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 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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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).
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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”.
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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.
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.
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).