The analysis of the philosophy of the new measures

Dr. Tsioutis gives the answer to why no total lockdown was imposed and to many other questions about the new measures, in a detailed record of the philosophy of the new measures

unnamed Coronavirus, new measures, TSIOUTIS

Last night's announcements are the strictest package in Cyprus announced since May. These are measures based on experience, knowledge, the degree of readiness of the community and the health system and, above all, on local characteristics, epidemiological data and observations.

Dr. Konstantinos Tsioutis proceeded to a detailed record of the philosophy of the new measures as well as the next steps that we should follow in order to limit the spread and more. Among other things, he answers why no total lockdown was imposed, how the dispersal in the affected areas of Limassol and Paphos will be limited, but also for the universal control of the population.

Some basic elements for the philosophy of the new measures:

Is the need for additional measures justified?

Many indicators such as cumulative impact, Rt, laboratory test positivity rate, remained consistently high (and some higher than acceptable) despite stricter measures over weeks.

The data show that the transmission may have stabilized to some extent, but the number of contacts remained high, resulting in continuous transmission in the community and an impact on hospitality indicators.

Intra-Community transmission is considered a given, and from a point k onwards it can take on alarming proportions. The increased transmission to the community took on the dimensions of epidemics, some even in areas with high risk groups for disease and transmission (nursing homes, slaughterhouse, etc.).

Supporting indications of the above:

- o Rt remains> 1 (so the epidemic curve continues and has an upward trend)
-% of positive laboratory tests has increased significantly (> 3-4%)

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Red lines highlighting the need to strengthen measures:

1. impossibility of timely & adequate tracking

2.increasing% test positivity (showing increased transmission)

3. inability to self-limit the large (and increasing) number of positive incidents and their contacts (do not forget that with an average of 10-20 contacts / person, contacts must also be self-limiting, so the number of people who * should * be limited at any given time are several thousand)

4. increasing number of patients

5. increasing number of positive cases (of which one% will end up in hospital and ICU with a delay of weeks)

6. Transition of affected ages with increase of COVID19 in persons> 60 years

Notes on hospitals

The readiness of the hospitals was strengthened with a plan of gradual recruitment of beds per city, staff recruitment, staff recruitment, training in essential areas such as intensive nursing care.

However

1. the possibilities in beds & staff are not unlimited

2. the number of patients can not always be predicted (eg% of people with disease who were treated started from> 12% in the first phase, to 9-10% during the summer, to ~ 7% now - but phenomena such as epidemics in nursing homes can adversely affect).

3. strengthening hospitals also means shifting resources (mainly human) from one department to another. This will undoubtedly lead to a reduction in the quality of care for both patients with COVID19 and other health problems (simply: if pulmonologists, cardiologists, physicians are recruited to strengthen ICUs, the health of people with chronic or acute problems who need them will be burdened It should be noted that ICU staff have been recruited and trained).

4. The fatigue (physical & psychological) of the medical staff is a significant negative factor in public health crises.
The implementation of measures is not only aimed at protecting the health system at the level of secondary / tertiary health care (ie hospitals).

Only patients with COVID19 who are being treated do not need care. There is a much larger% of patients in need of primary care & rehabilitation.

The health effects of # COVID19 coming soon

"I will be content with the fact that 30% of deaths due to COVID19 in Cyprus were in people <70 years old. "Even if these people had underlying diseases, it should be noted that> 12% of Cypriots suffer from diabetes & 25-30% have ≥2 diseases regardless of age", he states.

Stricter local measures in Limassol-Paphos provinces that have the highest epidemiological burden as shown in multiple indicators:

- cumulative impact of 14 days (as early as mid-October) ie "active" cases per population (based on diagnosed cases)

- the vast majority are domestic broadcasts

- high disease burden on total cases daily and cumulatively

-% on daily isolations

-% of hospitalized patients

-% of recent deaths

Entry-exit ban in epidemiologically charged provinces. What is it intended for:

- prevention of "diffusion" of incidents

- ensuring the implementation & effectiveness of the various local measures

- more detailed monitoring of the epidemiological picture by province

In the most affected provinces: restriction of mobility, restriction of hours, restriction of operation of social gathering places:

The degree of transmission of the virus depends on

A) The prevalence of individuals who potentially transmit (how many are)

B) The% and prevalence of (A) in circulation

C) The number of people who are injecting (may get stuck)

D) The degree of exposure / interaction between (B) & (C)

What do the above correspond to and how can they be reduced:

(A) is extremely high even with international data. It decreases with timely detection and limitation. We know that (C) is the most common in the community.

We do not know (B) but given the steady flow of new incidents and the Rt that remains> 1, it has probably not changed much, so people who transmit continue to circulate, most likely because they are not detected (in time or not at all).

(B) is detected (and reduced) by enhanced laboratory tests and effective tracking. D is reduced by distancing measures (either voluntarily by restricting contacts and gatherings, or compulsorily).

Reducing the maximum number of people to mass gatherings and banning the operation of social gathering places:

- gatherings are known to increase the risk of transmission and over-dispersion. The more people, (a) the greater the risk of having a transmitter (a person transmitting), (b) the more people at risk. Especially in areas of increased frequency, the (a) increases significantly.

- A recent article (Nature) from US urban data shows that mobility, traffic% & degree of synchronicity at venues have largely determined the transmission / spread of the virus. Places at greatest risk were restaurants, cafes, indoor sports facilities, hotels, places of religious worship. https://nature.com/articles/s41586-020-2923-3

In Cyprus * was observed * dispersal among many people in social gatherings (weddings, baptisms, parties, tables) and in sports venues. In fact, local epidemics recorded in the last month came from such events.

Hours limit:

Following on from the above, it again aims to reduce contacts, especially at times and in places where lifting suspensions and reduced control favor transmission.

In support of the above, these measures address not only local comments, but also in line with recent WHO recommendations https://who.int/publications/i/item/considerations-in-adjusting-public-health-and-social-measures-in-the-context-of-covid-19-interim-guidance

What is expected to happen if the measures succeed:

In the coming days-weeks, the increased numbers of patients in wards and ICUs will continue, as a very large load of "active" cases has accumulated.

Immediate reduction of contacts in the most affected areas  stabilization for the next few days and gradual reduction of daily incidents & gradual improvement of epidemiological indicators

Enhance tracking and test-trace-isolate, faster in less epidemiologically charged provinces, by phasing out transmission chains

What else needs to be done:

Strengthening communication strategy and emphasis on positive messages, successes, testimonials

Continuous tracking process support

Design and enhancement of laboratory investigation with rapid antigen tests

Why not generalized lockdown:

There is room for epidemiological and hospitality indicators for scalable implementation of measures (generalized in case of deterioration is not excluded)

The experience of the last months helps us to plan measures based on local observations

Minor blow to the economy

It is important to defend other aspects of society, such as socializing, family institution, mental health

Generalized lockdown is the last resort, which is binding and of unknown actual duration

Why not a complete travel restriction:

We continue and rely on a degree of individual responsibility and awareness

Most public spaces in epidemiologically "red" areas will be closed, the maximum number of people in gatherings is reduced, so the number of contacts is expected to decrease for psychological and social reasons, in order to prevent the unwanted effects of the March closure.

Why not laboratory testing of the entire population:

It is practically impossible to control everyone (so many positives will escape)

No matter how sensitive the test is, there will be many false negatives in the population, so again, positive ones that escape.

The control should be either parallel to the lockdown so that there are no movements & contacts, or "in installments" so in the meantime contacts with positives will continue & therefore incidents are avoided again.

If a lockdown is imposed during the audit to reduce contacts, the cost is doubled (lockdown + bulk checks).

The long-term effectiveness has not been evaluated, ie it is not excluded that there will be a need for the measure again.

Source: Sigmalive