France and COVID-19, How is it Grappling with the Pragmatics of Isolation

An interesting comment by Atlani-Dualt & Others published October 9, 2020 in the Lancet Public Health.

They suggest that the current phase of COVID-19 is forcing countries to choose between two strategies: one based on individual responsibility, and the other on coercive measures – the carrot and stick, a popular analogy.

Coercive isolation might be justified during emergencies, but its effectiveness during a long-term management phase is unproven in liberal democracies.

If isolation is imposed, people might either avoid testing and withhold contact information or reject COVID-19 regulations entirely.

In France, resistance to coercive interventions could plausibly fuse with protest movements such as the yellow vests.

The authors share two policy recommendations issued on 9 September 2020 by France’s independent COVID-19 scientific council appointed in March by President Macron.  Their recommendations were to shorten the official quarantine period to seven days and to offer incentives framed as rights to complement the duty of adhering to COVID-19 regulations.

In April and May 2020 respectively, the European Centre for Diseases Prevention and Control and the WHO updated their criteria for discharge from isolation from 14 to 10 days after disease onset. 

However, on the basis of robust scientific evidence and the French lead, several European countries are now considering reducing the quarantine to seven days.  Belgium announced a seven day quarantine period on September 23, 2020. 

Infectious viral shedding from infected individual comes from airway secretions and is best measured by the PCR nasopharyngeal swab. 

Transmission occurs almost exclusively during the first week, when high RNA concentration is detected.  Concentration decreases over time, remaining detectable up to 30 days after disease onset.

Transmission after day 7 is rarely reported except in severe cases or immunocompromised patients, and this timing is supported by a surrogate approach showing an absence of cultivable virus from clinic sessions after day 7 to 8.

The incubation period lasts between 2 days and 12 days with a median of 5.2 days.  Virus is detected in few cases beyond day 10 and transmission had been documented two to three days before symptom onset. 

Thus, they argue an effective isolation period for confirmed cases and contacts can be rationally decided, allowing strict isolation for potentially infective cases and avoidance of subsequent transmission during to the high shedding (contagious period).

In symptomatic cases, after day 8 of symptom initiation in the absence of fever, isolation can be lifted and residual risk controlled by vigorous wearing of surgical masks, hand washings and physical distancing for an additional week.

If fever remains, isolation must be maintained and patient follow-up must be carried out by an attending physician.  This strategy should not apply to patients who are admitted to hospital or immunocompromised patients.

For asymptomatic cases, the proxy for symptom onset is the date of collection of the positive sample (i.e. isolation seven days after the date of the positive sample).  If symptoms appear rapidly, isolation should be extended by one week after symptom onset. 

For contacts, isolation should be based on average incubation periods and pre-symptomatic viral excretion.  Therefore, for contacts, the seven day isolation should start immediately.

If contacts become symptomatic, they must be tested.  In the absence of the symptoms on day seven, a PCR screening swab should be performed.  This timing allows sample detection of pre-symptomatic or asymptomatic cases and corresponding surveillance until days 9 or 10, after which the risk of becoming symptomatic is very low.  A negative result should allow isolation to be lifted. 

Shortened quarantine should increase social acceptance of isolation, but additional measures are required.  Along with the continued use of barrier equipment, physical distancing and the test, trace, isolate strategy, the authors have recommended promotion of the duty of solidarity and provision of incentives and compensation framed as rights.

People who voluntarily self-isolate should have the right to claim paid work leave consistent with existing guarantees; loss of income payments for self-employed professionals and for those who cannot document regular incomes; medical school absence certificates for children of self-isolating parents; and payments for home care needs such as food, healthcare and social work. 

The French government accepted the shorter quarantine on September 11.  However, it has not as yet adopted the recommended incentives.

Since his appointment, the French COVID-19 scientific counsel has tried to bridge the historical tension between two French public health traditions: On the one hand a technocratic state, humanitarian verticalism, and on the other hand a universalist approach integrated with the welfare state social protections.

Currently, in this new phase, the concern is to maintain this balance and to avoid over verticalising the response, and to protect or support the economy while reducing COVID-19’s impact on health.  Without the incentives, the authors are concerned that France and other countries entering this second phase, although I would argue that this is the first phase just continuing, risk stumbling into a situation which is neither efficient coercion nor broad self-compliance, with the predictable if not inevitable outcomes of rising rates of infection, resurgence of the pandemic, imposition of coercive measures, and civil unrest in response.

Unfortunately, history illustrates when unrest threatens, governments tend to lose their belief in carrots instead of organising a debate about different options and feel obliged to pick up the stick. 

Such a debate might have been impossible in the pandemic’s first phase, however, in this current phase, it is time to move from the verticalist technocratic approach to one which is more inclusive and open. 

The London General Practice calls on all governments, all nations and all parties to work together to look after their populations and provide an effective means for destroying and managing this COVID-19 pandemic.