between the ‘fluization’ and the ‘covidization’ of the pandemic

Health

Salvador Peiro

Madrid

Updated:

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The “sixth wave”, with its large numbers of infections and its -not so large- numbers of serious cases, has brought a remarkable division in its interpretation and in the strategies to deal with it. And also in the strategies to approach the nearest future. .

Some, arguing the current “lightness” of most cases, are betting on the immediate end of the pandemic (not just the sixth wave, but the pandemic) and its endemization. An increasingly less aggressive SARS-CoV-2 would transform (inevitably, following a kind of evolutionary teleology) into a coronavirus similar to those that cause colds. In this scenario, the proposed strategies go through the end of the restrictions and the gripping of the epidemiological and healthcare approach to covid.

Others, arguing the enormous incidence of cases and that the leaks of that deluge leave a lot of morbidity, consider that talking about endemization is frivolizing a still very compromised situation (including hospitalizations, deaths, cases of persistent covid, etc.) and evoke the risk of spikes and new variants.

They are committed to “prudence” and the maintenance of restrictive measures. And they do it with a certain frizz, because they consider that flu costs (and will cost) many lives.

The debate has included the extrapolation of the evolution of the wave from countries in extremely different situations (South Africa), the confusion between the (reasonable) influenzaization of the epidemiological surveillance of covid with the (more debatable) influenzaization of its practical approach, quite evolutionary teleology and many other components.

controversial measures

The controversy has moved to the more practical aspects of dealing with the pandemic. To the almost absence of effective measures to reduce social interactions (beyond the isolation of positives, especially symptomatic ones), the reestablishment of measures of rhetorical effectiveness (masks outdoors, vaccination certificate) or strategies that feed inadequate expectations (antigen test to encourage interactions between people, covid certified to maintain activities -even large events- in closed spaces).

There is also debate about measures to contain the social and health disruption caused by mass transmission. That is to say, on the acceleration of third doses, reduction of tests, abandonment of traces and quarantines and shortening of isolations. For some they are excessive. For others, insufficient.

The debate, fueled in the media and social networks, has a certain voltage. With passionate supporters and opponents, generating confusion, uncertainty (consubstantial at the time) and bewilderment in the population.

The excess of noise contrasts with the absence of authorized voices –from the health administrations, above all– explaining the situation, their forecasts and the rationality of the measures they are adopting (or not adopting).

It is not a minor issue because some of these measures are, to say the least, controversial. Decisions must be made, but they must also be explained. And the argument that they have been adopted “unanimously by the autonomous communities” does not reveal the scientific, technical or social rationale that led to that “unanimity”.

What does flu imply?

Although no one explains very well what it is to get the flu, the essential difference between the approach to covid and that of other upper respiratory infections is the use of the etiological diagnosis to isolate. That is, the identification of cases through specific tests for their isolation during the contagious period and the quarantine of suspected cases (incubation period).

Covidization or influenzaization does not depend so much on the type of virus that heads the neologism as on the relationship between transmission and severity. A situation of high transmission and severity would force covidization. If the disease is severe but the transmission is very low, we could ebolize, as was done during the Ebola outbreaks of 2014. A situation of high transmission and very low severity (eg, the common cold) allows flu. That implies not isolating the cases, nor their contacts. Do not track or test.

The flu, although it gives its name to the neologism, is of uncertain behavior. We usually deal with it by getting the flu. Although it would not hurt to transfer some of the things we have learned with covid to its management. But we probably wouldn’t do it in a pandemic season, like 1918 or 1958. In fact, in 2009, we prepared to covidize the influenza A (H1N1) pandemic, which, in the end, was much less serious than expected by the WHO.

Is covid currently a seasonal flu?

By volume of infections it is obvious that no. The 2019-20 flu season is estimated to have caused 619,000 cases in the entire season (490,000 the previous season). And they were enough to overwhelm hospitals. Like almost every flu season.

The covid, in just this month of January 2022, has caused more than 3.5 million cases in Spain. And it has significantly hindered the care of other patients. Covid is not a flu. And if ever a flu season reaches these figures it is doubtful that we would want to flu.

confirmed cases of covid-19 per million inhabitants in the fifth and sixth waves in Spain 29/02/2022

The 2019-20 flu season caused 27,700 hospitalizations. In the month of January 2022 alone, covid has caused 41,600. And in terms of mortality, the 2019-20 season resulted in 3,900 deaths attributed to the flu. A figure similar to the covid deaths in January, when the “wave” of deaths still does not seem to have peaked. In fact, it is very likely that the –supposedly mild– sixth wave will end up leaving more deaths than this summer.

Daily deaths confirmed by covid-19 in the fifth and sixth waves in Spain.  Daily deaths confirmed by Covid-19 in the fifth and sixth waves in Spain.
Daily deaths confirmed by covid-19 in the fifth and sixth waves in Spain. Daily deaths confirmed by Covid-19 in the fifth and sixth waves in Spain.

And this despite coming from a long period of excess mortality that should have “harvested” (harvesting effect) the deaths of people with the highest risk of death.

Is the current covid the same covid as last winter?

Not remotely similar. The protection against severe covid offered by vaccines is maintained (even more so with third doses) and omicron, the currently predominant variant, appears to be less severe.

Despite the many infections, reinfections (in people who had had the disease) and “gap” infections (in vaccinated people), hospitalizations, ICU admissions and deaths are slowly growing. The curves of cases and severe cases have been decoupled. Moreover, the hospitalization and ICU curves also seem to be decoupled.

Covid is not a flu, but neither is it the covid before mass vaccination.

Cases, hospital and ICU admissions, and deaths in Spain compared to the third wave (winter 2021).  The curve is modified to take into account the delay between case confirmation, hospital admission, ICU admission and death
Cases, hospital and ICU admissions, and deaths in Spain compared to the third wave (winter 2021). The curve is modified to take into account the delay between case confirmation, hospital admission, ICU admission and death – OurWorldinData. Data extracted on 29/02/2022.

Many cases are asymptomatic or paucisymptomatic. Similar to uncomplicated influenza. But they are big numbers. And large numbers produce significant social disruption (including transport, education, health…) and health (overflow of primary care and emergencies, added to an incessant trickle of hospitalizations that makes it difficult to care for non-covid patients).

This social and health disruption is also peculiar. Most sick leave is not caused by the poor clinical condition of the patient, but by the isolation protocol itself. The saturation and overflow of primary care are not due so much to the severity of the conditions or the need for clinical follow-up, but rather to the application of a strategy of etiological diagnosis (tests), follow-up and management of isolation (including sick leave, labor certifications and schoolchildren, and paracetamol prescriptions) which is one more shot in the foot of primary care.

If covid is no longer “the covid of 2021” and it is not a flu, how do we deal with it?

The trickle of serious cases of the many already infected will continue in the coming weeks. And the many infected will still infect many people. Less and less, but it is difficult to predict how much and how.

This wave, unlike others, will not end abruptly as a result of restrictions, but rather due to depletion of susceptibles (and third doses). We also expect fewer serious cases, once the cases caused by the delta variant are replaced by omicron cases and the unvaccinated – which have generated a huge volume of serious cases – become infected.

Prudence would advise maintaining – at least for a while – some effective measures to reduce contacts that are less intense than other times: isolation of positive and symptomatic patients, teleworking, limitation of mass events, masks on public transport and closed spaces, etc. And a public discourse that reinforces the population’s adherence to these measures (before the confusion with the masks outdoors).

Coherence would advise abandoning rhetorical measures, including those that put pressure on the unvaccinated. Although it is true that they have occupied hospitals and ICUs (disproportionately consuming a scarce resource, forcing a lot of non-Covid activity to be paralyzed), from the point of view of transmission their relevance is less and less. The lifting of restrictive measures associated with vaccination has allowed a high transmission and the unvaccinated have not had this time the “protection” that the restrictions offered them.

And it is also advisable to resume social communication. Give honest explanations of why things are done or not done. Inform the population of the «plan». In practice we are moving to self-diagnosis, self-tracing, self-isolation and self-care. This transformation of the approach to covid requires giving the population the necessary instruments for self-care. And that means effective communication.

Finally, we must resume the recovery of our health system and its adaptation to the Spanish society of the 21st century. It is not just a digitization issue. Not just more resources. More of the same will not be enough for a system that, essentially, still maintains the schemes with which Social Security built it in the early 70s of the last century.

Salvador Peiro. Researcher, Health Services Research Area, FISABIO PUBLIC HEALTH. Originally published on THE CONVERSATION. IS

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