democratic control.
-An impartial ethical monitoring system.
-An intervention respecting privacy and limiting intrusions to the strict necessary.
– An intervention intelligible to the public, including technically (open source code, auditability of algorithms, etc.).
-Respect of ethical principles regarding health and personal data.
-High level of guarantees of security, transparency, reversibility and continuity, in particular through shared solutions serving the public interest (principle of “common”).
-Continuous monitoring of health, social, psychological, legal or economic risks to allow for error reporting and rectification.
-Possible questioning in appropriate legal forms.
-Time limit and explicit exit strategy (erasure of data, absence of tacit extension, etc.).
-An exit strategy that applies to both the public authorities and the companies concerned.
-Evaluation of the intervention
-Public health objectives strictly linked to the fight against the epidemic
-Objective of greater effectiveness in relation to expected public health effects.
-Communication concise and understandable by all results.-Focus on vulnerable or stigmatized groups to ensure that they have equal, unbiased access to intervention.
-Limitation of statements to essential information, without unjustified personal or clinical details.
-Protection against fraudulent or malicious uses (hacking, scams, stolen property, etc.).
-Accessibility for audit and evaluation purposes.
2. Sovereignty and effects on the health care system
On another scale, the deployment of digital solutions can affect the health care system over time, which can be impacted by innovative digital solutions. Without evoking scenarios – however plausible – of a “Uberisation” of the health system, a digital strategy can lead to a significant technological rupture. While the use of digital health has long been the subject of innovations in France, including in the context of derogations (Article 51 of the Law on the Financing of Social Security), the solutions adopted during the epidemic can cause an unprecedented acceleration.
French Tech offers promising hopes and is mobilizing to develop new solutions in an epidemic context. Some solutions are developed in conjunction with public authorities (teleconsultation, logistics, applications, etc.). These options can be part of a not only sovereign but also European framework, by devising European options available in the French context, or by pooling European-wide options designed in a sovereign framework. Whatever the level of intervention, cooperative work between research and industry, between public and private actors and by associating citizen initiatives, can be mobilized. The Epidemic Research Support Committee can help identify useful technological options.
A digital strategy mobilizes a broader technological complex, both biological and digital,
combining public and private capacities, partly international, in a not only cooperative context (European logic, statement by G7 heads of state and government, for example) but also competitive and sometimes protectionist. These links between health, industrial and geopolitical logic are also evolutionary. They require vigilance devoid of naivety on their possible medium-term effects. Beyond the immediate issues, of particular importance, there are issues whose systemic consequences may prove even more important. These issues need to be clarified as soon as possible. The urgency of immediate health objectives can pave the way for an in-depth redefinition of health system regulations, affecting all stakeholders.National regulation can be followed by more international logic likely to escape the logic of sovereignty; a public dominant guarantor of a high degree of solidarity, can be associated with commercial purposes associated with digital in unprecedented proportions; with a professional and institutional organisation, can succeed industrial logic reshaping care activities. Even if these new logic are not absent from the French health system, they can accelerate and change the characteristics of the French health system and the respective positions of the health actors, whether they are professionals, patients or public and social organizations. Particular attention must be paid to the speed of change. The epidemic environment creates a strong demand for digital health services, anchored in pressing and urgent needs. The incentives for these developments are very strong for certain actors, who can legitimately see, beyond commitments motivated by the common good, structural economic opportunities in the medium term.
The usual regulatory elements for this type of evolution, whether professional, institutional or legal, are weakened by the epidemic context. Health workers, who are overwhelmed by their professional duties, can value industrial logic because of its immediate effectiveness, while their consequences can prove problematic. Thanks to technological irreversibility, these developments, if not regulated, can produce important systemic effects. Several scenarios can be outlined. They all describe a logic of rapid innovation, which appears indispensable, but whose effects are differentiated. These scenarios do not exhaust all the possibilities. They can be specified according
to the observed effects.
– Strong innovation scenario without systematic change: accelerated technical innovations without systemic change; effects remain limited to the time of the epidemic, and then serve as support for incremental extensions and innovation logics in a health system that maintains its overall equilibrium.
– Scenario of strong innovation with systemic change: accelerated innovations with long-term effects on the organization of care and the health system, producing a systemic change in which new industrial operators acquire a structuring capacity at the expense of professional and institutional actors, with difficulties of public regulation due to strong international logic, the irreversibility of technological options, the high speed of sustained deployment of innovations, the active political work of the sectors concerned; the delay of regulatory institutions compared to the stakes in a context of structuring not only national but also global.- Strong and regulated innovation scenario: accelerated innovation in the time of the epidemic, mobilizing technological options compatible with the logic and information systems of the French health system, combined with public regulation work, ranging from the regulation of technological options to the supervision of market players, until their integration into the public sphere for reasons relating to the sovereignty or solidarity of the French health system.
EXPERIENCES OF OTHER COUNTRIES ON EXIT FROM CONTAINMENT AS OF 18 APRIL 2020
The objective of this point is to study the exit strategies established by the other European countries, similar to France in institutional, economic, legal and technological terms. However, it is necessary to recall that these comparisons of European strategy are limited since the national situations are extremely heterogeneous from the epidemiological point of view. Thus, exit strategies from containment cannot be transposed into the same modalities in France. In addition, these operational strategies are evolving rapidly.
Two specific points are addressed: the reopening of schools and the specific procedures for deconfinement of people at risk.
1. The reopening of schools
As of 19 April 2020, UNESCO, in charge of the global monitoring of national school closure decisions related to COVID-19, has identified 191 state closure decisions. In Europe, all schools are closed at national level, with some exceptions:
– Belarus, which has put no containment measures in place since the beginning of the COVID-19 pandemic;
– Russia, which leaves these decisions to local authorities;
– Sweden, which maintained the classes for those under 15 years;
– Iceland, where nurseries and primary schools remained open under conditions of compliance with health measures;
– Denmark, which after a national decision to close all schools and nurseries on 14 March, decided to open these establishments on 15 April under certain conditions.
-Procedures for opening schools in Denmark
On Wednesday 15 April 2020, Denmark was the first European country to set up a lockdown to open schools. The implementation of this gradual reopening took place in two stages: the choice of the levels to be opened and the variation of the different sanitary conditions to be respected for the levels chosen.
The Danish Prime Minister, Mette Frederiksen, first explained that only certain levels would be affected by the reopening of April 15, in order to allow the economic protection of the country: nurseries, kindergartens, primary schools, first and final. Colleges and high schools will not open until May 11, with the exception of the two exam levels already mentioned.
After these choices, a very precise specification was drawn up by the Danish Minister for Children and Education, establishing the list of conditions to be met to ensure the health safety of pupils and staff:
– hand washing every two hours, for students and teachers;
– a distance of two meters in the classrooms;
– indoor games limited to groups of 2 children and groups of 5 children for the outside
– schools must be cleaned twice a day;
– parents are advised not to put their child in school at the slightest suspicion of contamination.
However, as of 15 April 2020, only half of the Danish municipalities have managed to implement and comply with these specifications. An additional period has been granted to the institutions of these communes, which must be able to welcome their students on 20 April 2020.
Norway and the Czech Republic have developed a reopening strategy similar to that of Denmark. Norway, which set up a flexible confinement on 12 March, announced a gradual reopening of nurseries on Monday 20 April 2020, followed by schools, colleges and high schools scheduled for 27 April. The Czech Republic has chosen a gradual deconfinement from 20 April 2020, with the opening of open-air markets, the authorization of wedding ceremonies under conditions, the opening of shops of artisans. In this context, a reopening of schools is planned for April 20, with a priority to welcome examination classes.
Other European countries: reopening plans for May or September 2020
Other countries are planning to reopen schools such as Austria, Germany, Luxembourg and Belgium.
The reopening plans will have to be produced in the coming weeks, with the objective of a reduced reception of students in May, beginning with the first and final classes in Germany for example.
Some countries, including Italy, have already announced that schools will remain closed until September 2020. The Portuguese Government said the same on 9 April, leaving the question of the examination classes in abeyance. The United Kingdom is currently uncertain as to the usefulness of a reopening since the GCSE (equivalent of the college patent) and the A level (equivalent of the baccalaureate) have been cancelled and universities are organizing independently, most have already implemented remote exam modalities.
2. Populations at risk: international, European and British examples
At the international level, on 2 April 2020, the Regional Director of the World Health Organization (WHO) for Europe expressed the need to adjust exit measures according to risk factors, particularly for the elderly: Many European authorities are now urging older people to stay at home for a long period of self-isolation (otherwise known as “shields”), especially those who are immunocompromised or suffering from chronic diseases. For them, we need to secure updated care plans, identify pathways to services, monitor their compliance with prescribed medications, supplies and equipment; transportation and support for self-management, access to rehabilitation and palliative care, if necessary. Overall, making sure we stay connected is critical.”
At the European level, the President of the European Commission, Ursula von der Leyen, also announced that the elderly could remain isolated until the end of 2020, in order to protect themselves from COVID-19, admitting that the isolation measures were «difficult», while stating that this was a “life and death” issue for this population.
As a national example, concerning the maintenance of restrictions for people at risk at the exit of confinement, the United Kingdom has very quickly positioned itself, and this, by announcing from the beginning of the containment measures that it would apply for a longer period of time for people who are called “extremely at risk”.
On March 22, the British government announced the first three weeks of confinement for the entire population, the people considered "extremely at risk" (transplant recipients, immunosuppressed individuals, severe asthma patients, cancer patients, etc.) and registered in the National Health Service (NHS) files, or 1.5 million people, have been advised by telephone and letter that they should adhere to a strict (no release) containment of at least 12 weeks. The British government has set up a delivery service to provide them with food and medicine. There was also a telephone follow-up: the “UK Government National Shielding Service” is responsible for contacting people who are “extremely at risk” in order to gather information on their daily difficulties, information transferred to the local authorities responsible for arranging assistance for these persons.
A second group of people ‘at risk’; was identified by the UK national authorities: this second specific population is subject to the same duration of confinement as the general population but must take "additional precautions", recommended by the NHS. This population includes 19 million Brits (people over 70, pregnant women, people with heart disease, etc.).
For the general population, confinement was extended by three weeks from April 20 with a government announcement on April 16, 2020. As a result, at-risk individuals should be confined twice as long as the general population, based on government decisions and NHS recommendations
¹•Jean-Laurent Casanova’s position: FFP2 (or N-95) masks must be available and accessible to all healthcare professionals in contact with infected or potentially infected patients, and therefore contagious. These caregivers are at high risk of contamination. For the general population, surgical masks or equivalent are sufficient.
²*Jean-Laurent Casanova’s minority position: he proposes that the contacts of all diagnosed cases be traced via their smartphone. To do so, the smartphone and Bluetooth should be turned on at all times when each person is travelling in the public space. It proposes that the government make this recommendation mandatory for all smartphone owners, subject to possible exemptions.