One year later: lessons learned during and after the activity of the coronavirus hotline in the canton of Fribourg
“He went like one that hath been stunned,
And is of sense forlorn:
A sadder and a wiser man,
He rose the morrow morn.”
From: Samuel Taylor Coleridge, The Rime of the Ancient Mariner, 1834
One year ago, from 18 March to 15 June 2020, three physicians answered medical questions of callers to the coronavirus hotline in the canton of Fribourg. The details of the activities, type of questions, advice given, the correlation between the symptoms and results of the tests and some observations on the outcome at 3 months are reported in a separate publication. Looking back today, some lessons should be retained.
First, the staff running the hotline, as well as all organisers involved in the management of the first wave, had to lead a fight against a new enemy they were not familiar with, and take decisions based on the best possible assumptions, with limited technical resources. As new evidence emerged and delivery of test, consumables and protective devices increased, changes in procedures occurred. A recent book from the Historical Society of the canton of Fribourg describes very well the huge managerial problems induced by the pandemic . There were gaps in communication between persons involved in the management of the situation and, in spite of all plans, most people were taken by surprise. Deficient communication or contradictory information sometimes induced uncertainties among the population and healthcare workers themselves, as reported by a recent Swiss survey .
Second, the testing strategy, owing to limited access to the tests, was insufficient and allowed possible transmission of the virus from persons with mild symptoms not severe enough to justify a test. This may have contributed to the extension of the epidemic. During the first wave, only polymerase chain-reaction (PCR) tests were available, with delays of up to several days between the sampling and communication of the results. The availability of rapid tests, which seem to be better correlated with the presence of live virus , during the second wave and the extension of testing not only to persons with symptoms but to all exposed contacts, probably allowed for a better control of the chain of transmission. As the testing was initially restricted to persons with severe symptoms needing hospitalisation, the absolute number of cases notified during the first wave was probably much lower than the real number of people infected by the coronavirus, giving the impression that the second wave was much more severe than the first one. One argument for this is the fact that the mortality rate was higher during the first wave than during the second, but this could also have been due to a better management of severe cases during the second wave. A study from Spain published in July 2020 confirmed that a large number of persons who were not tested during the acute clinical phase of the COVID-19 had a positive serology and up to one third of them never experienced symptoms . A similar difference between the number of inhabitants with a positive serology in summer 2020 and the real number of persons notified of a positive PCR test was observed in Fribourg . We have also learned to differentiate between test positivity and clinical disease, with an emerging group of the population testing positive but without clinical disease. The main question remains how to assess the risk of transmission between these infected but asymptomatic persons and their contacts .
The observation gathered during the hotline activities confirmed that the symptoms induced by the SARS-CoV2 infection were very diverse, sometimes difficult to distinguish from influenza and without clear correlation with the positivity of the PCR test. In some cases, particularly if the test was performed in the early phase of the disease, the tests had to be repeated to demonstrate a conversion from negative to positive. The detection of infection cannot rely solely on the clinical symptoms but has to integrate the test results, and sometimes the serology is needed to confirm a prior infection.
Another important learning point is the fact that many patients who recovered from the COVID-19 complained of persistent symptoms, mainly prolonged tiredness, as reported by a limited group of patients who called the hotline. This was unusual, difficult to explain and treat, and may have serious consequences, for instance among healthcare personnel . Months later, so-called “long COVID” has been identified in a large proportion of former patients, although its exact cause remains unknown [8, 9]. Further sequelae from the infection have now been well described, mainly in patients who were hospitalised for severe infections .
Finally, when the activities of the hotline came to an end, in June 2020, many people believed that life would soon be the same as before the pandemics and were prone to forget all precautions. One year later, we have to admit that social, cultural and economic life is still deeply disturbed, and the impact of the coronavirus on life expectancy is evident . The only positive message is that efficient vaccines became available at a speed that nobody could foresee and that we now have a tool for the control of the pandemic . The price to pay for this good news was high but there was no other option. We may feel sadder about that, but did we become wiser men?
Jean-Pierre Zellweger, Pulmonary physician, Villars-sur-Glâne, Switzerland, jean-pierre.zellweger[at]hin.ch
- de Steiger A, Steinauer J. Urgence: L'Etat de Fribourg face au Covid-19. Société d'Histoire du canton de Fribourg; 2021.
- Gilles I, Perriraz M, Lesage S, Rawlinson C, Peytremann-Bridevaux I. [Experience of the first wave of Covid-19 by the professionals of 11 hospitals in French-speaking Switzerland]. Rev Med Suisse. 2021;17(730):514–7.
- Dinnes J, Deeks JJ, Adriano A, Berhane S, Davenport C, Dittrich S, et al.; Cochrane COVID-19 Diagnostic Test Accuracy Group. Rapid, point-of-care antigen and molecular-based tests for diagnosis of SARS-CoV-2 infection. Cochrane Database Syst Rev. 2020;8:CD013705.
- Pollán M, Pérez-Gómez B, Pastor-Barriuso R, Oteo J, Hernán MA, Pérez-Olmeda M, et al.; ENE-COVID Study Group. Prevalence of SARS-CoV-2 in Spain (ENE-COVID): a nationwide, population-based seroepidemiological study. Lancet. 2020;396(10250):535–44. doi:https://doi.org/10.1016/S0140-6736(20)31483-5.
- Anker D, Chiolero A, Epure A, Magnin JL, Schmid A, Carmeli C, Rodondi PY, Cullati S. Corona immunitas Fribourg: immunité de la population, épisode 1/2020. Université de Fribourg, Laboratoire de santé des populations (#PopHealthLab); 2020.
- Sakurai A, Sasaki T, Kato S, Hayashi M, Tsuzuki SI, Ishihara T, et al. Natural History of Asymptomatic SARS-CoV-2 Infection. N Engl J Med. 2020;383(9):885–6. doi:https://doi.org/10.1056/NEJMc2013020.
- Praschan N, Josephy-Hernandez S, Kim DD, Kritzer MD, Mukerji S, Newhouse A, et al. Implications of COVID-19 sequelae for health-care personnel. Lancet Respir Med. 2021;9(3):230–1. doi:https://doi.org/10.1016/S2213-2600(20)30575-0.
- Nehme M, Braillard O, Alcoba G, Aebischer Perone S, Courvoisier D, Chappuis F, et al. COVID-19 Symptoms: Longitudinal Evolution and Persistence in Outpatient Settings. Ann Intern Med. 2021;174(5):723–5. doi:https://doi.org/10.7326/M20-5926.
- Sudre CH, Murray B, Varsavsky T, Graham MS, Penfold RS, Bowyer RC, et al. Attributes and predictors of long COVID. Nat Med. 2021;27(4):626–31. doi:https://doi.org/10.1038/s41591-021-01292-y.
- Morin L, Savale L, Pham T, Colle R, Figueiredo S, Harrois A, et al.; Writing Committee for the COMEBAC Study Group. Four-Month Clinical Status of a Cohort of Patients After Hospitalization for COVID-19. JAMA. 2021;325(15):1525–34. doi:https://doi.org/10.1001/jama.2021.3331.
- Wanner P. A precise measure of the impact of the first wave of COVID-19 in the life expectancy: regional differences in Switzerland.
- Desmond A, Offit PA. On the Shoulders of Giants - From Jenner’s Cowpox to mRNA Covid Vaccines. N Engl J Med. 2021;384(12):1081–3. doi:https://doi.org/10.1056/NEJMp2034334.