Containment is the only option says French expert
Bahram Bodaghi MD, PHD, FEBO
Bahram Bodaghi MD, PHD, FEBO, spoke with EuroTimes editor Sean Henahan, providing his perspective as a specialist in inflammatory and infectious diseases of the eye. He is the Chair, Professor of Ophthalmology & Visual Sciences at Sorbonne University in Paris, France. He is the Secretary General of the French Society of Ophthalmology and President of the International Ocular Inflammation Society.
Q: How are you doing? What is the situation in Paris?
A: National containment has been declared since Tuesday, 17 March. We are currently still working in the hospital but only seeing patients on an emergency basis. We have cancelled all elective surgeries. I’m working with the French Society of Ophthalmology to coordinate with colleagues and assist them all over France.
Q: Is your centre still doing intravitreal procedures?
We are. However, the problem in Europe is that things are very heterogeneous. Austria has almost discontinued intravitreal injections for one month. In Italy injections have stopped and the army is being deployed to enforce the containment. This is not yet the case in France but it may be strengthened.
Q: From your perspective, what is the best approach to control the spread of COVID-19?
A: The best approach to control the spread of COVID 19 depends currently on where you are and this is a major issue. Things are really changing fast now. In Singapore, Hong Kong and Taiwan they were able to very efficiently and rapidly control the disease. We are reaching a consensus that containment is the only option if we want to stop the spread of the virus. Without containment you are only delaying the progression of the disease and you will end up with the difficult situation that we see today in Italy, one that may be coming in France.
Strict containment is the real key to success. We will need strategic approaches if we want to succeed rapidly.
You cannot compare Europe to Hong Kong or Singapore. You have many big countries across Europe with very little coordination among health authorities. So far each country is trying to resist the virus by itself, making its decisions based on its health capacities, and social characteristics. This will probably change in the future.
It is important to realize that COVID 19 is not the flu. What we see in Italy, France and Spain, where the pandemic is heating, is not the rate of mortality itself, it is the disorganization of the health care systems. For example, you have much more risk of dying from a myocardial infarction in these areas today because most of the ICU beds are taken up with COVID patients. In ophthalmology we will probably see patients coming in with much more severe lesions, and levels of disease than before because patients are in containment at home, not getting their injections, not getting to see their ophthalmologists.
Q: What is the potential for treating COVID 19 with current or experimental agents?
A: We currently have no anti-viral agents known to be effective against COVID. I’m very interested in a study conducted in Marseille by Prof Dider Raoult. The study involved 36 patients among whom 20 received hydroxychloroquine, 3 tablets per day and azithromycin. They report viral load reduction/disappearance within a few days. This is single arm protocol, but the preliminary results are promising.
I am working in one of the major hospitals in Paris managing patients with COVID. If my colleagues become infected, they are considering using this protocol since there is nothing else available. Further studies are underway to evaluate the efficacy and safety of this approach.
Q: It appears that ACE inhibition is involved in the infection. What are your thoughts on the use of ACE inhibitors or anti-inflammatories in patients who have the disease.
A: We received an alert from the French health authorities. If you have a viral infection and you are taking NSAIDS, you may be in trouble because they are inhibiting an enzyme which may aggravate your viral infection and create diffeerent complications. This may be an important risk factor for younger people. With COVID-19 you have patients in their 50s in intensive care units who may be on ventilation for two weeks, so you want to decrease any risk factors you can.
Q: What can we learn about COVID 19 from the previous experience with different cornonavirus outbreaks with SARS and MERS? How does COVID 19 compare with these?
A: With SARS and MERS we were facing more virulent agents, they were more dangerous, with higher mortality rates. However, these diseases were much more contained in their regions, China and the Middle east. The important thing is that these diseases did not recur. This is important, the error we made in Europe and Western countries, was that we thought COVID was another SARS or MERS. We thought it would stay in China and Asia. That was our first mistake. Now it is proving difficult to resolve.
Q: Are you concerned that different strains of COVID 19 can emerge?
A: I am not as concerned about mutations, although I may be wrong. Viruses are very peculiar agents. They cannot continue to proliferate without a host. I am more concerned that once the virus is contained in one region, infection may recur by being imported back into that region by travellers. This is beginning to happen in Singapore and Hong Kong. In China they have no more local cases, but they do see cases being imported.
This is important. If you get COVID infection 85% of the population will be immunised. The remaining 15% of population may not be immunised even after being infected. Those people could be re-infected. Projections of current pandemic suggest anywhere from 50% to 80% of population will be infected eventually. The more you contain the population, the less people will get infected, but if you open your borders and infected people come, the epidemic can start again. In Korea now they are not only taking temperature of visitors, they are doing the PCR testing on visitors from countries at risk.
Q: What are the challenges for developing a vaccine?
A: A lot of people are working on this. With SARS and MERS you didn’t have new infections or mutations. It wasn’t as important to have a vaccine as is the case for influenza. The difference is that COVID is now worldwide. A vaccine will be very important for this disease. COVID may become a recurring problem year after year. Even though the genetic sequence of COVID-19 is available, and the virus has been isolated in culture, it will take months to develop a vaccine which will then need to be tested. Trials are said to be starting in US soon.
Q: Finally, what is your advice to your colleagues in ophthalmology?
A: My advice is be safe, take all appropriate precautions to protect yourself and your patients. Remember the virus can be found in the conjunctiva. We are all in this together, and must fight strongly this viral war.