Underdetection of cases of COVID-19 in France threatens epidemic control

Giulia Pullano, Laura Di Domenico, Chiara E. Sabbatini, Eugenio Valdano, Clément Turbelin, Marion Debin, Caroline Guerrisi, Charly Kengne-Kuetche, Cécile Souty, Thomas Hanslik, Thierry Blanchon, Pierre-Yves Boëlle, Julie Figoni, Sophie Vaux, Christine Campèse, Sibylle Bernard-Stoecklin and Vittoria Colizza ()
Additional contact information
Giulia Pullano: INSERM, Sorbonne Université, Institut Pierre Louis d’Epidémiologie et de Santé Publique, IPLESP
Laura Di Domenico: INSERM, Sorbonne Université, Institut Pierre Louis d’Epidémiologie et de Santé Publique, IPLESP
Chiara E. Sabbatini: INSERM, Sorbonne Université, Institut Pierre Louis d’Epidémiologie et de Santé Publique, IPLESP
Eugenio Valdano: INSERM, Sorbonne Université, Institut Pierre Louis d’Epidémiologie et de Santé Publique, IPLESP
Clément Turbelin: INSERM, Sorbonne Université, Institut Pierre Louis d’Epidémiologie et de Santé Publique, IPLESP
Marion Debin: INSERM, Sorbonne Université, Institut Pierre Louis d’Epidémiologie et de Santé Publique, IPLESP
Caroline Guerrisi: INSERM, Sorbonne Université, Institut Pierre Louis d’Epidémiologie et de Santé Publique, IPLESP
Charly Kengne-Kuetche: INSERM, Sorbonne Université, Institut Pierre Louis d’Epidémiologie et de Santé Publique, IPLESP
Cécile Souty: INSERM, Sorbonne Université, Institut Pierre Louis d’Epidémiologie et de Santé Publique, IPLESP
Thomas Hanslik: INSERM, Sorbonne Université, Institut Pierre Louis d’Epidémiologie et de Santé Publique, IPLESP
Thierry Blanchon: INSERM, Sorbonne Université, Institut Pierre Louis d’Epidémiologie et de Santé Publique, IPLESP
Pierre-Yves Boëlle: INSERM, Sorbonne Université, Institut Pierre Louis d’Epidémiologie et de Santé Publique, IPLESP
Julie Figoni: Santé publique France, Direction des maladies infectieuses
Sophie Vaux: Santé publique France, Direction des maladies infectieuses
Christine Campèse: Santé publique France, Direction des maladies infectieuses
Sibylle Bernard-Stoecklin: Santé publique France, Direction des maladies infectieuses
Vittoria Colizza: INSERM, Sorbonne Université, Institut Pierre Louis d’Epidémiologie et de Santé Publique, IPLESP

Nature, 2021, vol. 590, issue 7844, 134-139

Abstract: Abstract As countries in Europe gradually relaxed lockdown restrictions after the first wave, test–trace–isolate strategies became critical to maintain the incidence of coronavirus disease 2019 (COVID-19) at low levels1,2. Reviewing their shortcomings can provide elements to consider in light of the second wave that is currently underway in Europe. Here we estimate the rate of detection of symptomatic cases of COVID-19 in France after lockdown through the use of virological3 and participatory syndromic4 surveillance data coupled with mathematical transmission models calibrated to regional hospitalizations2. Our findings indicate that around 90,000 symptomatic infections, corresponding to 9 out 10 cases, were not ascertained by the surveillance system in the first 7 weeks after lockdown from 11 May to 28 June 2020, although the test positivity rate did not exceed the 5% recommendation of the World Health Organization (WHO)5. The median detection rate increased from 7% (95% confidence interval, 6–8%) to 38% (35–44%) over time, with large regional variations, owing to a strengthening of the system as well as a decrease in epidemic activity. According to participatory surveillance data, only 31% of individuals with COVID-19-like symptoms consulted a doctor in the study period. This suggests that large numbers of symptomatic cases of COVID-19 did not seek medical advice despite recommendations, as confirmed by serological studies6,7. Encouraging awareness and same-day healthcare-seeking behaviour of suspected cases of COVID-19 is critical to improve detection. However, the capacity of the system remained insufficient even at the low epidemic activity achieved after lockdown, and was predicted to deteriorate rapidly with increasing incidence of COVID-19 cases. Substantially more aggressive, targeted and efficient testing with easier access is required to act as a tool to control the COVID-19 pandemic. The testing strategy will be critical to enable partial lifting of the current restrictive measures in Europe and to avoid a third wave.

Date: 2021
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DOI: 10.1038/s41586-020-03095-6

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