By RAGHAV GUPTA, MD
“In seeking absolute truth, we aim at the unattainable and must be content with broken portions.”– William Osler
A colleague shared an experience with me about testing one of his patients for the novel coronavirus and it left me a bit puzzled. An elderly gentleman with past medical history of severe COPD and non-ischemic cardiomyopathy came to ER with shortness of breath, edema and fatigue. Chest X-ray suggested pulmonary edema. He wanted to test him for SARS-CoV-2 but hesitated. Eventually he was able to order it after discussions with various staff administrators. Dialogue included sentences like “why do we need testing? He has CHF, not COVID-19” and “it could create panic amongst staff taking care of him”. I applauded my colleague’s persistence as eventually the test was done. Few of us have probably gone through or are going to encounter a similar scenario as we ‘re-open’. To not test is counter-intuitive and more like an escape from diagnosing the virus rather than the virus itself.
One – the mere fact that we might hesitate before testing for a virus which is a cause of a (currently ongoing) pandemic should ring all the bells of concern about lack of an optimal strategy. Inadequate testing has remained the Achilles heel of our stand against COVID-19 because, to have a lasting stand, we must know where to take the stand.
Two – the concern of CHF raised above is clinical and valid, but it is of grave importance to understand that CHF and COVID-19 are not mutually exclusive. Heck, we now know that even the infamous flu and COVID-19 are not mutually exclusive. Common protocols from 2 months ago to test for flu in sick outpatients and not test for COVID-19 if flu was positive was like the prey closing its eyes and hoping the predator does not see it. It did defer the use of an already scarce resource, testing. SARS-CoV2 is a virus and the disease caused by it is called COVID-19. Virus can be ubiquitous; disease does not have to be. A patient with CHF exacerbation can be an asymptomatic carrier of SARS-CoV2 but may not phenotypically express the disease manifestations of COVID-19. Or maybe his COPD or CHF exacerbation has happened due to the COVID-19 inflammatory response? What we know about COVID-19 is that we don’t know enough and therefore we cannot rule it out. Especially in the middle of an ongoing pandemic.
Three – yes, panic is plausible and possibly natural in the presence of poor communication. But let’s hypothetically consider that a patient (not presenting with COVID-19 symptoms) is positive for the novel coronavirus. A nurse or a physical therapist or a respiratory therapist would want to be informed and they should be. A false positive with PCR testing is extremely rare and hence a positive test can alter the delivery of care to be more streamlined and with lower staff exposure and hence eventually lowering the spread to the other patients. The false negative rate is also 20-30% and hence we cannot be certain. But if we don’t use what we have, we have nothing at all.
Four – as a patient, if one knows that they are being screened, it would make them feel more comfortable regarding measures taken by the hospital in order to lower the spread. It reinforces that the other patients being taken care of by the nurse have also been screened. Therefore, again reducing the risk of spread. Patients are more likely to seek help if they know about universal test screening measures taken rather than suffer at home to avoid exposure to the virus from hospitals. It could lessen the ripple effects of the virus that we are have come to know about (1, 2).
Suffice it to say that when it comes to the pandemic management, for a long period to come, the hindsight will be the year 2020. As I write this, we are a third of the world’s 4 million cases and closing towards 100,000 deaths even after we had a 3 months head start on this. We comprise of only 4% of the world’s population but more than 30% of COVID-19 cases. And SARS-CoV2 has given no hint to be leaving anywhere soon. Wuhan has reported new cases again for the first time in more than a month. Almost all epidemiological analysis suggest that there will be waves of highs and lows of positive cases. COVID-19 will continue to play infectious whiplash with us in the foreseeable future. FDA just gave emergency use authorization for a drug that possibly reduces the time to recovery. It is not a cure and not a treatment strategy we are accustomed to. Prevention remains key. In addition to broad use of masks and personal hygiene, the only other defensive blueprint we might have is to know who has it. More than 25% of infected patients may be asymptomatic and spreading the virus without knowing about it. Therefore, common sense would argue that to wait for the symptoms or to let the mingling go back to “normal” without knowing the status of current true prevalence of the virus could be a mistake.
Since we have known about this disease, we have been raised in a COVID-19 test-poor country and the only thing we know is being frugal when it comes to testing for this virus, we just cannot get ourselves to be extravagant with it somehow. Even now when we reportedly have ample testing available. Generally, we are not used to rationing. However, with COVID-19, we are getting our first taste at rationing all kinds of supplies, tests, supportive treatments, hand sanitizer, and, of course the toilet paper. And being thrifty is a good thing really; when it comes to money management. Do not spend what you do not have. But how many of us believe that the ability to test for a virus responsible for the global pandemic is a luxury expenditure? We must break the state of coagulum where we need code words like “fever” or “cough” to get tested. Positive test rates have just started to come below 10%. We need to get and sustain it to below 5%. Especially as the states have started to open, universal screening for the SARS-CoV2 at various times and places need to be discussed. An observation study from New York found that > 13% women were positive for SARS-CoV2 on universal screening when they arrived for delivery. With no symptoms. It was a small study; it has profound implications. As community prevalence increases, strong considerations should be made to make universal screening with RT-PCR testing as a standard practice in emergency rooms for all encounters in the future to maintain the healthcare system as a sanctum of care rather than abetters of viral dispersion.
Social distancing has worked in many states and the only way to further lower the daily number of new cases would be a stricter shutdown. There is a palpable fear that a prolonged containment could result in dystopian economic and social aftermath. Therefore, possibly it is time to open back up. But if we do it without a wider testing strategy, it’s only a matter of time before we could be backed into a corner. Government has been trying to increase diagnostic test availability and reportedly has done it. But it may be up to us to utilize it. Supply can only follow increasing demand and the infrastructural plan to utilize it. Therefore we must find a way to increase testing locations and ease of access. Mass blanket guidelines may be difficult to make and even more confusing to implement by individual states. What would work in New York may not be best in Kansas. Maybe it’s time for the states to consider their own testing rules by educating and making multiple small-scale testing sites a part of a “new-normal”. Or perhaps stopping for a routine random or weekly rapid test available at the workplace could become a part of life. In addition to guiding a trace, a positive screening test can identify someone who may be a carrier, who in future may never show symptoms. And therefore, if not tested, diagnosed and quarantined, would continue to disseminate the virus. If the already exposed do become infected, they would be spotted with further routine testing they would encounter down the line and then could be quarantined. Again, not a fool proof miss-no-one strategy but better than all the uninformed potential viral reservoirs running amok unchecked. Early quarantine is better than no quarantine for those infected. What if there is a role of low viral load during the initial periods of infection and the infectivity potential of that person? The White House has remained ‘open’ and functioning by routine weekly testing and quarantine those possibly infected or exposed and hence reducing the spread. States and businesses need to consider implementing mechanisms to combat the next wave before it hits. Mainstream media and social media would have to pitch in to reach the masses about access and importance of testing. Could testing sponsorship be a part of the government business stimulus package? Economy will grow with time but can only sustain it if commerce remains uninterrupted and the way to ensure is to provide the businesses with the testing capacity they need to run without a speed-bump. The inconvenience will be a small price to pay for our freedom, to avoid a lockdown.
Because it’s impossible to escape the virus today, we cannot live in the state of ignorance. The long q-tip might just save us if we decide to use it. It is impossible to be perfect with screening based on the technology we have and we will miss some due to false negative rates. But if we do not screen, we will miss them all. We must be content with the broken portions. Because in this case, ignorance is not bliss.
Raghav Gupta is a practicing interventional cardiologist in the Midwest.