Imagine a dystopian society, where each citizen is constrained to a series of behaviors limiting not only his individual, but collective freedoms. In this society there is a presumption of guilt: everyone is guilty until proven innocent. Moreover, it is impossible to convince of his innocence, because no proof is admissible, but any demonstration of the opposite is routine. The state, which records misdeeds, also tracks the potentially harmful actions of its citizens. Cautionary behavior is reinforced under penalty of punishment and encouraged under the banner of a moral duty. For this, different communication tools are used to persuade citizens, including a stigmatizing vocabulary. And the element that completes the whole is the reproduction of the same operation by the neighboring states.
As you can see, this is a dramatized description of the crisis we have been experiencing for a year now. If various societal emergencies can justify suspending the usual functioning of a democracy (of which war and pandemics are a part), this type of society would be designated as totalitarian in the absence of powerful justifications(extraordinary assertions require extraordinary proofs as Carl Sagan used to say). The implementation of heavy measures in our society was based on the threat (related to the lethality) of the coronavirus and the maintenance of these conditions is based on the number of contaminated (and potentially contaminating) people. Both justifications deserve to be revisited.
At the beginning of the crisis, the case fatality rate used for SARS-CoV‑2 was the apparent case fatality rate. In other words, mortality due to COVID-19 was calculated based on the number of people who died relative to the number of patients. With this high rate, fear was used to justify widespread containment. Even if I am not convinced of the interest of the measures taken at the time to fight against the epidemic with the information that was then available (I detailed the reasons in a previous article Errare humanum est, perseverare diabolicum(1)), the surprise effect and the mimicry of neighboring countries could be used to defend the decisions taken. But this apparent case fatality rate really only reflects the state of our health care system, which was too overwhelmed to care for patients. And drastic measures such as severe reduction (or even cessation) of commercial activities, culture, services, health care (excluding COVID), sports, social activities, etc. can only be short term solutions in my opinion. Indeed, the collateral damage including several categories of victims: those of health impacts (lack and postponement of care), psychological (domestic violence, saturation of child psychiatric admissions, suicides…), economic (bankruptcies, job losses) etc.,… increase with time until a tipping point is reached, where these damages become more important than the threat that is being fought. Therefore, the threat of the coronavirus must be constantly re-evaluated and the continuation of heavy measures is only justifiable on the basis of a lethality rate that clearly exceeds that of collateral victims.
To do this, it is necessary to calculate the infection fatality rate. This number is automatically lower than the apparent rate, because COVID-19 victims are not only linked to the sick, but also to healthy carriers of the virus. Indeed, a person can have contracted the virus without showing any symptoms (called asymptomatic). And it is the consideration of these asymptomatic people that I think is the real crux of the problem.
When healthy carriers were discovered (a common occurrence in infectious diseases), rather than reassure itself of a lower than initially calculated case fatality rate, the government took a stand. He concluded that from then on, everyone, sick or not, was a potential threat. A press article published by the RTBF on April 13, 2020 informed us that the containment of the virus is even more complex, because the [personnes asymptomatiques] do not know they are sick ( …) The infectious disease specialist contributing to the article spoke of those sick people who do not know they are (…) How many are there? For the moment it is impossible to know(2). Our society has jumped with both feet into the expression of Jules Romain: Every healthy man is a sick man who ignores himself (in « Knock or the Triumph of Medicine »).
Thus, since the first year of the pandemic, we are still in a ready-to-wear mode: one measure applied to everyone. We have accumulated considerable knowledge since the beginning of the epidemic and can now identify the profiles of vulnerable people, the overwhelming majority of whom are elderly and/or have co-morbidities (such as obesity or diabetes). And unlike diseases such as polio, COVID-19 does not primarily affect children and does not leave them with any after-effects. Children constitute a considerable fraction of the asymptomatic. According to the report of the European Centre for Prevention and Control(3), children are
- less frequently ill than adults and are rarely severely affected and
- less likely to be contaminated and contaminating in turn.
Furthermore, educational personnel are no more at risk of being contaminated than people in other occupations, and closing schools should be a last resort given the impact it would have on education, mental and physical health, and the economy and society at large. Therefore, the question around the closing of schools and the potential imposition of masks on children in my opinion should not even arise. Analysis of the data on COVID-19 and transmission of the virus shows that the severity of the disease increases with age across the population(4). Because the elderly have less robust immune systems overall than younger age groups, they are more vulnerable(5). This would explain, by the same logic, why people with other diseases are at greater risk of developing more dangerous forms of COVID-19.
But the burning question is how the virus is transmitted by healthy carriers. While several studies suggest that asymptomatic people contribute to only a small fraction of infections(6), thus contradicting the presumption of infectiousness of any person (which is the current position of our society), the scientific literature remains divided on the subject. Several factors account for the lack of consensus, including confusion between the terms « asymptomatic » and « presymptomatic » and uncertainty about the timing of symptom onset in ill patients. Unlike the « asymptomatic » (carriers who will never become ill), the« pre-symptomatic » are carriers of the virus who are healthy today, but ill tomorrow (and who will therefore become symptomatic). The contagiousness of these two categories is essentially related to two factors: the viral load released by the carrier of the virus (i.e. the number of viral particles exhaled) and the capacity of any recipient to defend himself against infection. As this second factor has already been discussed above, what about viral load? There is surprisingly little literature on the viral load related to coronavirus, information that is crucial for studying an epidemic and managing a crisis (this is not specific to Belgium, even if it wants to be a global player in biotechnology(7)).
Studies examining the dynamics of SARS-CoV‑2 suggest that viral load is likely to be highest at the earliest onset of symptoms(8). A logic explaining the transmission of the virus by different categories of people can thus be proposed: the viral load is dependent on the capacity of our body to fight the virus. Asymptomatic people have no symptoms because the virus has been neutralized by their immune system. They can only transmit a very low viral load. Presymptomatic patients, on the other hand, are likely to produce the most particles at the onset of the first symptoms, before the immune system can take over (the mobilization of the immune defense explains the symptoms). Symptomatic patients have the highest viral load (which is related to the severity of their condition)(9)) and are more likely to transmit the virus by coughing or sneezing, etc., if their viral load reaches a certain threshold for contamination to occur (which would probably be of the order of one million viral particles released(10)). It should be noted that this threshold remains undefined, which is incomprehensible to me, given that we have already been confronted with this virus for a year.
If the carriers of the virus only present a threat of the most serious contagion when the first symptoms appear and the clinical profiles of vulnerable people are known, is there still a reason to impose the heavy measures on everyone? Our society justifies this on the basis of quantity (the number of infected) rather than quality (the threat posed by those infected) and one of the problems contributing to this health crisis is the use of PCR as the sole means of testing for SARS-CoV‑2. This technique does not inform about the contagiousness of the virus carrier. PCR detects the presence of the virus in the manner of a fingerprint and therefore does not tell us anything more about the virus than the fingerprint tells us about the behavior of its owner. It should only be used to differentiate among patients (i.e. symptomatic) those with COVID-19 from those with another respiratory disease. As a general rule, it should be noted that in science any test must be confirmed by a complementary method at the risk of having biased data. In the case of PCR as a single screening tool, « phantom » outbreaks have been described in the past(11).
The inertia of our government to change its preventive strategy seems to me to be due to an all-or-nothing model. The State functions according to a deontological ethic, which means that rules must be respected as a matter of principle and in all circumstances ( never steal, perjure yourself, kill…). Therefore, any practical objection, such as the calculation of collateral victims in comparison to direct victims of COVID-19, is considered immoral. Indeed, the questioning of the price to be paid for the maintenance of sanitary measures falls into another domain of ethics called consequentialist, which consists in weighing the pros and cons of each action. The drifts of consequentialism pointed out by deontologists concern the sacrifice of a minority for the well-being of a majority. In the face of the health crisis, advocates of the measures denounce a neglect of the vulnerable (and especially the older generation) by those who are not at risk in the name of supposed leisure, which leads to an often very perverse and abusive guilt-tripping of young people. Yet the call for a review of measures is not about sacrifice, but rather about establishing precautions based on science and with the goal of specifically protecting the population at risk. Moreover, the vaccination strategy chosen by our leaders is based on collective immunity. However, herd immunity can also be achieved through transmission of the virus within the non-vulnerable population (including children), so the two strategies are not mutually exclusive.
It is time to establish precautions made (no punintended ), rather than persisting with sanitary rules in ready-to-wear. It is important that we get off the slippery slope to a health dystopia, where the rights of the citizen will continue to be violated in the name of hygiene. This is what demonstrations such as Still standing for culture or Trace your circle and citizen collectives such as Belgium United for Freedom are calling for. The divide in our society between the various pro and anti is growing every day, tending towards a quasi-religious level. Indeed, I recently discovered the term « coronasünde », a German word for a sin-corona. It describes the occasional side step by social pressure in people who respect sanitary measures. Hopefully, this divide will stop deepening, but to do so, it would be necessary to adapt our model to our understanding of the epidemic. For me, this absolutely has to do with our society’s view of healthy carriers of the virus.
I invite the readers of this article to re-examine their vision of this societal crisis (even if the fruits of their reflections would lead them to the positions they already held). Whether readers agree or disagree with my perception of the crisis, one thing can unite us: the need to revise the health care budget in this country. Let’s make every sick man a healthy man who doesn’t know it.
- Errare Humanum Est – Perseverare Diabolicum, https://www.kairospresse.be/article/errare-humanum-est-perseverare-diabolicum/
- Coronavirus en Belgique : malades asymptomatiques, la grande inconnue ? RTBF https://www.rtbf.be/info/societe/detail_coronavirus-en-belgique-malades-asymptomatiques-la-grande-inconnue?id=10481260
- ECDC enfants : COVID-19 in children and the role of school settings in transmission — first update, https://www.ecdc.europa.eu/en/publications-data/children-and-school-settings-covid-19-transmission
- Levin AT, Hanage WP, Owusu-Boaitey N, Cochran KB, Walsh SP, Meyerowitz-Katz G. Assessing the age specificity of infection fatality rates for COVID-19: systematic review, meta-analysis, and public policy implications. Eur J Epidemiol. 2020 Dec;35(12):1123–1138. doi: 10.1007/s10654-020–00698‑1. Epub 2020 Dec 8. PMID: 33289900; PMCID: PMC7721859.
- Chen Y, Klein SL, Garibaldi BT, Li H, Wu C, Osevala NM, Li T, Margolick JB, Pawelec G, Leng SX. Aging in COVID-19: Vulnerability, immunity and intervention. Ageing Res Rev. 2021 Jan;65:101205. doi: 10.1016/j.arr.2020.101205. Epub 2020 Oct 31. PMID: 33137510; PMCID: PMC7604159.
- Deux exemples d’articles concernant le faible de contagiosité des asymptomatiques: Qiu X, Nergiz AI, Maraolo AE, Bogoch II, Low N, Cevik M. Defining the role of asymptomatic and pre-symptomatic SARS-CoV‑2 transmission — a living systematic review [published online ahead of print, 2021 Jan 20]. Clin Microbiol Infect. 2021;S1198-743X(21)00038–0. doi:10.1016/j.cmi.2021.01.011; Cao S, Gan Y, Wang C, Bachmann M, Wei S, Gong J, Huang Y, Wang T, Li L, Lu K, Jiang H, Gong Y, Xu H, Shen X, Tian Q, Lv C, Song F, Yin X, Lu Z. Post-lockdown SARS-CoV‑2 nucleic acid screening in nearly ten million residents of Wuhan, China. Nat Commun. 2020 Nov 20;11(1):5917. doi: 10.1038/s41467-020–19802‑w. PMID: 33219229; PMCID: PMC7679396.
- Emploi. Expert en biotechnologie? Partez en Belgique, https://www.courrierinternational.com/article/emploi-expert-en-biotechnologie-partez-en-belgique
- Deux exemples d’articles concernant la charge virale des pré- et asymptomatiques: Savvides C, Siegel R. Asymptomatic and presymptomatic transmission of SARS-CoV‑2: A systematic review. Preprint. medRxiv. 2020;2020.06.11.20129072. Published 2020 Jun 17. doi:10.1101/2020.06.11.20129072; Cevik M, Kuppalli K, Kindrachuk J, Peiris M. Virology, transmission, and pathogenesis of SARS-CoV‑2. BMJ. 2020 Oct 23;371:m3862. doi: 10.1136/bmj.m3862. PMID: 33097561.
- Fajnzylber J, Regan J, Coxen K, Corry H, Wong C, Rosenthal A, Worrall D, Giguel F, Piechocka-Trocha A, Atyeo C, Fischinger S, Chan A, Flaherty KT, Hall K, Dougan M, Ryan ET, Gillespie E, Chishti R, Li Y, Jilg N, Hanidziar D, Baron RM, Baden L, Tsibris AM, Armstrong KA, Kuritzkes DR, Alter G, Walker BD, Yu X, Li JZ; Massachusetts Consortium for Pathogen Readiness. SARS-CoV‑2 viral load is associated with increased disease severity and mortality. Nat Commun. 2020 Oct 30;11(1):5493. doi: 10.1038/s41467-020–19057‑5. PMID: 33127906; PMCID: PMC7603483.RAG interpreation and reporting of SARS COV‑2 PCR results
- Quelques sources concernant la charge virale nécessaire pour la culture du coronavirus, utilisée pour l’extrapolation d’un seuil de contamination: Wölfel R, Corman VM, Guggemos W, Seilmaier M, Zange S, Müller MA, Niemeyer D, Jones TC, Vollmar P, Rothe C, Hoelscher M, Bleicker T, Brünink S, Schneider J, Ehmann R, Zwirglmaier K, Drosten C, Wendtner C. Virological assessment of hospitalized patients with COVID-2019. Nature. 2020 May;581(7809):465–469. doi: 10.1038/s41586-020‑2196‑x. Epub 2020 Apr 1. Erratum in: Nature. 2020 Dec;588(7839):E35. PMID: 32235945; Qiu X, Nergiz AI, Maraolo AE, Bogoch II, Low N, Cevik M. Defining the role of asymptomatic and pre-symptomatic SARS-CoV‑2 transmission — a living systematic review [published online ahead of print, 2021 Jan 20]. Clin Microbiol Infect. 2021;S1198-743X(21)00038–0. doi:10.1016/j.cmi.2021.01.011; La Scola B, Le Bideau M, Andreani J, Hoang VT, Grimaldier C, Colson P, Gautret P, Raoult D. Viral RNA load as determined by cell culture as a management tool for discharge of SARS-CoV‑2 patients from infectious disease wards. Eur J Clin Microbiol Infect Dis. 2020 Jun;39(6):1059–1061. doi: 10.1007/s10096-020–03913‑9. Epub 2020 Apr 27. PMID: 32342252; PMCID: PMC7185831; RAG interpretation and reporting of SARS COV‑2 PCR results (Sciensano) https://covid-19.sciensano.be/sites/default/files/Covid19/20201208_Advice%20RAG%20Interpretation%20and%20reporting%20of%20COVID%20PCR%20results.pdf
- Outbreaks of Respiratory Illness Mistakenly Attributed to Pertussis — New Hampshire, Massachusetts, and Tennessee, 2004—2006; https://www.cdc.gov/mmwr/preview/mmwrhtml/mm5633a1.htm