The study was conducted to estimate the impact of implementing the suppression strategies on the daily and total number of expected COVID-19 cases in France, Italy, and Spain; these estimates were extrapolated based on the response to the suppression plans that were implemented in China, and proven to be effective. Our findings indicate that Italy is expected to be the most impacted among the four, followed by Spain, then France. This expected high impact in Italy is represented by the highest number of confirmed COVID-19 cases and death until the end of April.
The study estimated the number of COVID-19 cases in Italy to be more than twice the current number of cases in China, which will make Italy the most impacted country in Europe. Spain will be the second in Europe with more than 153,013 cases in total. Our estimates for France to the end of April was found to be between the middle range and the worst scenario (61,896–161,832) in Massonnaud et al. study, who have forecasted the number of cases to the middle of April [5]. This validate our method of visual extrapolation, and put our estimates between the middle range and worst scenario, closer to the middle range.
The need for ICU bed is one of the indicators for the readiness of healthcare systems in such crises. Based on the previous data from China, about 5% of all confirmed cases with COVID-19 needed to be admitted to intensive care units (ICU), and 2.3% needed to be on invasive mechanical ventilation [6]. Nevertheless, a study indicated that about 16% of patients in Lombardy, Italy needed to be admitted to the ICU [7], which is much more than what they have expected or planned for. Before the epidemic, there were about 5,090 ICU beds in Italy, which was then planned to be increased to about 9,000 beds [8]. Even with the most conservative estimates, this limited number of ICU beds facing the large expected number of cases, we do not expect the healthcare system and the healthcare workers in Italy to be able to withstand these large number of cases, and if not supported by all means, specially medically trained personnel, the system will collapse very soon. Moreover, we started to see the fatality and infections among healthcare workers as a result for this crises [9, 10], when we were about a week away from the expected peak of the curve for Spain. In France, the healthcare system had about 5,000 ICU beds initially, and they are working to increase it by about 4,000 units, to reach a total of about 9,000 units, in order to meet the upcoming needs [8]. Based on the previous information, our estimates suggest that the health care system in France will be able to sustain the current epidemic with the current support, which is similar to what Massonnaud et al. forecasted in the middle range scenario [5]. Spain had about 4,400 ICU beds before the epidemic, and they did not report plans to increase this number till the end of March. However, with the increased number of cases at the end of March, they started adding ICU beds in the beginning of April. Similar to Italy, we did not expect the health care system in Spain to withstand the upcoming large number of cases till the end of April, which will affect the healthcare workers and their patients. The signs of collapse for the healthcare system in Spain has already started to appear at the end of March, as more than 3,500 healthcare workers in Spain tested positive for COVID-19, which represent about 14% of all infected patients in Spain at that time [11]. Moreover, as the number of critical cases started to surge in Spain at the end of March, physicians in the ICU started to prioritize whom should be put in the ICU and on mechanical ventilation [12], that when Spain was about a week away from the expected peak for the new-infections curve.
Knowing all the previously discussed pressure on the healthcare systems in Italy and Spain, Italy and Spain are expected to lose more than 20,000 and 14,500 patients, respectively. While France is expected to lose about 5,000 patients, which is again between the middle range and the worst scenario (3,237–11,025) that were reported by Massonnaud et al [5]. However, if the healthcare systems in Italy and Spain collapse, then nobody can expect what will happen or even predict how the people in the countries would behave.
Based on the cumulative number of confirmed cases in the three countries, France was the fastest to react to the epidemic, as it reacted before their daily new confirmed cases hit the 1,000 cases mark, which we believe to be very critical in the progression of the transmission. Therefore, it would be the least impacted among the three. France reaction was not as fast as China, France had more than 3,500 confirmed cases when reacted whereas China had only 574 confirmed cases and had very limited information about COVID-19, compared to the rest of the world now. Nevertheless, we believe that China had more than that number at that time, but they have just started tracing and testing suspected cases which was then translated into a surge in the number of newly confirmed cases, which we took into consideration when extrapolating the curve.
With the limited evidence about the appropriate timing and duration for implementing any of the suppression strategies [13]. it was not easy for the decision makers in France, Italy, and Spain to decide when should they initiate any of these strategies, and for how long it should remain in place. Moreover, this difference in timing for implementing different suppression strategies was one of the major reasons behind the variation in the number of current and expected cases of COVID-19 in these countries. Furthermore, the number of confirmed cases when initiating the suppression strategies have impacted our estimates, and we suggest that it should be taken into consideration when deciding to make such an action in the future. However, more research is needed to find when should different suppression strategies be initiated in similar situations, and for how long it should remain in place.
The study had some limitations, the use of visual extrapolation from one case to another is not statistically sophisticated, however our results for France were close to the middle range predictions in Massonnaud et al. study [5]. We were not able to determine if the change in the reproduction rate (Ro) for the infection as a result for the suppression strategies would be as responsive in France, Italy, and Spain as it was in China, but there is no previous evidence to contradict that. Also, the use of a constant Ro throughout the study forecasting duration would be against the assumption that the suppression strategies would invert the Ro, therefore we do not believe a constant Ro should be used in such case. Moreover, the uncertainty around the disease itself and how it could impact different populations is another limitation that we have faced, but nothing is currently known about that, and it is an area for future research. Lastly, we do not know if people in the European nations would behave similar to the Chinese when the suppression strategies are implemented and kept in place for some time, and since there is no evidence against that we assumed that they would behave the same way.