Epidemiologist Antoine Flahault has long been one of the great defenders of the so-called “zero Covid” strategy. Most countries that have implemented it – Australia, New Zealand, Japan, South Korea, etc. – come back today. But the strict virus control measures that they applied for almost two years allowed them to wait for the arrival of vaccines by very strongly limiting deaths in their population, without slowing down their economy.
As of February 20, Japan had thus had 21,844 deaths since the start of the pandemic, South Korea 7,450, Australia 4,929 and New Zealand 53. Against 136,664 in France – and this figure continues to climb , our country still deploring between 200 and 250 daily deaths in recent weeks. “Enough, enough, enough”, exclaimed Professor Antoine Flahault recently on Twitter, calling on the rulers of rich countries to implement a “zero death by Covid” strategy. The Express asked him what he meant by that. Here are his explanations.
L’Express: You recently mentioned the idea that developed countries could reduce to zero, or in any case reduce very sharply, the number of deaths from Covid. What would this policy consist of?
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Pr Antoine Flahault : We know very well who is dying today from Covid: unfortunately these are unvaccinated individuals with comorbidities, as at the start of the pandemic, but also immunocompromised patients in whom vaccination was not sufficiently effective and very elderly with immunosenescence. So, in the vast majority of cases, it is not by chance that one dies after infection with Sars-CoV-2.
At the same time, we now have a therapeutic arsenal which should make it possible to avoid the hospitalization and death of most patients at risk of developing severe forms. This is why I wonder, seeing the current mortality rates after an infection: do we really do everything in our developed countries to administer drugs that are known to be effective in reducing the lethality of this infection?
Are you talking about antivirals and anti-inflammatories?
Absolutely. The first category can be associated with certain monoclonal antibodies, which need to be administered within five days of infection, by intravenous injection in the hospital. Some lose their effectiveness against Omicron, but not all.
And, still among the antivirals, Paxlovid arrives in pharmacies. In the form of tablets, it must also be taken early after the first symptoms and can be prescribed by a general practitioner. Its handling remains complicated, due to numerous drug interactions, but it should still be able to help a certain number of infected people. Just like Remdesivir administered intravenously, which is very effective when given quickly after infection, even if it requires a visit to the hospital.
“A real race against time sets in as soon as the patient at high risk of complications is detected positive”
We also have Evusheld, a monoclonal antibody that can be given as a preventive measure to kidney transplant recipients, for example, to replace the vaccine when it does not prove protective in these very immunocompromised patients. It too must be administered by injection in a healthcare facility. Finally, for hospitalized people whose condition worsens, there are powerful anti-inflammatory drugs, such as dexamethasone or tocilizumab.
Some of these products have shown, in clinical trials, an efficacy of up to a 70% to 80% reduction in mortality. But, in view of the still high lethality rates, it seems possible that all the patients who could benefit from it do not yet have access to it.
How is this explained?
For antivirals and monoclonal antibodies, you have to go very quickly if you want to administer them on time. This assumes that the people likely to benefit from them are aware of their existence, that they are given priority for PCR tests and that the results are communicated to them very quickly.
A real race against time sets in when the patient at high risk of complications is detected positive. However, I have not seen, at this stage, any communication campaign to inform these patients, nor even really the doctors. Regarding Evusheld, we know that patient associations have denounced the difficulties they encountered in obtaining it. Furthermore, monoclonal antibodies are quite expensive and require medical personnel trained for their administration and dedicated to this task, and this personnel was difficult to find in times of high hospital saturation and significant absenteeism.
As for tocilizumab, it is the timely repositioning of a drug that had been developed against infrequent rheumatic diseases. The laboratory therefore finds itself today with an influx of requests, without having really been able to size its production to meet this planetary need. And, in fact, the clinicians who take part in the group of experts that I chair with the regional director of the European office of the World Health Organization report to us obvious supply difficulties, just like for certain monoclonal antibodies.
Are some states doing better than others?
Mortality rates vary by country. Within the European continent itself, there are quite notable differences: in Switzerland, the lethality of Covid seems lower, as in the Netherlands and Norway. It would be interesting to look closely at whether this corresponds to different ways of caring for infected people.
With the rapid decline in the number of cases, it is hoped that the number of deaths will also decline rapidly. What more could we do to avoid finding ourselves in the same situation in the event of a new epidemic wave?
The big risk would be to turn the page too quickly and no longer invest enough in prevention. We are talking here about the prevention of transmissions and the prevention of serious forms and deaths in infected people. There is actually no reason that another wave does not occur and its violence will depend on the characteristics of the next variant, but also on the state of our preparation. We must therefore anticipate this likely future by continuing to seek more effective vaccines against transmission, drugs similar to Paxlovid, but with fewer drug interactions.
If we want to reduce the risk of transmission of the virus, we must also invest in improving the quality of indoor air. Since 99% of contamination occurs indoors, the microbiological quality of the premises we frequent must be as good as that of the outdoor space where less than 1% of contamination occurs. It’s not a simple question.
It is probably more a policy of major works that is involved and, unfortunately, European leaders do not seem to be interested in this issue. It would also be necessary to take advantage of the calm weather which is announced on the health level to set up epidemiological surveillance more up to the challenges we are experiencing. Until now we have had very imprecise instruments to measure and anticipate the epidemic phenomena that we have experienced. The North American authorities spoke of an inaccuracy of a factor of 4: when the health watch reported 400,000 cases on the territory, perhaps there were 1.6 million contaminations on the territory, it is not nothing like level of inaccuracy!
“Until now we have had very imprecise instruments to measure and anticipate epidemic phenomena”
There are methods to obtain more precise estimates, such as the polling techniques used in politics. We could constitute panels representative of the population and carry out PCR tests on saliva samples taken regularly. It would be more reliable, and much less expensive than the tens of millions of PCRs carried out in France in January 2022.
We can understand that it was perhaps not desirable to modify the instruments of epidemiological measures in full wave, but we would blame ourselves in the event of a resurgence of the pandemic for not having been able to take advantage of the lull to do so. It will therefore soon be time to think about this overhaul of health monitoring and this should also benefit the monitoring of other respiratory viruses, such as influenza.
With BA.2, isn’t the next variant already here?
It’s hard to say at this point. It is, according to the official taxonomy of viruses, a sub-variant of Omicron and not a variant in its own right. Admittedly, it is more contagious than the other sub-variant (BA.1) which was dominant until now in France, but everything will depend on the level of immune escape of this BA.2 sub-variant with BA.1 .
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If infection with BA.1 in most cases protects against reinfection with BA.2, then one can hope that this BA.2 subvariant will not cause a major rebound. Currently, it is known from experience in Denmark, where BA.2 has become dominant, that some BA.2 reinfections have occurred in persons recently infected with BA.1, but these cases appear to be relatively rare.
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