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This statement was originally published in The Lancet on 2021-01-21.

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Un plan de acción para la defensa paneuropea contra las nuevas variantes del SARS-CoV-2

Authors: Viola Priesemann, Rudi Balling, Melanie M. Brinkmann, Sandra Ciesek, Thomas Czypionka, Isabella Eckerle, Giulia Giordano, Claudia Hanson, Zdenek Hel, Pirta Hotulainen, Peter Klimek, Armin Nassehi, Andreas Peichl, Matjaž Perc, Elena Petelos, Barbara Prainsack, Ewa Szczurek

This translation was provided by María Jesús Díaz Candamio

Los casos de COVID-19 están aumentando en Europa. Las medidas actuales no están reduciendo suficientemente la propagación del virus y están surgiendo nuevas variantes del SARS-CoV-2. Las variantes B.1.1.7 y B1.351, identificadas por primera vez en el Reino Unido y Sudáfrica, respectivamente, se han extendido a muchos países europeos1,2,3,4,5. Aunque sus propiedades biológicas aún están por caracterizar, los datos epidemiológicos sugieren que estas variantes tienen una mayor transmisibilidad6,7. Estas propiedades virales podrían incrementar el número de reproducción efectiva R en la población. En el caso de B.1.1.7, las estimaciones sugieren que R podría aumentar de 1 a aproximadamente 1,4 si no hay cambios en el comportamiento de la población3,4. Si es cierto, muchos países que han reducido R a 1 o menos se enfrentarán a una nueva ola de propagación viral a pesar de las medidas actuales8,9. Una vez que se haya establecido una variante más contagiosa, será cada vez más difícil estabilizar el número de nuevas infecciones.

A pesar de la disponibilidad de vacunas eficaces, la producción y la vacunación llevarán meses. Los países tendrán que gestionar un elevado número de casos y su impacto adverso durante los próximos meses. Con el lento aumento de la inmunidad de la población y la presión de selección evolutiva sobre el virus, continuará la aparición de nuevas variantes del SARS-CoV-2, lo que podría conducir a variantes más contagiosas y a variantes que podrían hacer que las vacunas sean menos efectivas. Estas variantes podrían exacerbar rápidamente la crisis, mucho antes de que se vacune a un número suficiente de personas. Mientras se esperan datos experimentales para comprender los rasgos de las nuevas variantes, deben tomarse decisiones paneuropeas y deben tomarse medidas de inmediato para contener la propagación de nuevas variantes.

Si no se toman medidas para prevenir la propagación de nuevas variantes con ventajas selectivas, aumentará el número de casos y los ingresos hospitalarios. Tal aumento podría conducir al colapso de los sistemas de atención de la salud. En muchos países, los hospitales ya no pueden brindar una atención de la calidad habitual a todos los pacientes. Muchas unidades de cuidados intensivos ya están por encima de su capacidad y los procedimientos que no son urgentes se han pospuesto durante semanas o meses. El diagnóstico tardío y las dificultades en la atención a otras enfermedades plantean riesgos de salud adicionales no solo para los pacientes con COVID-19, sino para toda la población.

Los profesionales de la salud y otros trabajadores de primera línea ya han estado trabajando en condiciones extremas durante la mayor parte del año pasado, y esto ha tenido un impacto severo en su salud física y mental. Si variantes como B.1.1.7 conducen a un nuevo aumento de casos, esto podría abrumar a los trabajadores sanitarios, llevando los sistemas sanitarios al límite. Garantizar que se alivie la carga que pesa sobre los profesionales sanitarios y, al mismo tiempo, salvaguardar la sostenibilidad del sistema es de vital importancia. El apoyo adecuado para estas fuerzas cruciales podría requerir fondos adicionales.

La contención y la mitigación es un desafío aún mayor al surgir una variante más infecciosa. Suponiendo que la variante B.1.1.7 aumenta R de 1 a aproximadamente 1.4, y luego permite que se propague sin un cambio en el comportamiento de las personas, se puede esperar que el número de casos se duplique cada semana. Serán necesarios grandes esfuerzos para reducir R a 1 o menos y recuperar el control. Actuar antes de que B.1.1.7 se haya extendido ampliamente significa que esos mismos esfuerzos importantes podrían reducir considerablemente el número de casos nuevos y ralentizar el establecimiento de B.1.1.7.

Swiss cheese model including new variants
This work by Riina Rupponen is licensed under CC BY 4.0

Europa debe actuar ahora para retrasar y prevenir una mayor propagación del SARS-CoV-28,9, en particular B.1.1.7, incluso en ausencia de datos experimentales finales. Es necesario formular un plan claro para la acción paneuropea inmediata y el establecimiento rápido de medidas de salud pública, ya que es probable que sigan surgiendo nuevas variantes con mayor infectividad. Sugerimos posibles medidas básicas en el panel. El principio rector es reducir el número de casos lo más rápido posible, ya que esto tiene grandes ventajas para la salud, la sociedad y la economía8,9. La acción conjunta de todos los países europeos hará que cada esfuerzo nacional y local sea más efectivo e impactante y, por lo tanto, contribuirá a proteger la salud pública en toda Europa8.

Cuanto más duran las restricciones y menos efectivas se vuelven, más se agotan los recursos psicológicos, sociales y económicos de las personas. Como las nuevas variantes requieren medidas aún más estrictas y más largas que las medidas existentes, es de suma importancia garantizar que las personas con cargas particularmente pesadas reciban apoyo financiero y social, que las cargas sociales se distribuyan de manera justa y que los servicios de salud mental satisfagan la creciente demanda para hacer frente al duelo, aislamiento, pérdida de ingresos, miedo, abuso de alcohol y drogas, insomnio y ansiedad como resultado de la pandemia y las estrategias de encierro. También se deben considerar los factores contextuales y los factores que afectan el comportamiento de riesgo, como la percepción del riesgo.

Los principios básicos de acción son evitar la importación de nuevas variantes, prevenir su propagación y mejorar la vigilancia molecular. Cuanto antes y más eficazmente actúen los países, antes se podrán relajar las restricciones. Todos los tipos de medidas deberían coordinarse y sincronizarse en toda Europa. Cada reducción adicional del contagio (es decir, de R) cuenta, ya que reduce la duración necesaria de las medidas estrictas más que proporcionalmente.

  1. Lograr y mantener un número reducido de casos con una estrategia de prevención clara.
    1. Definir objetivos claros y reavivar la motivación: definir claramente los objetivos que deben cumplirse para que se levanten las medidas y explicar la razón de ser de ellas; transmitir de manera convincente que la lucha contra la pandemia requiere un esfuerzo colectivo que sea de interés para todos los ciudadanos; y garantizar un apoyo social y económico adecuado para quienes lo necesiten.
    2. Actuar temprano: implementar medidas de mitigación antes de que aumente el número de casos.
    3. Reduzca el número de contactos físicos: relaciónese con la menor cantidad de personas posible; implementar y mejorar la educación en línea y desde el hogar. Deben preferirse las burbujas sociales pequeñas y estables, y los grupos estables en el hogar y en el trabajo a los contactos alternos.
    4. Prevenir el contagio con medidas individuales como el distanciamiento físico, la higiene, las mascarillas, la ventilación y el uso de filtros, evitando los espacios cerrados y concurridos y permaneciendo en casa ante los síntomas; proporcione máscaras FFP2 a los necesitados y a todos los que no pueden trabajar desde casa.
  2. Supervisar la propagación del virus y de variantes individuales
    1. Probar, rastrear, aislar, apoyar: hacer cumplir el aislamiento obligatorio de las personas con infecciones confirmadas y fomentar la cuarentena preventiva de los casos sospechosos; Apoyar a las personas y familias afectadas.
    2. Detectar y realizar pruebas de forma preventiva: ofrecer pruebas en escuelas y lugares de trabajo sin costo para detectar brotes temprano y proteger a las personas; aumentar la capacidad de prueba para satisfacer la demanda; Utilice la vigilancia de aguas residuales para detectar sobretensiones locales.
    3. Incrementar la secuenciación genética y la detección basada en PCR de la variante B.1.1.7, así como otras variantes de SARS-CoV-210.
  3. Detener el virus en las fronteras y protejer a los vulnerables
    1. Reducir los viajes dentro y fuera de las fronteras nacionales y exigir pruebas y cuarentena para los viajeros transfronterizos; las pruebas deben ser necesarias 24 horas antes del viaje y de 7 a 10 días después del viaje; Poner en cuarentena a cualquier persona que llegue de países con transmisión local de COVID-19.
    2. Mejorar la protección y el apoyo a las personas mayores y los grupos vulnerables; Fomentar el intercambio europeo sobre estrategias y medidas exitosas para acelerar el progreso.
  4. Incrementar la eficacia y el ritmo de la vacunación.
    1. Acelerar la vacunación: mejorar el suministro, la entrega y la asignación de vacunas mediante el aprendizaje mutuo y la cooperación internacional; coordinar esfuerzos para aumentar la producción de vacunas.
    2. Monitorizar los contagios entre las personas vacunadas para detectar una posible reinfección con nuevas variantes o un manejo deficiente de la vacunación lo antes posible.
    3. Responder preguntas urgentes a través de la cooperación internacional; investigar formas de mejorar los regímenes de vacunación para optimizar la logística o aumentar la disposición a vacunarse utilizando datos de varios países.

Swiss cheese model including new variants
This work by Riina Rupponen is licensed under CC BY 4.0

References

Supplementary Information (SI)

In the following, taking an epidemiological perspective, we focus on the core principles that can slow down the spread of the virus, and noting that the aforementioned strain on public health and personal well-being need to be taken into account as well. To reduce the strain on health, society and economy, the necessary duration of strict measures should be as short as possible - which should be achieved by making them as strong and effective as possible.

It is worth stressing that our conclusions are not limited to B.1.1.7 or other variants identified to date: they apply in general whenever the emergence of new mutations challenges existing practices and strategies. Improved surveillance is necessary to detect them as early as possible, and to allow countries to prepare. In addition, experimental data to understand altered biological characteristics will always lag weeks to months behind the first identification of a new variant by genetic sequencing. Thus, wide-ranging decisions always have to be taken at a time of high uncertainty, and certainly while evidence of the real impact of new variants is still emerging. But only then proactive measures can still be effective for containment or at least deceleration of spread. The following points provide a guideline, complementary to previous ones1,8.

Achieve and maintain low case numbers, with a clear prevention strategy

  1. Define clear targets and rekindle motivation. The motivation and ability of many people to comply with restrictions is waning (“pandemic fatigue”), rendering any NPIs (non-pharmaceutical interventions) less effective. Imposing ever stricter measures puts an increasing strain on societies and economies. Therefore, governments need to strengthen public spirits by ensuring that measures are fair and consistent. This includes clearly explaining the rationales and evidence underlying these measures, and making the base for their decision-making transparent. They need to convincingly convey that the fight against the pandemic needs a collective effort that is in the interest of every citizen, and to ensure that adequate social and economic support is available for those who struggle. An important element of this strategy is to set and communicate common targets that will end the lockdown when met, instead of setting specific dates (that are then revised and extended, which compromises public morale further). People need to be re-empowered in the sense that it is in their own hands and in their own interest to comply with public health measures.
  2. Act early. Implement mitigation measures before case numbers spike. A preventive implementation of mitigation measures can slow down the expected increase of case numbers or even reduce current case numbers, thus alleviating the burden on the healthcare system. Especially given the interval of at least 7 days between infection and reporting of a novel case, reporting is always delayed, and mitigation measures, if taken only after case numbers start to rise, may already have reduced effectiveness. Acting promptly is therefore crucial to save lives.
  3. Reduce the number of physical contacts. Physical contacts in all contexts bear the risk of contagions, and as the secondary attack rate of B.1.1.7 is probably 14% instead of 10% in the UK6,7, reducing contacts is even more important to slow the spread and reduce the number of new cases. This applies to all contacts at family and social gatherings, at work, at school, or in public places. The principle for everyone should thus be to meet as few different people as possible. Home-office and online schooling should be implemented whenever and wherever possible. Support for home-schooling parents should be scaled up. Group sizes should be reduced, and group members should remain the same. In all circumstances of private and professional settings, small, stable social bubbles or groups should be preferred over alternating contacts.

    Public transport is ideally run with at most a fraction of seats occupied, as long as case numbers are high. The use of public transport is reduced by home-office arrangements, closing schools, and stay-at-home orders. While the risk of contagion in each type of public transport is very hard to infer, the setting - many people in a closed, crowded space - clearly bears the risk for contagion. Therefore, to protect those who cannot work from home and have to rely on public transport, public transport at peak hours should be used only by those who strongly need it and the number of vehicles should be increased. Moreover, starting times of work, retail, and schools should be staggered.

  4. Prevent contagion by the continuation of individual measures. By now, the transmission paths of SARS-CoV-2 are much better understood. We know that a key risk lies in ballistic drops and aerosols, with the latter accumulating suspended in air shared with an infectious individual. Therefore, the advantages and the principles of transmission prevention should be clearly communicated in easy language. Effective prevention measures are by now well known; they include physical distancing, hygiene, wearing of face masks, ventilation and use of filters, avoiding closed and crowded spaces and staying at home when experiencing symptoms. Meeting outside instead of inside can reduce the risk of contagion by a factor up to 2011. The more effective FFP2 masks should be provided at no cost to those in need, and for all employees at work.

Monitor the spreading of the virus and of individual variants

  1. Test, trace, isolate, support (TTIS). Detecting and breaking infection chains strongly contributes to mitigation of the spread. Here, individuals can support the health authorities, e.g. by noting down their contacts at a regular basis. Complementarily, tracing apps prove useful. Both facilitate a swift identification and quarantine of potentially infected contacts. Moreover, the knowledge gained from contact tracing improves our understanding of which contacts bear a greater risk of contagion. The necessary isolation and preventive quarantine should be clearly encouraged, enforced, and individuals should be supported. It is crucial to report case numbers, and data on hospitalization and deaths, including complementary information on local and national level, and ensure they are openly published and machine readable for scientific evaluation.
  2. Screen and test preventively. Given the circulation of new variants, wherever people have to meet in person, prior testing and regular screening is of even greater importance than has been the case previously. Access to tests should be facilitated, and the testing capacity has to be increased to meet the demand. At the workplace, employers should offer regular testing at no cost to their employees, ideally twice a week. Complementarily, regular, anonymous screening is helpful and important to detect outbreaks early at workplaces, schools, universities, and elsewhere. Moreover, waste-water surveillance to detect local surges and general screening is easy, anonymous, and cost efficient to implement.
  3. Long-term lockdowns, or expansive quarantine rules, due to the burdens they impose on those affected, become increasingly ineffective and invite people to circumvent them. Therefore, with the increasing availability, accessibility and decreasing cost of rapid antigen tests, and with the first certified at-home tests becoming available, participation in non-essential activities (ranging from cultural and sports activities over restaurant visits to body-related services) should be made dependent on a negative test result not older than 24h. It is important to ensure easy access for all citizens to tests, in particular to employees at work, and that there are no other formal or informal barriers to test-taking. Policy makers should also ensure that sufficient production capacity is made available for the subsequent increased demand in tests.

  4. Increase sequencing and PCR-based detection of the B.1.1.7 variant. Improved surveillance allows a better prediction of case numbers and mutants. It is important to not only report case numbers but also to increase sequencing and PCR-based detection of the B.1.1.7 variant, as well as other variants of SARS-CoV-210.

Stop virus at borders and protect the vulnerable

  1. Reduce all travel within and across countries. Reduction of domestic and transnational travel can slow down the overall increase. Restricting mobility within a country and transnationally helps to slow down the spread of the new variant and isolate possible outbreaks of the new variant before they spread to other areas or countries. This (a) leads to a slower average increase of case numbers in the entire country, (b) reduces the number of regions requiring stricter containment measures, and (c) enables hospitals from less affected regions to support others.
  2. Require tests and quarantine for cross-border travelers. Preventive testing and quarantine for transnational travelers slows down the transborder spread of new variants. Therefore, two tests (at most 24 hours before travel, and 7-10 days after travel) should be required for anyone arriving from countries with local COVID-19 transmission. In addition, a strict quarantine of at least 10 days should be ordered for anyone arriving from countries with high prevalence or novel suspicious variants.
  3. Improve the protection of, and support for, the elderly and vulnerable groups. The best protective measure is to bring case numbers down. At high case numbers the number of undetected infections increases, and the virus is inadvertently brought to the vulnerable population8. At high case numbers, an efficient protection of the vulnerable population has not been achieved yet. In any case, protection and support plans for the vulnerable, incorporating and extending the points above, need to be improved. Here, European exchange about successful strategies and measures will speed up the progress.

Increase the efficacy and pace of the vaccination

  1. Speed up vaccination. B.1.1.7 has increased the need to speed up vaccination. In order to improve vaccine supply, delivery and allocation in terms of priority groups, international cooperation is urgently needed to be able to learn from each other and to implement the most effective strategies in terms of European public health and global public health security. Decision-making becomes more effective when uncertainty is reduced by combining different sources of data and data from many countries. Moreover, governments should coordinate their efforts in scaling up the production of the vaccines taking into consideration supply chains and the need to increase capacity.
  2. Monitor infections among vaccinated people. Vaccination is a weapon also against the current new virus variants. Initial analyses indicate that the mutations found in the novel variant do not decrease the potency of the vaccines5. However, mutations may arise against which the vaccines are less effective. This requires monitoring of infections among vaccinated people.
  3. Answer urgent questions through international collaboration. Many questions need answering quickly: Can we improve vaccination regimes, e.g. administer only one dose to people that have already been infected as a booster to better manage scarce resources? Would that compromise the ability to identify escape mutants? How can logistics be improved? What parameters ought to be considered in terms of allocation for effective vaccine delivery in remote and inaccessible regions? How can people best be motivated to take the vaccine and what are the best strategies to overcome vaccine hesitancy and vaccine refusal?

Additional References