Policy responses for France - HSRM


Policy responses for France

1.4 Monitoring and surveillance

In prevision of preparing the end of the lock-down by May 11, the transparency of epidemiologic surveillance will be improved at the local area level. Estimations of the risk of epidemic will rely on the local weekly rate of new cases, the local hospital capacities in intensive care services as well as on local testing capacity. Départements will be classified based on their level of risk: green for the least risky areas, orange for those with a medium level of risk and red for the most at risk. Indicators used for this are still being refined and mistakes were found in the first mapping made public on April 30. The final mapping will occur on May 7, with only two levels (green or red), and will guide local adaptations of the first measures to ease the lock-down period.

Monitoring and surveillance of the epidemic during the transition period will be strengthened in four stages: 1/ contact tracing of all confirmed cases by health professionals in primary and hospital care; 2/ further contact tracing by specifically-trained agents of the national health insurance fund (health squads), using telephone surveys to inform and provide advice to all identified contacts; 3/ monitoring by regional health agencies to identify potential chains of transmission and clusters of cases at the local area level, set up since the beginning of the epidemic, will continue; and 4/ this will be doubled by local and national surveillance carried by the National Public Health Institute and the Ministry of Health.

Contact tracing by the national health insurance fund relies on 6500 agents (medical, administrative or social staff), subject to medical confidentiality, who received an ad hoc training from regional health agencies and local branches of the National Public Health Institute. They will phone within 24 hours all identified contacts of every single confirmed case, in order to inform them regarding the potential contamination risk, and the measures to follow: isolation and testing. These ‘squads’ will work every day from 8am to 7pm, even on week-ends. Some agents from local territorial public agencies may be called upon to back up the national health insurance fund. On September 11, the government announced that about 2,000 new staff will be dedicated to contact tracing. The system of phone calls will be backed-up by mailing and texting contacts to reduce the workload in the context of an exponential increase in the number of positive cases in October. Regional health agencies will be in charge of contact tracing when a case is detected in a collective place (school, nursing home…). In December, it was announced that an additional retrospective tracing method, to identify the source of contamination of positive cases, and not only potential individuals contaminated by positive cases, is being considered (similarly to what is implemented in Japan). Since April 2021, this new method is finally being experimented in two départements.

Primary care physicians also contribute to the tracing of patients. They have a higher fee (€55 instead of €25 for a regular consultation) to receive patients who are tested positive, to confirm the diagnosis and to carry out the first steps of contact tracing.

The government proposed to create a national repository of cases tested positive in hospitals and medical laboratories (Sidep repertory, ‘Système d’information national de dépistage’). It is managed conjointly by the Ministry of Health, the Parisian hospitals (AP-HP), the national public health agency and medical laboratories. Another repertory of contacts of all confirmed cases (Contact Covid) is managed by the SHI fund to ease tracing. The National Commission for Data Protection and Liberties (CNIL) was consulted on the creation of such repertories, but the Ministry of Health announced that data will not be kept after the end of the epidemic. On May 11, the Constitutional Council banned the access of social care providers (notably community social welfare centres which are in charge of supporting socially vulnerable individuals to access financial aids at the local level, ‘centres communaux d’action sociale’, CCAS) to this database. Later, the authorization to maintain those repositories was extended until the end of the state-of-health emergency (at least until mid-February 2021).

Following the onset of the second wave of the epidemic, monitoring and surveillance of the spread of the infection has evolved to include three key indicators at the local level: the incidence rate of the disease, the incidence rate of the disease in people aged over 65, and the share of patients with Covid-19 in intensive care units. The stringency of measures to contain the spread of the epidemic is adapted based on these indicators. In the most affected areas, measures notably include the closure of bars, cafés and sport clubs and the implementation of strict sanitary protocols in restaurants (theatres and cinemas, where sanitary protocols were already set up, can remain open). Working from home is also strongly encouraged.

The monitoring and surveillance of the epidemic is integrated in a prevention and management plan with four stages. The first stage consists in limiting the introduction of the virus on the national territory (from February 23); the second stage (reached on February 29) consists in limiting the spread of the virus on the national territory; the third stage (reached on March 14) consists in reducing the effects of the epidemic; and the fourth stage consists in going back to the baseline situation before the start of the epidemic. However, surveillance measures were implemented in France from January 10.

The definition of Covid-19 cases is quickly evolving to take into account the latest scientific and medical knowledge on the virus. As of March 3, the definition of a possible case includes the association between a clinical criterion (acute respiratory infection) and an epidemiological criterion (stay or travel in a cluster of confirmed cases or close contact with a confirmed case), except for individuals presenting some symptoms of acute respiratory infections for which no etiology is identified. A confirmed case is an individual, displaying or not symptoms, with a test confirming the infection by the SARS-CoV-2 strains of the virus.

The surveillance at the national level includes several aspects: the description of the epidemic (over time but also spatial surveillance of the epidemic, follow-up of its severity and identification of the most at-risk population groups, estimation of its impact on the community and care facilities) as well as the characterization of the strains of SARS-CoV-2 in circulation and the evaluation of containment measures implemented.

The monitoring and surveillance strategy includes the collection of data on clusters of cases in nursing homes, of emergency and hospitals for Covid-19, of deaths for Covid-19, of strains of Covid-19 in circulation and of acute respiratory infections in the general population. The surveillance of ambulatory care was implemented later than that for hospital care, only since the week 12 (March 16-22) of the epidemic. There were about 42,000 GP visits for a suspicion of coronavirus at week 12. This monitoring and surveillance strategy is coordinated by the National Public Health Institute, for the Ministry in charge of health, and relies on a network of numerous stakeholders such as regional health agencies, networks of GPs (réseau Sentinelles), the national reference center for viral respiratory infections, etc.

Monitoring of deaths outside hospitals have started since April 1. The National Public Health Institute provided all medical nursing homes a questionnaire for daily reporting on the number of Covid-19 cases. Reporting of cases relates both to suspect Covid-19 cases based on symptoms and on confirmed cases based on testing. In any case, the government has been trying to answer the concerns regarding the lack of transparency and improve public information on deaths related to Covid-19 in different settings. The National Institute for Statistical and Economic studies (INSEE) has also started publishing daily death rates on its website since the first week of April.