Since the deconfinement, on May 11, the control of contact cases and the rise of contamination chains has been one of the priorities of the government’s health policy to stem the Covid-19 pandemic. Four months later, when the number of contaminations increases sharply in France, what conclusions can be drawn from this method?
“Protect, test, isolate.” On April 28, 2020, before the National Assembly, Édouard Philippe announced the priorities of the deconfinement plan. Among them, the creation, in each department “of brigades responsible for putting together the list of contact cases”. Each cases of Covid-19 detected in the territory must lead to an investigation in order to identify and support people at risk. Yet four months later, as France faces the dreaded second wave, it is clear that this ambitious plan has not been enough to stem the spread of the virus.
“Contact tracing” is not a new device: it is part of the measures to combat emerging diseases planned by the WHO. But the device deployed by the government of Édouard Philippe is unprecedented in its scope. Some 5,000 agents from the Primary Health Insurance Fund (CPAM) are involved in this task. Carole Besnier, prevention officer at the CPAM in Mayenne, was trained in May to conduct health surveys related to Covid-19. “Doctors are on the front line, they receive test results, educate patients and give us the information,” she explains.
“We are then required to contact positive cases or people with symptoms within four hours to go over their schedule and establish a list of contact cases. Finally, we call these people within 24 hours to notify them, evaluate the isolation measures to be put in place and direct them to testing. “
The CPAM platform operates seven days a week and centralizes all contact cases. The most complex situations that can generate clusters, on large gatherings or in public institutions for example, are reported to the Regional Health Agencies (ARS) who then decide on the procedure to follow.
“The feeling of having to negotiate”
On paper, the rules are clear: anyone identified as a contact case must be tested and remain isolated until the test result. However, in reality, agents must take into account the specific context of each person, recognizes Carole Besnier: “We must already assess the degree of risk, if people have been in contact outside two meters away. , even without a mask, in this case the risk is low. In an office, on the other hand, if only one person wears a mask and it is made of fabric, the danger is greater. Moreover, the situation is sometimes delicate with one person. who is just starting a new job or who has young children in school. We have to show pedagogy and find suitable solutions “she concludes.
This situation, Lina * was confronted with after an evening with friends in a Parisian apartment. “Four days later, one of the people tested positive for the coronavirus. The next day I was contacted by the CPAM,” said the young woman, surprised by the speed of the treatment. “The interviewer was very professional, she asked me lots of questions and gave me recommendations. It turns out that teleworking is possible for me. On the other hand, she advised me to keep my son at home then that he had barely started his return to school and she even asked me to have my groceries delivered. For my son, I agree even if it is complicated, but the groceries I said no, I do Be careful and I put on my mask. I understand that they want to make people aware of the risk, but I found the approach quite guilty. I had the impression of having to negotiate, “she underlines.
The government wanted to avoid a restrictive system and relied on public understanding. If it is more flexible, this device raises the question of proper compliance with the instructions and therefore the effectiveness of such a measure. Pierre * was identified as a contact case after a professional meeting. He teleworked but left his children at school. “I was notified 10 days after the meeting. I had no symptoms and was close to the 14-day quarantine period already. I went to get tested but didn’t want to turn his life upside down. my family, “admits the bank employee, whose test turned out negative.
No priority access to tests
CPAM officers follow up on contact cases and put them in touch with testing laboratories. “We have all the information and are directing people to get tested as quickly as possible. The laboratories must then contact positive cases within 48 hours,” explains Carole Besnier. The investigator says this system works well in Mayenne. But this was not always the case: “Today, people do not have any difficulty getting tested because we passed a big peak at the end of June-beginning of July. At that time the situation was more complicated for them. laboratories, ”she admits. The situation can become all the more complicated asin France, tests are free and contact cases do not benefit from privileged access.
For Lina, the search for a laboratory was a real ordeal: “I asked the CPAM agent if she could find me an appointment. She told me that it was up to me. On the other hand, the document indicating that I am a contact case entitles you to four free masks in pharmacies, great! ”she quipped.
“The labs around my house were overcrowded, I finally got to get tested on Saturday morning, but it took two hours and I didn’t get the results until Tuesday.” For Pierre too, the research was akin to a real obstacle course: “I found a lab quite easily but I realized that it was a serological test (antibody) and not PCR. (virological) asked. Then, all the labs offered me appointments beyond the 14-day period. One of our colleagues finally found one and we all got tested in the same place. “
A system that will evolve?
While the contact case control system remains a central step in the fight against the Covid-19 epidemic, it has shown its limits in several respects. Changes are now desired by the government.
First do spend the sheltering period from 14 to 7 days, period from which patients are less contagious. “It is better eight well-respected days than 14 badly respected days,” said Martin Hirsch, the general manager of the AP-HP, on LCI Monday, September 7, stressing the difficulty of assessing compliance with isolation measures.
On the difficulties of access to the test, the Minister of Solidarity and Health Olivier Veran reaffirmed, Tuesday, September 8 on France Inter, the importance of the “prioritization” of patients. “A person who is in contact, must be tested in a hurry. Out of the question that she would be turned away from a laboratory […] We are going to work even harder on this, ”the minister said.
But in addition to logistical problems, the overall strategy also raises questions. Some specialists wonder if this heavy and expensive device is still appropriate in the current context: “The strategy favored by the government is effective in the context of a relatively contained epidemic. When this increases too much, the tracing of cases becomes too much. heavy and complicated “, estimates Marc Gastellu-Etchegorry, epidemiologist at Epicenter Médecin Sans Frontières, contacted by France 24.” However, this device mobilizes many epidemiologists, and it should not be maintained at all costs at the expense of other areas of research such as transmission factors, which is essential.
Finally, between the anxiety of uncertainty, laboratory research and logistical problems, measures targeting contact cases represent a significant psychological weight.
Lina, who finally tested negative, found the experience very disturbing: “For days, before the result, I was anxious, wondering if I had been able to infect other people too. Today my social life is going. Suffering from it is sure, because I know that I can be in contact again and I especially do not want to find myself in this situation again with my son and my companion “.
* The first name has been changed.