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.