After we have been publishing assessments of the medical situation and strategy related there to, our constituents have told us that they would appreciate to hear from a real medical Doctor with suitable experience to receive his expert medical advice related to the current medical crisis. We are delighted you have agreed to give us some of your precious time to answer a few questions which have been posed by our constituents. Thank you very much for meeting with us!
Amcham: What did you hear, when did you hear it and what were your first impressions related to the coronavirus?
Dr Schockmel: I first heard about the new coronavirus in January 2020 when I was a visiting physician at the University hospital Freiburg i.Br. in Germany. My impressions were mixed, since reactions in Europe were quite different from those in Asia. In Asia, the new coronavirus SARS-CoV-2 was taken very seriously and put into the context of the deadly SARS virus that had emerged in 2002. Also, it is a well-established practice in East Asian countries to wear face masks and practice social distancing in the context of respiratory infections. In Europe, however, many experts initially considered SARS-CoV-2 to cause a kind of more severe flu, and did not see its pandemic potential.
AMCHAM: When did you gain the opinion this was a pandemic and why?
Dr Schockmel: It was the rapidity with which the new coronavirus spread and the number of hospitalized cases in Italy, France and Spain that made it become obvious that this virus is highly transmissible and on its way to cause a pandemic.
AMCHAM: What lessons have been learned regarding prevention and treatment during this pandemic?
Dr Schockmel: The most important lessons are that non-pharmacological interventions such as social distancing, wearing face masks, practicing hand hygiene, avoiding crowds, etc. are most successful in containing the spread of the virus. These classical infection prevention and control measures that are standards in every hospital have been taken into the community and implemented on a large scale. The first drugs that appeared promising were the antimalarial drug hydroxychloroquine and certain antiviral drugs against HIV. However, the efficacy of these drugs was not confirmed in clinical trials.
A first important new insight was the concept of “cytokine storm”, a life-threatening condition caused by an uncontrolled immune activation. The drug dexamethasone, a synthetic cortisone derivative, has been shown to be beneficial in this situation. Another important insight was that the acute respiratory distress syndrome caused by SARS-CoV-2 differs from the syndrome commonly observed in patients with bacterial sepsis.
AMCHAM: In hindsight, what actions do you believe the medical authorities should have done differently?
Dr Schockmel: I personally think that the first wave of infection was managed quite well in Luxembourg. First, our country had been fortunate to be behind countries such as Italy and France in terms of infection rates and hospitalization numbers. This allowed Luxembourg to implement a strict lockdown before infection rates got out of control. Second, Luxembourg benefited from other countries’ experience in handling the pandemic and preparing the health system for a major influx of patients. When it comes to the second wave of infection in autumn, one could consider from hindsight that certain preventive measures should have been implemented earlier.
AMCHAM: What is the current situation?
Dr Schockmel: The current situation is that infection rates remain relatively high and that an increased vigilance must be maintained. The screening of contact persons, travellers and the increased institutional screening by mobile teams in schools, long-term care facilities etc. has become indispensable.
AMCHAM: We are told the new variants of Covid-19 from Africa are more contagious but appear to be less deadly. Is this true?
Dr Schockmel: Viral variants such as the South African variant are successful because they are highly transmissible and bound to become the dominant strains over time. A higher transmission rate leads to higher infection numbers, more people being hospitalized and more people dying. Thus, a highly transmissible virus does not need to be more virulent to cause more deaths. To my knowledge, it has, however, not been established that the South African variant would be less virulent than other circulating strains.
AMCHAM: Are older patients really at inherently greater risk or is this greater risk just because they may have more immunity weakening other medical conditions already?
Dr Schockmel: It’s both. Older patients are at risk for more severe disease because of immunosenescence, i.e. their aging immune systems don’t allow them to cope as well with the virus as younger persons. In addition, older patients more often suffer from chronic conditions and comorbidities that put them at increased risk for more severe disease.
AMCHAM: Why is the vaccination of residents taking so long?
Dr Schockmel: Vaccination efforts are mostly hampered by supply problems. The current vaccination campaign is based on hospitals, mobile teams and a single vaccination centre. Once there is a larger vaccine supply, the additional vaccination centres that have been set up already will be opened to the public. In the future, one could also envisage the administration of vaccines in physicians’ offices, pharmacies, etc.
AMCHAM: When will all of the elderly at highest risk patients (over 65) be vaccinated?
Dr Schockmel: The roll-out of the vaccination campaign in Luxembourg will follow a 6-phase strategy. Focusing on age, this strategy means that residents in long-term care facilities are vaccinated in phase 1 whatever their age, persons aged 75 and above in phase 2, persons aged between 70 and 74 years in phase 3, and persons aged between 65 and 69 years in phase 4. Age-independent criteria for early vaccination apply for individuals with significant risk factors for severe Covid-19.
Generally speaking, risk for severe disease increases above age 65 and this is the reason why there is a prioritization into three distinct age groups of those aged over 65. With phase 2 bound to start shortly, there is a realistic chance that people over 65 will have been vaccinated well before the end of the year.
AMCHAM: For how long, and with what degree of protection, are the vaccines effective?
Dr Schockmel: While the currently available data indicate that vaccine-induced protection, as assessed by circulating antibodies in the blood of vaccinated people, lasts for at least three months, many experts expect that in analogy to other vaccines and on the basis of what is currently known about circulating antibodies in the blood of persons who have had Covid-19, protective, vaccine-induced antibodies will last up to 12 months or longer. Antibody concentrations may decline over time, but as long as immunological memory is maintained in an individual, he/she will produce high antibody concentrations upon encounter with the virus.
AMCHAM: Why is it necessary to have two doses of the vaccines?
Dr Schockmel: For current vaccines, the two-dose schedule, also called prime-boost schedule, corresponds to the schedule used in phase III clinical trials. While a single vaccine dose primes the immune system and induces partial protection against Covid-19, the second vaccine dose boosts the immune response and helps to establish immunological memory. The two-dose schedule induces high neutralizing antibody titers in most vaccine recipients, which may be important in the context of viral variants that blunt vaccine-induced immune responses.
However, in order to accelerate the development of herd immunity, countries such as Britain have opted to vaccinate a maximum number of people with a single vaccine dose, accepting a longer dosing interval between vaccine doses one and two. Personally, I find it legitimate for a nation to resort to this kind of approach in the face of a fast spreading epidemic and a healthcare system stretched to its limits, although one would wish for more data being available to back up this approach.
AMCHAM: What will it take and when will Luxembourg residents reach crowd immunity status and what does that mean?
Dr Schockmel: Herd (or crowd) immunity means that in a given community an infected person is unable to spread the coronavirus because his/her contacts have a preexisting protective immunity against the virus. This preexisting immunity can either come from vaccination (the safe way), or from prior infection with the coronavirus. The number most cited in this context is 70% of herd immunity, although, for a highly transmissible virus such as the coronavirus, this number might actually be higher.
According to current estimates it might take up to two years for Luxembourg to reach herd immunity, provided a majority of citizens is willing to get vaccinated. Fortunately, a certain normalization of life in society is bound to take place much earlier, once older people and people at risk have been vaccinated, frequent institutional testing in schools, long-term care facilities, etc. has become common practice, and rapid tests have been added to our armamentarium.
