In the last issue of Health & Home, I wrote about preparing for a long haul with social distancing and life at a different pace than we're used to. Not much has changed in that regard; in fact, attempts to resume life closer to usual have just emphasized that we are in a highly reactive time with seemingly small changes yielding significant consequences.
Opening the social spigot a bit (or a lot in some regions) has been followed by spikes of viral circulation. It is true that some of those spikes are a result of greater availability of viral testing. It is likely there has been a substantial proportion of asymptomatic or presymptomatic citizens walking around, we just were not as aware of this until greater testing capacity arose.
Still, what is clear now is that this is a sneaky virus, lurking around amongst the outwardly well-appearing and mobile masses, permitting passage to the vulnerable.
Complicating matters is the difficulty we Americans seem to have with tolerating infringement upon our independence and choice. While individualism has been a historical feature of American life, collectivism appears to be a far more functional approach to dealing with a pandemic.
There has been a muddling of medical and political priorities in the U.S. that has increased the internal resistance of an already complex circuitry, and wires are getting hot. To mask or not to mask? Is three feet of distancing not much worse than six feet of distancing? What is worse: aerosols, droplets or drips? How do you compare the cost of millions of school-age children suffering at home with their unemployed guardians, to thousands of elders and others suffering, even dying in the hospital? The compass seems to spin with a different north for each guide we turn to for navigation. Pressures and priorities vary for local, state and federal leadership in the domains of governance, health, education, and labor.
As time goes on we are less in the dark with this crisis, but it is important to consider this: It is most dangerous traveling at dusk or dawn. The contrast between a light sky and a dark road, the glare of a low sun, the sleepiness that tends to border the start and end of night, all compound the peril. Debate continues on whether we are in the evening twilight or we've made it to dawn, but in either case visibility is poor.
Some of our Southern states have volunteered to demonstrate the consequence of a hasty attempt to return to normalcy — at press time, their rates seem to set new records daily. In a few weeks, these same states will demonstrate for the rest of the nation what a quick and beautiful complete reopening of the schools will look like — it may take two to three weeks to see the consequences.
I don't think any of those observations are very helpful, and are in fact quite discouraging and depressing.
Here's some information I think will be useful.
Containment of this virus is key until we can get a vaccine, or until by some chance this virus mutates to a less deadly version.
Essential to this effort is identification, whether by symptoms, testing or contact tracing; followed by separation of those identified for a time sufficient to minimize the likelihood of them infecting others.
Let's look at testing.
Antibody tests look to see if an individual has markers of past infection, not present infection. There are numerous reasons these types of tests are not very practical or useful right now.
At this time it is not known which or how many antibodies correlate with protection from reinfection. Or even if these antibodies are protective at all.
There are also numerous different antibody tests and not all antibodies are specific to the novel coronavirus SARS CoV-2 that causes COVID-19. Some may be due to other coronaviruses, which are the second most common virus to cause the common cold.
Viral tests look for genetic material from the virus (slower, but more accurate results), or viral proteins (faster, but less accurate results) that if found in sufficient quantity indicate infection is currently present.
Timing is important. The virus has to begin replicating and eventually rise to a level in the body that the tests can detect. This can take anywhere from two to 14 days, but on average four to five days. So, testing the day after a known exposure is too early to yield a reliable result.
Instead, tests should be done either at the onset of symptoms, or between five and seven days after a known exposure.
When will you get your answer? The more accurate test that looks for genetic material from the virus itself, returns results in two to 10 days, while results for the less accurate test that looks for viral proteins can come as quickly as 15-30 minutes.
Keep in mind that while a positive result for either test is probably accurate, negative results have to be interpreted with caution, as false negative results are quite common. So, a negative viral test today does not mean it will be negative tomorrow, or up to 14 days after exposure.
Given the fact that the available tests are not perfect in terms of availability, accuracy and expediency, we're left with containment, which relies on utilizing isolation and quarantine strategies and pursuing rigorous contact tracing when possible.
Whew. Here's my takeaway:
While it is hard to imagine anyone choosing to run a world, nation, state, city or home this way — it seems the map used to navigate this crisis will be drawn by the many lessons learned here and abroad through trial and error, apparently with the Southern states choosing to go first.
Right now there is no valid "immunity passport" to be obtained through antibody testing.
Containment is key and while viral testing is an important part of that, it is not perfect.
Positive viral test results are very helpful, and when combined with rigorous isolation measures, are essential to containment. Viral testing is less helpful when results are negative since a negative test does not actually mean one is in the clear. This reality makes diligent quarantine measures essential for containment.
This is in fact the first rodeo for all of us, and while we will get through it, we are going to need to ride this bull for a lot longer than eight seconds. Hold on.
Matt Thompson is a pediatrician at Spokane's Kids Clinic.
Who Gets What and For How Long?
As with everything about this virus, things get complicated. Here's the rundown.
Isolation is separating someone who is contagious, whether with or without symptoms, from those that are not infected.
Quarantine is separating an exposed individual from others who they have potential of infecting, should they become contagious.
An individual who is symptomatic and confirmed positive with a test, or is symptomatic and presumed positive because of a known exposure should ISOLATE away from others until 10 days after the start of symptoms, or for at least 72 hours after the end of symptoms, whichever is longer. So an individual with 10 days of symptoms would need to isolate for 13 days, and an individual with three days of symptoms would need to isolate for 10 days.
An individual who is asymptomatic but tests positive should ISOLATE for 10 days from the day the positive test was obtained. So if it took seven days for a test to return positive, the person should isolate another three days after the result returns. If someone becomes symptomatic after a positive result (so they were really presymptomatic, rather than asymptomatic), they need to follow the ISOLATE guidelines: 10 days from the start of symptoms or at least 72 hours after the end of symptoms, whichever is longer.
An individual with a significant exposure to a known positive (unmasked, within 6 feet for 15 minutes or longer), whether awaiting a test result or not, should QUARANTINE for 14 days from the last day of exposure to the positive individual. This is a tough category to be in, because the person in quarantine may feel fine the whole time, and depending on their exposure, they may be out of circulation longer than a peer that tested positive and was out of isolation after 10 days.