COVID-19
CORONAVIRUS – the FAQs 4
August 28, 2020
COVID-19
CORONAVIRUS – the FAQs 6
November 27, 2020

CORONA­VIRUS – the FAQs 5

COVID-19

This is the fifth of a series of Covid-19 newsletters from FDIME (Foundation for the Development of Internal Medicine in Europe). The aim of the newsletters is to present qualified answers to the public, specifically on issues in which internists have a saying.
In this newsletter (FAQ) you may read about the situation in 9 different European countries, including a short update about the current measures.
FDIME is a non-profit organizations, which aims to improve medical care for patients in Europe and has several activities promoting medical research and medical education of young European specialists in internal medicine. FDIME supports young internists to attend the European School of Internal Medicine, participate in the European Exchange program and also provide grants for research in Internal Medicine.

You are also invited to pose additional questions, which we can try to answer in one of our next newsletters.

The Covid 19 situation in different (9) countries

Stefan Lindgren, Sweden, September 24 2020

1What is happening now in your country: is the situation stable or are cases increasing, what about clusters and measures?

The situation is stable but the number of identified cased is slowly increasing over the last weeks. However no increase related to admissions to hospital and intensive care and very low mortality.

2Is the policy to do massive PCR tests, in order to find “positive asymptomatics”, effective?

No, not according to our health authorities. We only test when there is a suspicion. More scientifically based studes have identified a very low number of positive cases in the healthy population.

3What to advice to protect the most vulnerable people?

This has been a large failure in Sweden in relation to frail elderly and non integrated immigrants. But the situation is better now. Vistis are again allowed in homes for elderly from October 1. The main advice is still to keep distance and avoid contacts, visits and going to work when you have symptoms.

4Do you have significant negationist movements against COVID in your country? Do you think that these demonstrations should be permitted?

No, that has not been the case in Sweden. Here the main policy is to educate and then trust that the population will follow the adivce and directives from the health authorities.

5What is the reason why lethality now is lower than in spring?

The most frail individuals have already died or overcome the infection. Routines have improved. The spread is mainly among healthy young individuals. But the risk is of course that the virus again may reach the vulnarable population.

6Do you think that a more coordinated European strategy would improve the situation or does each country have to resolve its own problem? (here we can review FAQs 3)

I basically believe that each country must find their own solutions. They depend on so many different factors. But universal advice is of course helpful.

7What is the situation of children and the return to school. What about the treatment of non-Covid 19 patients (seems to have normalized by now). Is it like this in your country?

Schools have been open all the time in Sweden. There is very little infection and no spread among children. It carries a big risk to keep children from going to school.There is still a back-lag of unmet needs and treatments among non Covid 19 patients and that is a concern when it comes to resources.

8Give scenarios: more lock-down, quarantaine (acceptable for the people?), what about travelling, what about economics. An alternative could be to report what we (and our colleagues) would tell our/their patients or to anybody when we/they are asked this kind of questions.
In Sweden we do not believe in lock-down. The consequences are too serious and the problems returnes and may even grow when societies open up again. Travelling is not advised currently although not forbidden. The economy is Sweden has overcome the pandemia fairly well. We believe that this is due to keeping the society and business open and to massive financial support from the Government.

Update Sweden, October 21, 2020

Over the last weeks the incidence of new cases has increased, particularly in the larger cities and among young adults. But still the incidence is much lower than in springtime. Admissions to hospital is slowly increasing but the number of patients needing intensive care is still low. The Swedish society is still open but recommendations to avoid public transport and private parties have been directed to people living in parts of the country with a higher incidence of new cases.

Nica Cappellini, Italy, September 27 2020

1What is happening now in your country: is the situation stable or are cases increasing, what about clusters and measures?
In Italy the situation is under control with a daily number of positive cases between 1300-1900 during the last 2 weeks. Mostly family clusters; some are asymptomatic. The measures remain: use of mask, wash hands, maintain distances in public places (restaurant, bar etc). School opened with strict measures: fever control, distances PCR test is more and more available but not massive; the priority is for family members of a positive case or for those who had contact with a positive case (there is possibility to trace the contact).
2What to advice to protect the most vulnerable people?
Avoid contact with people at risk to be carrier of infections, to be in contact with the GP in case of any fever of initial suspicious symptoms. To take influenza and pneumococcal vaccination in the coming weeks.
3Do you have significant negationist movements against COVID in your country? Do you think that these demonstrations should be permitted?
We have but there are not many followers. It is mainly a limited group of people sometimes with political opinions. Some of the negationists have been affected themselves and they change their mind. So far there were no big manifestations.
4What is the reason why lethality now is lower than in spring?
Early diagnosis and more adequate early treatment.
5Do you think that a more coordinated European strategy would improve the situation or does each country have to resolve its own problem? (here we can review FAQs 3)
I believe that a coordinated strategy would improve the situation but I believe also that it is difficult to apply. Any country has apersonal attitude.
6What is the situation of children and the return to school. What about the treatment of non-Covid 19 patients (seems to have normalized by now). Is it like this in your country?
For the schools we will see in 2/3 weeks how it will impact on the infection spread. The situation for non-covid patients so far is back to normal, hopefully this will remain.

Update Italy, October 25, 2020

1What is happening now in your country: is the situation stable or are cases increasing, what about clusters and measures?
Since September 15 the number of infected people started to increase with an increased number of positive swabs but few severe cases. Progressively the numbers increase and today the situation is out of control: 21.273; 128 deaths and increased numbers of people admitted to emergency room with a mean age of 67 years. There are indications to trace a positive case but this is not possible any more. Until today there were some common rules at the national level and decisions taken at the regional level according to the spread of the infection (Reducing school access, more strict control of transport etc) Just now new rules at the national level have been announced: Restaurants and bars must close at 6 p.m.; no movement outside the city or village where people live; smart working is recommended.
2Is the policy to do massive PCR tests, in order to find “positive asymptomatics”, effective?
It should be but now this is almost impossible. Some rapid tests will be used from Monday (261020) at school and also they will be made available in the hospitals in the most affected areas.
3What to advice to protect the most vulnerable people?
Personally I believe that a lockdown is advisable or at least to do a personal control on daily activity avoiding contact with the most probable carriers: young people, people working with other people outside of their own family. To wear the mask at any time going out and facing other people.
4Do you have significant negationists movements against COVID in your country? Do you think that these demonstrations should be permitted?
Unfortunately the number is increasing, not only negationists but also people in strike because they are loosing jobs . In some places a police intervention was necessary.
5Do you think that a more coordinated European strategy would improve the situation or does each country have to resolve its own problem? (here we can review FAQs 3)
In same way the answer is yes, although any country is facing a different situation and within the same country the situation could be different. I believe in a general strategy but adapted to the local situation.
6All children returned to school already in June and directly after the summer break. For young children there are no limitations and no need to stay home in case of a common cold. For older children the usual measures, such as social distancing etc. are in place. Because of the regular dropout of teachers because of (contact with) corona or burn-out, childen are sent home more often than before and remote digital education is again considered. As far as treatment of non-Covid 19 patients is concerned, this was nearly normalized. However, now with dis feared that again problems for non-Covid 19 patients may arise. It is tried very hard to avoid that.
The school activity is the main discussion point. The ministry of education and the government in general support the idea to keep the schools open, having implemented during summer time all the measures to ensure a safe reopening. The schools per se are well controlled but outside the school children and parents are exposed, thus as soon as a child is positive the whole class should go into quarantine. This situation gave rise to a political debate. So far, from Monday (251020) the high school will have virtual lessons whereas primary schools still remain open for face to face lessons.
7Give scenarios: more lock-down, quarantaine (acceptable for the people?), what about travelling, what about economics. An alternative could be to report what we (and our colleagues) would tell our/their patients or to anybody when we/they are asked this kind of questions.
In this present situation we have to control as much as possible the pandemia because the pandemia per se will affect economy etc. Thus implementing restrictive measures which may allow vital activities to continue and reducing as much as possible the non-primary activities will be of benefit first of all for the people, but also for the general economy which will have the possibility to restart (hopefully) better.

Runolfur Palsson, Iceland, September 28, 2020

1What is happening now in your country: is the situation stable or are cases increasing, what about clusters and measures?
In Iceland, we are currently facing a third wave of COVID-19 with an incidence of 118 per 100.000 in the past 14 days. We have limited countermeasures in place. Visitors are tested (PCR) at the borders, followed by 5-day quarantine and a second test. Those who test positive for SARS-CoV-2 will immediately undergo a test for antibodies. Social gathererings are limited to 200 people. We have a 1 meter physical distancing rule and people should wear a face mask when this distance cannot be maintained. Bars are currently closed because we experienced a cluster at one or two such places.
2Is the policy to do massive PCR tests, in order to find “positive asymptomatics”, effective?
We do massive contact tracing and testing of risk groups, i.e. individuals who have been exposed and are in quarantine. Also healthcare staff working in units where SARS-CoV-2-positive individuals have been identified, irrespective of direct contact. We believe this has been successful as we have been able to diagnose a number of individuals early and place them in isolation and their contacts in quarantine.
3What to advice to protect the most vulnerable people?
Limit contact with other people as much as possible and using social distancing, face masks and hand hygiene.
4Do you have significant negationist movements against COVID in your country? Do you think that these demonstrations should be permitted?
Currently, the public restrictions in Iceland are not great. However, control measures are in place at the borders and bars have been closed for the past week but may open again in the coming days. The business sector is unhappy, particulary the travel industry and bar and restaurant owners, and has been voicing objections, emphasizing that the consequences of the infection appear milder than before. Nevertheless, some people still become gravely ill and, in general, the Icelandic public understands and agrees with countermeasures that have been implemented.
5What is the reason why lethality now is lower than in spring?
Difficult to tell. The average age of patients is lower now and those at increased risk, namely elderly people and those with underlying conditions, are perhaps better protected. Furthermore, we are performing much more testing now and are diagnosing a higher proportion of asymptomatic or minimally symptomatic individuals.
6Do you think that a more coordinated European strategy would improve the situation or does each country have to resolve its own problem? (here we can review FAQs 3)
I think that a concerted European action might be useful. Nevertheless, each country must manage their own situation as there is variation between countries in the scope of the pandemic at any given time, as well as differences in the organization of the healthcare system. In addition, there are as cultural and socioeconomical differences that may influence the implementation of strategies.
7What is the situation of children and the return to school. What about the treatment of non-Covid 19 patients (seems to have normalized by now). Is it like this in your country?
Children are back to school although some disruption has occurred in recent weeks due to quarantine. We are still behind on providing care to patients with other conditions, particularly those that require elective surgery and other interventions. Waiting lists grew substantially during the first wave and we have not yet been able to get this in order.
8Give scenarios: more lock-down, quarantaine (acceptable for the people?), what about travelling, what about economics. An alternative could be to report what we (and our colleagues) would tell our/their patients or to anybody when we/they are asked this kind of questions.
This is the key question. I believe we need to strike the right balance. We will not achieve elimination of the SARS-CoV-2 virus until we have an effective and safe vaccine for the entire population. So we need to find a way to keep our communities running, relying on mild societal restrictions and personal measures, including physical distancing and hand hygiene to prevent transmission of the virus. A reasonable aim is to maintain a steady state of low-level or no transmission. I believe that border control is important, screening travellers, especially those coming from high-risk states.
The negative economical consequences of national response measures aimed at containing the outbreak are important and therefore should be limited when deemed possible. Complete lock-down should only be implemented when considered absolutely necessary. However, we must be able to control the spread of the virus as the worst economical outcome would probably occur if we loose control of the pandemic.

Update Iceland, October 27, 2020

The current wave of COVID-19 has escalated in recent weeks with the incidence peaking at 291 per 100,000 on October 17. The outbreak is mostly confined to the Greater Reykjavik Area. A large number of patients have been hospitalized, but interestingly few have required intensive care. Nevertheless, the authorities responded by enhancing restrictions in order to protect our healthcare resources. The current regulation on infection control measures includes a 2-meter social distancing rule and mandatory use of face mask whenever a 2-meter rule cannot be be sustained. Bars are closed. Contact sports are not allowed, but swimming pools are open with a limit on number of people allowed at the pool facility. Schools remain open with certain limitations regarding the number of students present in the classroom. However, neither lockdown nor curfew has been implemented. The outbreak has begun to subside.

Kim Pettersson, Finland, September 28, 2020

1What is happening now in your country: is the situation stable or are cases increasing, what about clusters and measures?
The incidence is now increasing rapidly during September, although the figures are still quite modest in Finland in comparison to most other European countries. There are some clusters, especially in Helsinki region, and in a few other cities in Finland.
2Is the policy to do massive PCR tests, in order to find “positive asymptomatics”, effective?
The amount of testing has been increased each week but it is still mostly aimed for symptomatic persons although it has increased also among exposed people and those with a close relative that has tested positive or been exposed. No resources yet to test the entire population.
3What to advice to protect the most vulnerable people?
To keep them isolated from younger people and from those who might have exposed seem to be the most efficient strategy at this point. To avoid crowds if possible and using masks and hand disinfection.
4Do you have significant negationist movements against COVID in your country? Do you think that these demonstrations should be permitted?
There has not been any report of people that are denying the existence of COVID-19. People have the right to demonstrate in Finland due to any reason.
5What is the reason why lethality now is lower than in spring?
It has now spread among the younger population. The older ones have still protected themselves by isolation. Also more testing among those without symptoms.
6Do you think that a more coordinated European strategy would improve the situation or does each country have to resolve its own problem? (here we can review FAQs 3)
A more coordinated strategy would certainly be useful with uniform recommendation. Regarding final enforcement local aspects and disease incidences should be regarded.
7What is the situation of children and the return to school. What about the treatment of non-Covid 19 patients (seems to have normalized by now). Is it like this in your country?
The children are attending day-care centers normally. But they are requested to stay home already at mild flu symptoms. Schools are being attended normally untill a true exposure has been established after which quarantine is ordered. There are only very few schools in quarantine now.
Treatment of non-Covid patients are back to normal at this point in Finland.
8Give scenarios: more lock-down, quarantaine (acceptable for the people?), what about travelling, what about economics. An alternative could be to report what we (and our colleagues) would tell our/their patients or to anybody when we/they are asked this kind of questions.
Decisions towards lock-down are expected in Finland in the near future if the incidence is continuosly increasing. The people have generally accepted quarantine when ordered. Travelling restriction will be taken into use again but maybe quite not as stringently as during the spring. Economics, especially tourism in Lapland, will be heavily affected and many cultural institutions will suffer heavily.

Update Finland, October 23, 2020

The Covid-19 figures in FInland have been increasing in a worrysome manner during august-october, although the situation is still very good in comparison to most other European countries. There seems to be a stagnation of the figures now during the very last 1-2 weeks but it is still too early to see whether there is a definite trend towards lower figures. There has been novel restrictions with the bars and restaurants that have to be closed by 11 o´clock P.M. Masks (mouthcaps) are highly recommended but compulsory only on certain institution such as in the trains and aviation traffic. The cultural institutions are still running but with a limited amount of audience, i.e. every second of every third place has to be empty. Distance working at home is still recommended. Schools and day-care centers are running normally and there are no restrictions regarding moving outdoors.

Verena Briner, Switzerland, September 30, 2020

1What is happening now in your country: is the situation stable or are cases increasing, what about clusters and measures?
with the highest numbers of cases: Geneva, Waadt (around Lausanne) and Zurich. There is a huge number of test done every day. The results are 225 tests of a total of 5959 positive (Switzerland total 8.57 Mio=million inhabitants) on September 28, 10 new cases hospitalized (total 4855 patients). The last week, the number of positive cases were ca. 400/day.
2Is the policy to do massive PCR tests, in order to find “positive asymptomatics”, effective?
It is very easy to get tested. Results are available within 24h. It was a rising number of tests done, but now it stabilizes. So far, a total of about 2.3 Mio Tests were done and 62’000 were positive. Some patients with a positive test were tested twice. The number of patients therefore is less.
3What to advice to protect the most vulnerable people?
Nursing homes are still restricting the number of visitors. Some do not allow foreigners in the restaurant. - There is a flyer provided from the governement: keep distance, wash hands, wear mask. It is not restrictive at all. In shops people are allowed to shop without mask. Fitness centres have restriction of number of people in the room, distance between machines is increased. Large stores have a counting system at the door (red stop, green enter).
4Do you have significant negationist movements against COVID in your country?. Do you think that these demonstrations should be permitted?
There are some reactions but of minor dimension. They should not be restricted. In the center of Switzerland, there are only a few patients and no reaction of the public.
5What is the reason why lethality now is lower than in spring?
The very polymorbid patients in spring died. High season for the influenza is more in spring than in winter. Maybe some of the people had reduced immuniy due to mild seasonal flue.
6Do you think that a more coordinated European strategy would improve the situation or does each country have to resolve its own problem? (here we can review FAQs 3)
It is an international problem and not national. With the creation of the EU, ‘teamwork’ was meant to start. We should continue to improve this idea.
7What is the situation of children and the return to school?
As I know school started. Some schools have reduced the number of pupils per room (half working in the morning, the other half in the afternoon).
8What about the treatment of non-Covid 19 patients (seems to have normalized by now).
Operations were postponed due to lockdown. Now it is possible to get operations and interventions. However, many patients are afraid to get infected with Covid!
9Give scenarios:
in many areas people did shop for people at risk. Shops have internet shopping available and bring food home. On the other hand, young people get more and more frustrated because they are not allowed to have big parties, etc. Solidarity with people at risk is less! more lock-down people generally do not want another lockdown. But people like to have the same basic restriction in all county areas and not as it is at the moment, that the governement of each county can do more or less what seems good, quarantaine (acceptable for the people?) it is less accepted than in the beginning, what about travelling a lot of movement from the german speaking part in Switzerland to the french speaking part and vice versa!, what about economics of course there are many businesses having problems (hotels in cities, tourist centres such as Interlaken, Luzern, watch industry, artists, cloth shops, international shops, etc.). The best business reported are caravan mobils (homemobiles), mountain hotels, bike stores. An alternative could be to report what we (and our colleagues) would tell our/their patients or to anybody when we/they are asked this kind of questions. My 99 y old aunt was very unhappy about the lockdown and the impossiblity to meet and have lunch in the nursing home. She would have preferred to face the risk of getting infected and die earlier. She felt very isolated.

Update Switzerland, October 26, 2020

1What is happening now in your country: is the situation stable or are cases increasing, what about clusters and measures?
The situation is not stable. During the last week on average there were 5500 new cases per day. These are about 18% positive tests of all tests done. The 7 days before it was about half. The number of patients in the hospital rises in parallel (about 2.5% of positive tested). At the time, there are 1159 Covid patients (7.1% of all beds) in Swiss hospitals. Hospital start limiting elective interventions (increase the empty beds).
2Is the policy to do massive PCR tests, in order to find “positive asymptomatics”, effective?
The capacity is about 25.000 tests per day. Results are received within one to two days. It depends on the lab. One hopes for effective fast tests.
3What to advice to protect the most vulnerable people?
The Federal Council advices older population and sick people to stay at home. Nursing homes are restricting visits and some even forbid to see inhabitants. Middle aged neighbours help older people (shopping, post office, etc.) even in cities.
4Do you have significant negationist movements against COVID in your country? Do you think that these demonstrations should be permitted?

At the time, there are 1159 Covid patients (7.1% of all beds) in Swiss hospitals. There are ‘hot spots’ with high numbers of cases in Geneva, Valais, Zurich. In Geneva and Valais, the Health authorities restricted e.g. bar and disco opening. In the county of Bern the number of visitors at the football and hockey events was reduced to 1000 people although Bern is not a ‘hot spot’. On the other hand, Zurich has also a higher rate of Covid infected people but did not increase the restriction. The different procedures lead to tensions among the population of the different counties and especially among the young population. The longer the epidemic lasts, the greater the tension between population groups. Solidarity begins to crumble. The old people can get used to the restrictions more easily and also stick to them. The young people are frustrated with the regulations and the closing of their preferred places such as discos and clubs.

In Switzerland demonstrations are allowed (needs permission, but is easily to get).

5What is the reason why lethality now is lower than in spring?
The old and sick individuals have either died in the first wave and/or are now more strictly keeping distance and isolation at home. In addition, the spreading is more frequent in bars, disco and clubs and not among older people.
6Do you think that a more coordinated European strategy would improve the situation or does each country have to resolve its own problem? (here we can review FAQs 3)
The number of Covid cases varies very much from area to area within a country and also from country to country. It makes sense to have some basics in common but hot spots have to be managed individually.
7What is the situation of children and the return to school. What about the treatment of non-Covid 19 patients (seems to have normalized by now). Is it like this in your country?
Schools were closed during the first wave and reopened when the lockdown ended in June. The gap between original Swiss and foreign school children with immigrant parents may widen in respect to knowledge/support and equipment and therefore progress in learning. On October 28, we expect further restrictions by the Federal Council. It is less likely that schools will be closed. Some universities are now only online. Non-Covid patients were less likely to see their GP or go to the hospital during the first wave. Then it normalized but since the numbers of Covid cases rises and the number of hospitalisation too, I guess, there will be a reduction of non-Covid patients admissions. Many people are afraid of getting infected in the hospital.
8Give scenarios: more lock-down, quarantine (acceptable for the people?), what about travelling, what about economics. An alternative could be to report what we (and our colleagues) would tell our/their patients or to anybody when we/they are asked this kind of questions.
The economic consequences of the lockdown were dramatically in Switzerland. There was 30billion CHF finance support to stabilize the economy. The Federal Council mentioned in an interview lately that there is no chance to have a similar finance help during a next wave and therefore no lockdown. Travelling is not forbidden but it is recommended to decrease. The graphic of 2020 shows that there was less public transportation and much more bicycle riding during the first wave. But now all transportations (car, train, bicycle) have come back to the state as it was before Covid started. – Quarantine is recommended when people had contact with Covid sick people and flue like symptoms. Without symptoms, the people have to strictly keep to the recomendations (distance, mask, hygienic means). When they have contact with people at risk for a severe coarse, they are kept in quarantine or in home office.

Jan Willem Elte, The Netherlands, September 30, 2020

1What is happening now in your country: is the situation stable or are cases increasing, what about clusters and measures?
Since mid-September figures are rising again in The Netherlands and approaching those from March 2020. Also the R value rose from 0.9 up to 1.3, so the second wave is there. Current cases are more often than before younger people aged 20 – 40 years and they appear to be less ill. Nevertheless hospital and intenive care admission are increasing. There are clusters in at least three provinces: North- and South Holland and Groningen. The big cities of Amsterdam, Rotterdam and The Hague have the worst figures. Measures have become more strict several times and since September 29 there is a must for mouthcaps not only in the public transport (which was already obliged since June 1st) but also in busy places in the affected cities. This obligation has been extended 1 day later to include the entire interior public space where the mouthcaps are urgently advised but not compulsary. Theaters etc. are allowed to have only a limited number of visitors, restaurants and cafés have to close early and also have limitations in number of visitors. All sports competitions are even without visitors and at home you may have three guests only.
2Is the policy to do massive PCR tests, in order to find “positive asymptomatics”, effective?
Although massive testing is advocated, there is a rather disappointing shortage of test material. Besides, waiting time at test locations is long, usually more than 48 – 72 hours. Probably this is also the reason why asymptomatics are not being tested. Quick tests are needed urgently and they will be available soon.
3What to advice to protect the most vulnerable people?
The most vulnerable people are advised to be careful and to keep to the general measures already applied since the beginning of the crisis. Social distancing is the most important advise.The nursing homes will most probably not be completely closed for visitors as in the beginning.
4Do you have significant negationist movements against COVID in your country? Do you think that these demonstrations should be permitted?
Yes we do have such a movement, originally called “viruswaanzin”= virus madness”, now renamed “viruswaarheid”= “virus truth”. They organize demonstrations and (mis)use young influencers. According to Dutch law it is not possible to forbid the demonstations, unless there is violence or demolitions.
5What is the reason why lethality now is lower than in spring?
Mainly because younger people are affected. A better understanding of the disease, including better treatment might also be of importance.
6Do you think that a more coordinated European strategy would improve the situation or does each country have to resolve its own problem? (here we can review FAQs 3)
In some aspect a coordinated European strategy might be helpful, especially with respect to traveling and the judgement of areas to be “green, orange or red”.
7What is the situation of children and the return to school. What about the treatment of non-Covid 19 patients (seems to have normalized by now). Is it like this in your country?
All children returned to school already in June and directly after the summer break. For young children there are no limitations and no need to stay home in case of a common cold. For older children the usual measures, such as social distancing etc. are in place. Because of the regular dropout of teachers because of (contact with) corona or burn-out, childen are sent home more often than before and remote digital education is again considered. As far as treatment of non-Covid 19 patients is concerned, this was nearly normalized. However, now with the expectations of new peaks of numbers of Covid 19 patients ahead it is feared that again problems for non-Covid 19 patients may arise. It is tried very hard to avoid that.
8Give scenarios: more lock-down, quarantaine (acceptable for the people?), what about travelling, what about economics. An alternative could be to report what we (and our colleagues) would tell our/their patients or to anybody when we/they are asked this kind of questions.
There is already more lock-down than before (see earlier) and it might be even stricter than that. A total lock-down, however, has never been employed in The Netherlands. Quarantaine is adviced (not compulsory) after air travel and visits to orange or red areas abroad and of course also after a positive test or after contact with a positive person. Unfortunately not everyone is convinced that this is a must, so the measure is not always adhered at. It is emphasized by the government repeatedly that people should adhere to this, but because of an unbalanced policy (no teststreet anymore at the airport, unsufficient test capacity) it is not always easy for the people to understand the urgency of the measure. Travel is very much limited, mainly restricted to the own country and only if safe. Unnecessary travel is advised against. Public transport is, however, fully available - with mouthcaps. The economics, as everywhere, is affected heavily. Mainly the sectors of transport, tourism, theaters/performances/arts, restaurants, hotels etc., sports and many more are dealing with big problems.

Update The Netherlands, October 21, 2020

Since the beginning of September numbers of positive tests are rising and now we have equal or even higher numbers than in March. We rank under the worst performing countries now, although people are less ill and younger than during the first wave. Numbers of hospital admissions are high (already a number of patients had to be replaced to hospitals in Germany), but there are less patients in the intensive care units than before. As a consequence of all this, restrictions have been adapted: mouthcaps in all public places, including shops; no teamsports (except professional football) and no visitors for all sports. All restaurants, cafés and bars are closed, cinemas and theaters are allowed only 30 people. At home not more than 3 visitors. Work at home as much as possible, no meetings in person. It has been tried to apply regional measures, but this failed and all measures now are countrywide.

Daniel Sereni, France, October 3, 2020

1What is happening now in your country: is the situation stable or are cases increasing, what about clusters and measures?

In France the number of Covid infections is increasing steadily since the beginning of August. More people than during last spring are tested (over 700 000 per week) but this does not suffice to explain the increase of positive cases. This rise in numbers is also provoked by a higher rate of positivity among tested people. One obvious explanation is the increase in indoors activities, the reopening of schools, universities, workplaces, etc. In early October the average number of new cases is over 10. 000 per day. We are clearly facing a new wave. But this surge is different from the first. An important difference to consider is the contamination rate or Ro coefficient which represents the numbers of persons contaminated from a single positive individual. This indicator reflects the rapidity of spreading of the virus in the population. In March Ro reached at peak level of 2.9; afterwards it decreased under 1.0 from April to June due to the confinement of the population. It started to increase again during summer but remained at a lower level than during the first wave: in the beginning of September RO was 1.4 with a tendency to a slight decrease at the end of the same month.

There is an important variability in the numbers of new cases between regions: more cases are observed in big cities and their suburbs. As a consequence of these new cases the number of hospitalised persons has also increased; but in the first days of October the situation remains under control as the capacity of the healthcare system is not overwhelmed.

Is the policy to do massive PCR tests, in order to find “positive asymptomatics”, effective?

The authorities are encouraging testing in the population. But this policy is limited by the capacity of the laboratories. Testing is also concentrated in areas with the highest number of cases and to contact people when a cluster has been identified. Unfortunately contact tracing remains unsufficently applied. Quarantine measures have been put in place in schools and workplaces. When a person is tested positive she is required to remain isolated at home for at least seven days after onset of symptoms or after the day of diagnosis if she is asymptomatic.

2What to advice to protect the most vulnerable people?
The most fragile people have been informed and measures have been taken to protect the most elderly, particularly in nursing homes. But a total confinement of these persons has been considered as unbearable and is no more recommended. The objective is to prevent their contamination by strict respect of protectvve measures.
3Do you have significant negationist movements against COVID in your country?. Do you think that these demonstrations should be permitted?
The negationists exist but are only a few. But not everyone accepts to follow the rules of protection like social distancing and wearing a mask.
Unfortunately there are still gatherings of people who take no precaution at all. This is frequently the origin of new clusters.
4What is the reason why lethality now is lower than in spring?
The proportion of severe cases is lower than during the first wave: the percentage of deaths among hospitalised patients is around 12% versus 25% in March. At the end of August only 10% of intensive care beds were occupied by Covid patients versus 138 % in April.These differences seem to be due to a higher proportion of young people among Covid positives. Young people generally have an asymptomatic infection or a mild disease. Another reason is the greater efficacy in the management of the severe patients, thanks to a better knowledge of the disease, improvement of care and use of new treatments . Besides the most fragile patients have already been hit by the first wave.
5Do you think that a more coordinated European strategy would improve the situation or does each country have to resolve its own problem? (here we can review FAQs 3)
The management of the pandemic demands various approaches. On one side it is important to take rapidly appropriate measures in a precise area: this is where fast local decisions are necessary. But at the same time it is also necessary to have a broader policy adapted to the fact that people travel from region to region. There is also the need for transport of equipments, medicines, devices etc, which can only be provided at the scale of a state. Issuing of regulations and measures to have them inforced is, at least in France, in the hands of the national government. But, above national governments and administrations, the existence of a European Union is extremely helpful in such a widespread epidemic. European agencies play an important role: the European Medicines Agency for development and availability of medicines and vaccines, the Center for Diseases Control for epidemiology. Europe is also providing coordination and funding for dedicated medical research and issuing regulations for prevention and care of the disease.
6What is the situation of children and the return to school?
Children have returned to schools early September. Protective measures are recommended. But they are difficult to apply. The number of cases among children remains limited and severe forms are exceptional in children.
7What about the treatment of non-Covid 19 patients (seems to have normalized by now). Is it like this in your country?
The present situation is obviously better now than in spring when a great part of medical resources were shifted to the care of Covid patients. But we continue to observe some negative consequences of the concentration of attention on Covid cases. For example the average number of surgical operations for retinal emergencies is presently lower than usual probably because patients could not and did not want to consult a specialist so that diagnostics were not made.
8Report what we (and our colleagues) would tell our/their patients or to anybody when we/they are asked this kind of questions.
The main messages I give to people are :
  1. During next fall and winter we must remained disciplined in applying the preventive measures: social distancing, wearing a mask and and hands washing.
  2. The situation will be better from the second quarter of 2021 because outdoor activities will again be more frequent so the number of contamination will decrease. Besides, it is higly probable that one or several vaccines will be put on the market during next year.
  3. But even if good vaccines are available in the first semester of 2021, it will take time before a sufficient percentage of the population is immuninised and the number of contamination stabilises at a low level. Voluntary preventive behaviour will still remain necessary.

Update France, October 22, 2020

The situation is gradually worsening since the beginning of October. The government has decided to implement new restrictions. Cafés and bars are closed, but restaurants remain open. A curfew from 9 pm to 6 am has been imposed in all French biggest cities plus the whole “grand Paris "area. Attendance in cinemas, theaters and stadiums is limited. Schools and working places remain open. There is no restriction to travel inside the country.

A new lockdown has been decided, starting the 30th of October in the whole country.

Ramon Pujol, Spain, October 10, 2020

1What is happening now in your country: is the situation stable or are cases increasing, what about clusters and measures?

In Spain the number of cases trends to increase in the last two weeks as does the number of hospital admissions and in the ICUs. These data are variable according to regions, being the community of Madrid the one that is the most worrying to the point that this weekend the state of alarm has been decreed.

The situation in the last week is worsening. More cases, more hospital admissions and more patients in the ICU. Now not only in Madrid, other Spanish regions have similar problems. Today a meeting of the president with all presidents of the 17th regional communities have decided that national curfew will be not ordered for the moment.

2Is the policy to do massive PCR tests, in order to find “positive asymptomatics”, effective?

It is effective in detecting new cases but not in reducing transmission. Having the asymptomatic infected identified is useful if strict isolation measures are followed accordingly.

PCR are performed in close contacts of cases and in individuals with clinical symptoms. Antigenic tests are also available for symptomatic (higher sensitivity) and some asymptomatic (lower sensitivity) groups.

3What to advice to protect the most vulnerable people?

The most vulnerable individuals must avoid contact with large groups of people as much as possible, especially in closed and poor ventilated places and without the usual protective measures (masks, hand washing and distance).

Now, the recommendation is to stay home as much as possible.

4Do you have significant negationist movements against COVID in your country? Do you think that these demonstrations should be permitted?

There has been some movement in this direction with a political background. They should not be prohibited but, at the same time, promoters who have no health-related interests should be investigated.

No changes in this topic.

5What is the reason why lethality now is lower than in spring?
Probably the virus has mutated and his lethal capacity has decreased; also the protection measures against contagion make the viral load of those infected lower.

Lethality is still lower than in the spring wave but this can change soon. The arrival of seasonal flu could act as an undesirable enhancer.

6Do you think that a more coordinated European strategy would improve the situation or does each country have to resolve its own problem? (here we can review FAQs 3)

Undoubtely, Europe must respond in a coordinated way and learn from each other the situation of the member countries. What is currently happening in Asia or America is of little help.

No changes in this topic.

7What is the situation of children and the return to school. What about the treatment of non-Covid 19 patients (seems to have normalized by now). Is it like this in your country?

The fear of the opening of schools and universities has not been a major problem except in isolated cases of orgies in some universities by groups of irresponsibles.

The situation in schools is similar. Few asymptomatic positive cases and few schools needed to close classrooms.

8Give scenarios: more lock-down, quarantaine (acceptable for the people?), what about travelling, what about economics. An alternative could be to report what we (and our colleagues) would tell our/their patients or to anybody when we/they are asked this kind of questions.

The current situation in Madrid is the paradigm. Citizens baffled by controversial measures between local and national governments and have led to a situation that we hope the state of alarm will stop.

The situation now has evolved to more severe restrictions: restaurants and bars closed, curfew in some regions but not lockdown so far.

A group of 55 Spanish scientific societies have published a decalogue addressed to politicians with the tittle : “You rule but you don’t know...how to manage the pandemic”.

Update Spain, October 22. 2020

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Mark Cranston, United Kingdom, October 15, 2020

1What is happening now in your country: is the situation stable or are cases increasing, what about clusters and measures?

The new system recently introduced by the UK government is explained here: https://www.gov.uk/guidance/local-covid-alert-levels-what-you-need-to-know#what-local-covid-alert-levels-mean/

Cases are increasing within the north and urban areas. Local and regional measures are in place as well as certain national ones ‘Rule of six’ i.e. no more than six people meeting together.

2Is the policy to do massive PCR tests, in order to find “positive asymptomatics”, effective?
There is mass testing amongst the population with symptoms. I am not aware of mass testing in order to find ‘positive asymptomatics’ I work in Cambridge University Hospital and 1000 staff were swabbed in June and 30 came back as asymptomatic positives. But I am aware of a strategy being carried out in the general population among a small number of people in an area to get a snapshot of asymptomatc positives – on a small scale I believe.
3What to advice to protect the most vulnerable people?
https://www.gov.uk/government/publications/guidance-on-shielding-and-protecting-extremely-vulnerable-persons-from-covid-19/guidance-on-shielding-and-protecting-extremely-vulnerable-persons-from-covid-19/
4Do you have significant negationist movements against COVID in your country? Do you think that these demonstrations should be permitted?
They exist, they are small and they are generally broken up by the police. I personally don’t think they should be permitted.
5What is the reason why lethality now is lower than in spring?
I believe it is too soon to answer that question as the UK is still in the midst of it’s second wave. The population who have had most cases are the young over the summer and are not as prone to serious complications as the frail elderly.
6Do you think that a more coordinated European strategy would improve the situation or does each country have to resolve its own problem? (here we can review FAQs 3)
Of course a consider unified agreement on economic and social measures in addition to the sharing of medical expertise and resources will surely be to the advantage of all. However, there is an element of locality that cannot be solved by strategy alone.
7What is the situation of children and the return to school. What about the treatment of non-Covid 19 patients (seems to have normalized by now). Is it like this in your country?
The children have returned to school in England in social ‘bubbles’ However, it is precarious and each school is vulnerable to positive cases and the impact on the physical and mental health of the young cannot be under-estimated. I believe there is a consequence for all of the time missed from school that will play out over the next couple of years.
8Give scenarios: more lock-down, quarantaine (acceptable for the people?), what about travelling, what about economics. An alternative could be to report what we (and our colleagues) would tell our/their patients or to anybody when we/they are asked this kind of questions.

I am seeing the non-COVID side-effects with more significant drug and alcohol/mental health problems as well as delayed diagnosis is cancer and the frail elderly who have deconditioned through shielding and the effects of the loneliness that brought.

Travelling and the economics of the loss of revenue to the aviation, hospitality and tourist industries is yet to be felt but will undoubtedly be large redundancies and the irreplaceable loss of certain infra-structure and cultural attractions etc.

More quarantine and less travel is likely and regional/local lockdown will continue for the next 12 months presumably.

Update United Kingdom, October 23, 2020

The situation is evolving almost daily. Wales and Northern Ireland have their own ‘circuit breakers’ with Scotland being far more cautious than England politically. The regions of England have a three tier level of restrictions. The north of the country is far more affected and is on the most strict isolation. It is a form of national lockdown that eventually come across the whole country but Cambridge still has a relatively low level of incidence.

Weddings are restricted to 15 people. Facemasks must be worn by all in shops and other places according to local rules (some schools and I believe most hospitals).

Families and friends are limited to groups of six maximum inside and outside. Working from home is encourage where possible.

There are many variances to rules on travel and meetings, which shops are open etc due to the devolved responsibilities of the nations within the UK.

The Foundation for the Development of Internal Medicine (FDIME),

Daniel Sereni, Ramon Pujol, Jan Willem Elte.

With the help of Imad Hatem, Nica Cappellini, Lorenzo Dagna, Chris Davidson, Runolfur Palsson, Stefan Lindgren, Vereny Briner, Werner Bauer (in random order).