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The 3 T’s model: Hitting the nail on the head

Apr 08,2020 - Last updated at Apr 08,2020

The COVID-19 pandemic of the twenty-first century is changing the shape of the world. Not unlike thisinfection, fear is going viral, with over half of the global population currently under home quarantine. Jordan is no exception; the Kingdom has come to a standstill,leaving people with many unanswered questions and concerns. With new hotspots being identified, a daily fluctuating caseload and occasional sudden surges in numbers, people tend to get frustrated with these changes.

The daily case report should be construed with caution, with no premature assumption of things getting out of hand or under control. The daily number of confirmed cases is an excellent measure of the performance in the last couple of weeks and for adjusting our future strategies accordingly. Frequent, and thorough evaluation of the situation based on data, albeit incomplete, is the hallmark of rapid, adaptive, evidence-based response.

Everybody is waiting for the inclining of the epidemiological curve. This will happen, but it takes time and effort and will come at a cost. Moreover, neither people nor the government can claim a victory after going through the curve. Data and prediction models forecast that it is not unlikely that communities might experience other spikes: a rebound of the epidemic, imported cases, or perhaps with the cycling of the seasons. In the meantime, we should make use of the time we get from the mitigation strategy to prepare for the future. Jordan has to anticipate all the possible scenarios, the good and the bad and put forward realistic plans anticipating: a sudden spike of patients seeking acute medical attention, and the serious adverse effectsand mortality for the current patients, which are not yet apparent. 

Expanding the Testing Capacity 

What are the advantages of the three T’s model (Test, Treat, and Trace)? To identify as many cases as possible, have them isolated and treated, and to identify their contacts and have them tested. This will break the chain of transmission in the community and modify the shape of the curve, but the question is: whom to test? There may be something boiling beneath the surface,such as silent infected areas or missed chains of transmission. Expanding the testing capacity will reveal these blind spots and buy more time to help in bringingthe curve under control. 

Testing capacity varies widely between countries and depends on resources, supplies and the availability of well-trained personnel. The methods of testing are of great importance when considering such a strategy. RT-PCR test is the most sensitive and specific practical test to diagnose the disease, but it is time-consuming and requires a well-equipped laboratory. Newer, portable, faster machines do not only hold promise in expanding the testing, but they also reduce the uncertainty caused by fixing and transporting the samples. 

One scientist in the UK argued that the lockdown-relax approach would exhaust the economy and risk the healthcare system. Dr. Julian Peto proposed a weekly testing of the whole population and immediate quarantine of the infected along with their contacts,reducing the infection rate of the entire community. Despite being less intrusive and limiting to the public than the 3 T’s model, it is, indeed, not practical for many countries. 

Only a few countries, like the UK, can bring such suggestions to the table, but Jordan can apply these strategies in hotspot areas, which are presumably few. In addition, taking a random sample from the public, as well as testing (and retesting) people running essential institutions, may be inviting and reassuring. Small businesses might also benefit from this strategy, and this may ease the economic consequences of the crisis after considering quality control and full collaboration from academic institutions, the private sector and pharmaceutical companies. Retesting should be considered for all contacts to overcome the false negatives due to test inaccuracy, inferior quality kits, and very early testing when the viral load is low. 


Keeping together by staying distant


Everyone is vulnerable, even the young who have a sense of being immune or unlikelihood of getting a serious infection. This misconception may come at a catastrophic cost and demands a change in the way we think about the disease. There is, indeed, a considerable number of asymptomatic people, who are most likely young and mobile, spreading the virus and igniting the outbreak. What can be done to control the unwitting spreaders, and shall we need to recommend the face mask in public?

At the beginning of the crisis, the recommendations did not advocate wearing masks for the asymptomatic, but as time passes, we are learning more about the disease. In the US, where there is an apparent shortage of surgical facemasks, the Centre for Disease Control and Prevention is recommending wearing cloth face masks, because they appear to lower the rate of transmission. This recommendation may also reduce the stigma that comes from wearing facemasks. People should get familiar with this new lifestyle particularly concerning massive entertainment venues and travel hubs.


Look before you leap


The question on everyone’s mind is “When do we reopen the country and relax the mitigation measures?”Although we eventually have to restart the economy with some degree of safety and certainty about the procedures, we do not want to push the country to its breaking point. Incomplete data and predictive models show that: the longer and the more stringent lockdownresult in better control over the epidemiological curve. Currently, one of the practical solutions after initial control is to relax the lockdown partially and observe. Authorities can be flexible while adopting this strategy, such as increasing measures in highly affected areas, while relaxing them in clear ones.

Interestingly, it appears that periodic lockdowns with short intervals of relaxation work effectively in local control of the disease. Serologic antibody testing can also play a crucial role in identifying people who are presumably immune to the disease and allowing an earlier return to work. Some countries are considering the idea of immunity certificates or colour-based coding based on their tests to facilitate movement and travel.However, this is applied to countries wherein the infection rate is relatively high.


Peculiar aspects of Jordan


Amidst this COVID-19 crisis, the situation in Jordan has multiple faces. The country with a population of around 10 million hosts more than 1.5 million refugees, sparking fears and real concerns. The situation in refugee camps needs strict monitoring, with any outbreak in refugee camps having drastic consequences on the healthcare sector and the economy.

On another note, our attitude towards science and research have to change after this pandemic. Several institutions are racing to find effective treatments or vaccines. A new era of decision-making science, scientist appreciation and raising the culture of research are the pillars of future strategies in research. Jordan needs more regulatory flexibility and support to launch randomised trials, and it is about time we consider adaptive clinical trials with better utilisation of resources and money.

If this crisis has taught the world anything, in terms of research, it is that we cannot wait until evidence has become overripe. Researchers must use theirexperiences and available knowledge to develop actionable solutions and implement them after testingand quality control using the Rapid-Cycle Researchmethodology.

The writer is Assistant Professor of Urology, School of Medicine, The University of Jordan. Visiting Professor, Department of Urology, the Medical University of Vienna, Austria. Chief Editor, Arab Journal of Urology. The views in this article are the author's own beliefs and do not represent the views of any organisations with which the author is affiliated. He contributed this article to The Jordan Times.

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