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 (chronic obstructive pulmonary disease) and heart failure came to the ER with shortness of breath, edema and fatigue. Chest x-day suggested pulmonary edema. He wanted to test him for SARS-CoV2 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 Congestive Heart Failure (CHF), not COVID-19” and “it could create panic amongst staff taking care of him”. I applauded his persistence as eventually the test was done. To not test is counter-intuitive and more like an escape from diagnosing the virus rather than escaping the virus itself.
One – the mere fact that we might hesitate before testing for a virus which is a cause of a (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. We now know that even the infamous flu and COVID-19 are not mutually exclusive. Common protocols from a few 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 at the time, 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 may be his COPD or CHF exacerbation has happened due to a milder COVID-19 inflammatory response? What we know about COVID-19 is that we don’t know enough about it and therefore we cannot rule out its presence. Especially while we are in the middle of a growing 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. Therefore, in an individual with high clinical suspicion of COVID-19, we cannot rely on a single negative result. But for lessening further exposure and resource allocation, a positive result can prove to be enlightening.
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 have come to know about (1, 2).
Suffice it to say that when it comes to 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 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 is carrying the virus. More than 25% of infected patients may be asymptomatic and spreading the virus without knowing about it. Therefore, 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 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%. Specially as the states have started to open, universal screening for the SARS-CoV2 at various times and places need to be discussed. An observational study from New York found that > 13% women were positive for SARS-CoV2 on universal screening when they arrived for delivery; with no symptoms of COVID-19. It was a small study; but 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.
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. However, it is 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 the individual states. Maybe it’s time for the states to consider their own testing rules by educating and making multiple 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 hence, if not tested, diagnosed and quarantined, they would continue to disseminate the virus. It is not a fool-proof miss-no-one strategy but is more acceptable than having all the uninformed viral reservoirs running amok unchecked. Early quarantine is better than no quarantine. What if there is a role of viral load during the initial periods of infection and the infectivity potential? 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 itself if commerce remains uninterrupted and the way to ensure it 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 another shutdown.
Because it is implausible to escape the virus, we cannot live in the state of ignorance. The long q-tip might 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. But if we do not test, we will miss them all. While we try to aim for the unattainable, we must be content with the broken portions. Because in this case, ignorance is not bliss.
Raghav Gupta, MD is an interventional cardiologist in private practice in the American Midwest. Twitter: @GuptaRMD