Interview: Professor Aura Timen, head of the Centre for Infectious Disease Control

‘Everything will depend on our hospitals’ capacity to provide respiratory support’

03/23/2020 | 4:06 PM

The day before the first person in the Netherlands tested positive for the new coronavirus, you gave an interview in de Volkskrant. You talked about your work at the RIVM [National Institute for Public Health and the Environment], now that the coronavirus has reached Europe. One month later, what are your thoughts when you look back on that day?

‘It feels like it was a year ago. It was an oasis of calm compared to where we are now, and what we’re going through now. Things are almost indescribably hectic.’

In the Netherlands, all kinds of measures are now in place to limit the spread of the virus. What role is the RIVM playing in this?
‘We are advising the government on which measures to adopt, and we also have the task of coordinating the implementation of those measures. We have set up an Outbreak Management team to do this. In times of crisis, that is the body that provides substantive advice on how to combat the epidemic. The team looks at how the virus is spreading and what we need to do to contain it. We also watch closely what is happening in other countries, where the virus broke out earlier than here.’

‘It’s always a delicate balance: we don't want to paralyze our society, but we do need to be prepared to do what it takes to slow down the spread of the virus.’

‘First, local measures were taken in Noord-Brabant. It then quickly became necessary to introduce these measures across the rest of the Netherlands. Because it was clear that if we did not intervene, we would run into capacity problems in the healthcare system within a certain number of weeks. We wanted to prevent what is happening now in Italy, where the healthcare system is being overwhelmed. But of course, it’s a delicate balance: we don't want to paralyze society, but we do need to be prepared to do what it takes to slow down the spread of the virus, because then you reduce the chance that elderly people and other vulnerable groups will be infected. They have the highest risk of complications and death. In each phase, a new set of measures is required.’

But it’s striking that the Netherlands is not completely ‘locked down’, unlike many other European countries.
‘If you lock everything down, you will just get hit by the virus later. And you can’t keep everything shut for a year. The virus is not going to disappear, it will just keep circulating. But at the moment, this virus is new for everyone. That means we need some level of immunity in the population, because indirectly that will protect the elderly and other vulnerable groups and enable us to manage the consequences better. A total lockdown would not help us to achieve that.’

‘The coronavirus is here to stay’

‘At one end of the scale, there is the ‘do nothing’ scenario. That might happen in a situation where you don’t yet know that the virus is spreading in the population, as happened in Italy at the start of the epidemic. If that happens, the hospitals and intensive care wards will quickly fill up and the mortality rate will go through the roof. The other extreme is China, where everything has been closed down and boarded up in order to contain the virus. Now they are slowly easing those measures. It will be interesting to see what happens next there. Because the virus is here to stay.’

Can the Dutch healthcare system handle this epidemic?
‘Everything will depend on the capacity of hospitals to care for patients and ventilate critically ill patients in their intensive care wards. That's really what this epidemic will come down to. At the moment, staffing does not seem to be the main problem. Extra support is coming in from all sides. The good thing is that this crisis is bringing people together. Hospitals are looking at how they can increase their intensive care capacity – by postponing non-emergency operations, for instance. There are some big challenges in Noord-Brabant, and by the time this interview is published, an appeal will probably have been made to transfer some patients away from Noord-Brabant to hospitals elsewhere, such as in the north of the country where things are still very quiet.

Is it sensible that schools in the Netherlands have been closed?
‘That was a policy decision that involved weighing up several different arguments. Our main argument is that children do not seem to contribute significantly to the spread of the virus. That’s also what we see in the data from China. We are currently setting up a study in Noord-Brabant to find out more about the role of children in the spread of the virus.’

When do you expect all the measures taken in the Netherlands to start having an effect? How quickly can we flatten the curve?
‘We’ll be monitoring that closely, of course. I think the earliest that we could see some levelling off is late March or early April. And specifically, we will be hoping to see a fall in the numbers being admitted to intensive care.’

Will the death rate for this virus continue to be higher than with regular flu?
‘What we don't know about this virus is how many people are or have been infected. So we need more research, serological studies to see how many people have the antibodies in their blood. That’s when we will get more clarity about the real mortality rate.’

‘We are seeing the effects of globalization: we travel around a lot, and the world is like one big village’

The new coronavirus, Sars-coV-2, has officially been declared a pandemic by the World Health Organization (WHO). How did they reach that decision?
‘There are three conditions: it must be a new virus that has never previously circulated in humans. That means there is no immunity in the population. It must be caused by a pathogen that makes people sick to a significant extent. And finally, there must be distribution across several continents. Those three conditions have all been met. We are seeing the effects of globalization: we travel around a lot, and the world is like one big village.’

‘We are working day and night, and through every weekend. We are always here’

The swine flu in 2009 was also a pandemic. What’s the difference between then and now?
‘Things were also very hectic during the swine flu pandemic. But the difference is that swine flu disappeared almost completely in the summer. That's usually the case with flu viruses. We hope that the coronavirus will also fade away in the summer, but we don’t know yet.
In the summer of 2009, we were preparing for mass vaccinations. When the virus reappeared in the autumn, we had enough vaccines in stock for a substantial proportion of the population. A third of the population was vaccinated in a two-month period. Now, we’re hoping that the coronavirus epidemic can be slowed down enough for a vaccine to become available. But until that time, we’re working day and night, and through every weekend. We are always here.’

Does communication determine the extent to which the pandemic can be controlled?
‘Yes, because if the message is communicated accurately and clearly, we can encourage people to adopt the behaviours that are needed. So at the moment, that message is: stay home if you feel unwell, practise social distancing, wash your hands more thoroughly and more often, don't organize parties or social gatherings. We’ll see how effective these messages have been in the next three weeks.’

‘The picture we get from the panel surveys that we carry out with the Nivel research institute is that Dutch people are fairly calm, have confidence in the measures that have been imposed and are complying with them. Of course, social media use has grown substantially over the past several years, enabling people to stay in touch much more easily. And if a European country takes really radical measures, the online debate will very quickly become heated.’

‘Ultimately, carnival was one of the drivers. That’s why we are still seeing more cases in Brabant and Limburg’

For a long time, the RIVM was continuing to tweet out messages saying ‘there’s nothing to worry about’ – at least until the beginning of March.
‘Well, for a long time, there really was nothing to worry about. We based our advice on the risk estimates published by the WHO and the European Centre for Infectious Diseases (ECDC). And working with Erasmus MC, we were keeping track of the cases of patients who had the coronavirus. Those infections weren’t related to cases in China, but from Italy and a little later from Austria. With the exception of a few clusters in Germany and France, the picture in Europe until 21 February was pretty quiet. And then the number of cases in Italy started to rise very sharply. We had a massive influx of infections from northern Italy. That coincided with the holiday period here in the Southern region, and also with carnival. Ultimately, carnival was one of the drivers. That’s why we are still seeing more cases in Brabant and Limburg.’

You hold the chair for Responses to Communicable Diseases in Global Health at VU Amsterdam. Isn’t this the ideal case study for your research?
‘Yes, I think we’re going to learn a lot from this pandemic. But at a time of crisis, your first priority is doing everything you can to fight the spread of the virus. My PhD students will be doing research wherever that’s needed and practical. Infectious diseases continue to fascinate me, because they can always surprise you. I’ve been working in this field since 1996 and I thought that I’d pretty much seen it all. But what we’re going through right now… No, I’ve never experienced this before.’

Aura Timen (1966) has been head of the National Coordination Unit for the Control of Infectious Disease at the RIVM (National Institute for Public Health and the Environment) since 2011. She is also a special professor in the chair for ‘Responses to Communicable Diseases in Global Health’. Aura Timen graduated in medicine at Vrije Universiteit Amsterdam in 1995, and she teaches and specializes in Society and Health. She holds a PhD from Radboud University Nijmegen and has done extensive research in the field of communicable diseases, both in the Netherlands and internationally. She is an active participant in various national and international networks.