On the 9th of November EL MUNDO newspaper published an article from the Cantabrian doctor Javier Crespo Garcia, Head of Digestive Medicine at Marques de Valdecilla Hospital in Santander, titled “The containment of the COVID-19 pandemic is possible: Self-diagnosis, geolocation and technological platforms”. This has had a remarkable social impact.
Dr Crespo is a prestigious doctor who specialises in Gastroenterology and Hepatology at the Marqués de Valdecilla University Hospital. He is also a lead professor at the University of Cantabria and a researcher focusing in the area of “clinical and translational research in digestive diseases”. Dr Crespo is also President of the Spanish Society of Digestive Pathology (SEPD).
“The containment of the COVID-19 pandemic is possible: Self-diagnosis, geolocation and technological platforms” is an essay in which Dr Crespo refers to the three aspects supported by the World Health Organization (WHO) for the containment of the COVID-19 pandemic: “test, treat and trace”. In his essay, Dr Crespo analyses the current situation, describing logistical problems such as those related to the completion of mass screenings and proposing alternative solutions.
Dr Crespo confirms that despite being eight months down the line since the beginning of the pandemic, mass testing is a long way away, trackers are conspicuous by their absence and contacts isolation is scarcely effective.
In relation to the diagnosis of infection, Dr Crespo wonders: Is it possible that we can self-diagnose? The answer leaves no room for doubt. Dr Crespo supports self-testing and discusses the possibility of testing the entire population at home, as well as screening in all kinds of centres that have a high footfall of people, such as hospitals, schools, work centres and sports facilities.
Containment of the COVID-19 pandemic is possible: Self-diagnosis,
geolocation and technology platforms.
Dr Javier Crespo
President of the Spanish Society of Digestive Pathology (EDPS)
The World Health Organization (WHO) defends the “test, treat and trace” trilogy as a holy grail of containment of the COVID-19 pandemic. However, as has been demonstrated in various countries around the world, one of the most difficult logistical problems to solve is the completion of mass screenings. There are several alternatives for these: the use of converted non-sanitary facilities, field hospitals, specially dedicated areas of some hospitals, pharmacies, etc. But despite being more than eight months since the start of the pandemic, mass testing is not in place, trackers are not visible, and the “surgical” isolation of contacts is scarcely effective.
The unequivocal finding of the failure of all SARS-CoV-2 containment measures must necessarily lead us to reflect on whether we can change the course of this pandemic with the containment measures applied so far. It leads to the question of whether instead of implementing 21st century measures, we have used processes from the early twentieth century. During these months, control has been attempted through interpersonal physical distance, the use of masks, a marked reduction of our social activity, limitation of movement, territorial and home lockdowns. The failure of these measures is therefore an obvious reality and the verification of a collective failure in the containment of this disease. Measures very similar to these were taken during the so-called Spanish flu in 1918, with a catastrophic results; should we now expect a different outcome?
Diagnosis of infection by this virus is based on the detection of RNA by a test called polymerase chain reaction (PCR) performed with nasopharyngeal samples, a procedure requiring specialized healthcare personnel, and centralized laboratory facilities. The progress made thus far in facilitating the study of this infection is impressive. For months, we have had serological tests, capable of highlighting the existence of antibodies against this virus, of extraordinary sensitivity and specificity, which would allow us to define precisely the current prevalence of this infection.
Recent studies have shown that the use of other bodily fluids, such as saliva, are useful for establishing the diagnosis of this infection, This has numerous advantages: the patient can obtain his sample easily and without discomfort, and does not require specialized health personnel for its management. Additionally, fast tests for application on-site that do not require sanitary facilities are available, with results available in a few minutes and that the patient himself can self-administer. But is it possible that we can self-diagnose?
Let’s look at an example. A few months ago, our working group analysed the prevalence of SARS-CoV-2 infection (data awaiting publication). We selected a group of people representative of the general population of Cantabria and sent them, by post, a quick test for the detection of antibodies against the virus, a link where they could access an online epidemiological questionnaire and an explanatory video informing them in detail of the procedure and even how to “upload” the results to this platform. A phone number and email address were made available for any type of query. That is, we carried out a study by what we could call telemedicine in a general population previously untrained and we analysed the effectiveness and potential barriers to the implementation of this type of intervention. The result of this innovative work was highly hopeful: more than 80% of the participating subjects were able to complete the entire study protocol and about 10% of the participants managed to finish the work with discreet remote assistance. These results suggest that the use of such a methodology is viable in our country.
As mentioned previously, according to WHO, massive testing is a key point in infection control, but in real life it presents enormous difficulties. For this reason, it should be considered a combination of massive self-testing, similar to that expressed in the previous example, in addition to screening in all types of centres that bring together a high number of citizens, such as hospitals, schools, work centres or sports facilities. The whole population, previously informed through an exhaustive informational campaign in both public and private media and social networks, would receive at home a quick test for serological diagnosis, a quick test for the diagnosis of potential active infection and a tube for saliva collection, a link to complete a short epidemiological questionnaire and a brief explanatory video of the whole process.
Each and every one of us should self-test with the quick tests, send the tube containing the saliva sample to the address indicated in the instructions and complete the online survey where we will include the result of the self-tests that we have done thus far. Saliva shall be sent to centralised laboratories where, depending on the previous results, they will decide the convenience of doing a conventional PCR. The overall results of this information, which has been obtained quickly and effectively, will be uploaded to a technological platform that will inform in real-time both individual and health authorities simultaneously. As a result of this action we can achieve diagnosis of infected, symptomatic and asymptomatic people, allowing the practice of “surgical” lockdowns which are exclusively limited to individuals with an active infection and their close contacts, facilitating the containment of the pandemic.
Undoubtedly, this represents a remarkable challenge; but less of challenge than COVID-19 itself sets out. It requires a high level of commitment from all public administrations and civil society as a whole, which must be involved in the solution to this challenge. An army of volunteers will be necessary to help people who are not trained for self-screening, remarkable investment in technological material, both material that can be inventoried and fungible material, a remarkable dose of enthusiasm will be necessary and the availability of a large group of experts who design the final operation with absolute precision will be essential. it is, in short, a country-wide project that responds to a global threat to our society as the present one. If we are able to mobilize the entire adult population, in an absolutely ordered manner, every four years and evaluate the result of the survey (the vote) in less than 24 hours, why can´t we make ourselves an extraordinarily simple, inexpensive and widely accessible self-test. And when we ask ourselves what should we choose, economy or health, we will be able to answer, we choose both health and economy.
It is true, this initiative will encounter numerous problems that will need to be solved. Perhaps the most important one for its success is the requirement of universal participation. This objective will only be viable with accompanying social and economic measures that facilitate self-isolation. Economic compensation, automatic stigma-free time off work or the implementation of different fiscal measures during the period of self-isolation will be essential to the success of this comprehensive plan.
Other measures will also be necessary for the success of the programme, such as the availability of quarantine accommodation for people whose homes are not fit for purpose and the availability of social services staff to support vulnerable people. The use of technological platforms and the geolocation of infected people somehow restrict our rights. But this restriction, whose only purpose is to cut off the transmission of the disease in a similar way to that achieved by some Oriental countries is, in my opinion, justified if we want to simultaneously preserve our health and our way of living. Without a doubt, a state of alarm that limits our freedom of movement and enforces home lockdowns is more intrusive of our rights than the geolocation and use of different telematic codes, assigned by our health administrations.
With a new lockdown in the horizon, our healthcare system will be tested all over again, through weeks of intense care pressure. Our hearts will suffer due to hundreds or thousands of citizen deaths. But if we can put into practice the above-mentioned plan, which is ambitious but possible, we will keep our hope intact. This second outbreak will be the last, we will not suffer further lockdowns, we will be able to contain the infection with low levels of incidence until finally one or more vaccines become available, which control this infection in the long run. No, we mustn’t get carried away with optimism. But let’s at least allow science to lead us down the path of hope.