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COVID-19 Update May 14, 2020: Testing – Necessary but Not Sufficient; Health Cures Economies

By Dr. Arthur Lavin

Glossary

  • Virus– a type of germ that consists solely of a bit of genetic material (DNA or RNA) wrapped in a protein coat.  The coat gets the genes into the target cell where the genes force the cell to make zillions of new viruses, and on it goes.
  • Coronavirus– a species name of a number of different viruses.  Called corona because its protein coat is studded with spike shapes that form a crown, halo, or corona of spikes
  • SARS-CoV-2– the specific name of the new coronavirus
  • COVID-19-the name of the illness that the new coronavirus is causing
  • Endemic– an illness always present in a region.  One could say strep throat is endemic in the US
  • Epidemic– a sudden burst of an illness that comes and goes over a limited time
  • Pandemic– an epidemic that bursts across the world not just one region
  • Spreadability– how contagious is the disease, how many people will end up infected
  • Severity– what harm does the disease cause, in terms of  how sick you get and how many it will kill
  • Mask- a mask is a loose-fitting cloth or textile that covers the mouth and nose loosely.  A surgical mask is a mask used in surgery
  • Respirator-  for the purposes of the COVID-19 pandemic and other respiratory illnesses, a respirator is a mask that fits very snugly or tightly to the user’s face.  An N95 mask is a respirator.
  • Personal Protective Equipment (PPE)- PPE are any item that covers any part of the body with the design and intent of keeping viruses in the environment from infecting the wearer of the PPE. PPE’s include all masks (which includes respirators), face shields, eye shields, gloves, gowns.
  • Ventilator- a ventilator is a machine that can force a person unable to breathe to inhale and exhale and control both effectively.  They are sometimes called respirators, but during this pandemic the word respirator is now reserved for reference to a tightly fit mask.
  • Live Virus Swab– this is the swab which attempts to swipe live virus from one’s nose or throat to see if you are currently infected.
  • Antibody Test- (aka serology test) this is the blood test which looks for antibody to the SARS-CoV-2 virus to see if you have been infected in the past.

 

Spreadability

In nearly every post in Real Answers, there has been observation about how this virus, the SARS-CoV-2 virus, spreads.  How well does it spread, how does it physically spread, how to stop it from spreading.

Today, it is time again to talk about how we stop it from spreading.

The Importance of Spreadability

To a very deep level, everything threat from every germ can be defined by its spreadability.  This virus, the SARS-CoV-2 virus, teaches us much on this point.

First, before this virus existed, it could not spread at all.  No virus, no spread, no pandemic, no COVID-19.

Second, once the virus mutated into existence and move amongst humanity, it cannot do any harm unless it spreads.   This was the focus of many earlier posts, when we had no idea, would this virus spread easily and rapidly or really not at all.  Sadly it is now a firm fact that if left alone to spread, it spreads wildly, with one person spreading it to an average of 5.7 people when left to do so.  To put that into perspective once again, 10 rounds of 5.7 people catching COVID-19 each round leads to one person becoming 36 million cases.

Third, since 1 case has not become 36 million cases after far more than 10 rounds of spread, clearly something has interfered with the spread of the SARS-CoV-2 virus from person to person.   This is good news, it means that actions people take can interfere with the spread of the virus.

Fourth, if humanity finds a way to clear the planet of the SARS-CoV-2 virus, that would obviously be the only way to conclusively end all the death and suffering this virus is striving to create.   At this point the only path to this option would be a vaccine, and it would have to be a highly effective and safe vaccine.

The Near Hope

And so it is most clear, how well the SARS-CoV-2 virus spreads decides all our fates.  Before it arrived it had no role in our lives, now present, it conquers cities where it can spread freely.  Humanity may one day remove this virus by vaccine.  But until then, our near hope, is that we put our proven ability to reduce its spreadability to work.

The more we keep it from spreading, the better off we will be, by so many measures:  by how many get sick, by how many get hospitalized, by how many suffer organ failures, by how many die.

Our Proven Paths to Interfere with the Spread of This Virus

Since this virus first began to spread, humanity has found two strategies that have proven to slow its spread.

One is sustainable, one is not, but both slow its spread.  One can actually stop the spread, the other cannot.

One strategy that has slowed the spread is to have everyone stay home.

It can be called the isolate everyone strategy, and it should sound familiar, it is the American strategy, the one that has defined our last few months.  We haven’t actually isolated everyone, a lot of people have essential jobs and continue to go to work.  But enough of America stayed home, and isolated at home, that the spread of the virus slowed down.  It did not stop spreading.  At its best the American strategy led to fewer deaths and fewer new cases each day, but never has achieved no new cases and no new deaths day to day.  Sadly, in areas of the US outside of areas around NYC, this strategy has slowed spread, but no even decelerated it.

So one problem with the idea of isolating everyone at home is that it is impossible to achieve completely, and has so far proven impossible to achieve a true stop to the spread.  The other problem with this strategy that we have all come up against, is that it is unsustainable.   Telling everyone that the best way to avoid getting dangerously ill is to stay isolated at home clearly ruins the economy, catastrophically.  Catastrophic damage to the entire economy is unsustainable.

The second strategy humanity has used is to isolate the infected outside the home.  

This strategy is not based on asking everyone to stay home and stay isolated.  Instead, this strategy relies isolating those infected and leaving everyone else open to work and play normally.  The American plan isolates everyone at home, this plan, in place in 32 countries around the world, isolates only those infected and does so outside the home.

This strategy has actually allowed whole nations to record a far more dramatic drop in the spread of the virus, some even recording no new cases on some days despite lots of testing, and many have had days with no deaths from COVID-19 on many days.

The goal of isolating everyone who is infected outside their home until no longer contagious is sustainable because it does not require shutting down the economy.

Will More Testing Stop Spread Enough?

Now we can take a look at how we go forward here in America.  Some say the best path forward is to “re-open” which mainly consists of opening businesses and entertainments, sometimes in stages, sometimes all at once.  Others say we should not re-open without more testing.

There is not evidence to suggest that simply re-opening will slow the spread of the SARS-CoV-2 virus.  This is a strategy based more on hope than biology.  The evidence is overwhelming that when people gather with no real attempt to interfere with the spread of this virus, the virus spreads, and spreads well.

But what about testing, is testing a strategy that can slow the spread of this virus?  The answer is that testing is necessary to any strategy that does not rely on everyone staying home, but it is not enough, not sufficient.  Why not?   Think for a moment what the actual goal of any strategy to save lives before this virus is ended.  Such a goal can be reached, while the virus swarms around the globe, only by interrupting the spread, as noted above.  If you test someone, and do not take any further action, the virus spreads without being prevented from spreading.

And so testing can only stop the spread of this virus if it is part of a system that isolates those found to be infected.  A system would involve programs that test enough of the people most likely to be infected to find as close to all the infected in our nation at any point in time.  Then finding everyone who possibly could have caught the virus from these tested and found positive must happen.  Then placing everyone found to be infected away from those not infected.  Do all this, and the SARS-CoV-2 virus spread can be very well interrupted.

Let’s look at each step and see what happens if any one of them do not take place:

  1. If there is no testing.  Then we have no idea who is infected, so the infected spread the virus with no interference, the virus roars unimpeded.  This is what we did before we locked down and we saw the virus spread wildly.
  2. If there is testing, but not with any focus.  Only people with severe symptoms who come to the doctor get tested, we do not try to find the infected, seek them out, and test them.   This approach is our current situation, we test people being admitted to the hospital, but not really anyone else.  There is no effort to seek those who may be infected but have no symptoms or only mild symptoms.  So far, there is no evidence that this plan will slow down the spread of the virus.  Again, in our communities where people gather closely enough to allow the virus to spread, testing only those who need hospitalizations has had no impact on the spread of the virus.
  3. If there is plenty of testing, and includes those likely to be infected but not so sick, but no contact tracing.  We know about a young man who was tested positive had careful contact tracing.   It was discovered that 7,200 people came into contact with this person and others in contact with them by the time he got tested, and when all of them were tested, 40 other infected people were found.  None of those 40 infected people would have been found and isolated from infecting so many more, without careful contact tracing.
  4. If there is plenty of testing, including those likely to be infected, and all those with positive tests lead to careful contact tracing, but none of the infected are isolated.  It should be obvious how this plan would fail to slow the spread of this virus.  Diagnosing someone as positive does nothing to stop their virus from spreading to people, only isolating those infected actually achieves our ultimate goal here, to interfere with the virus spreading.

And so, when we think about the need for more testing, it is important to keep in mind what is actually needed is a system, only a system can possibly implement all these necessary steps.

But is it worth it?  What can be achieved if most or nearly all of the infected are identified by widespread yet focused testing and contact tracing, and isolation of as close to all the infected as possible and isolated outside the home so no one can catch the virus?

Here is what you get with such a system.   You get a nation that has days with no new cases, none.  You get a nation with days with no one dying, none.  And all this with people working and playing.   This is after all what we all want.  So the question remains, why not take these known steps, already demonstrated to be very doable in many democracies in the world?

The good news is that we can choose this path.  The bad news is that we have not so far.

Health Cures Sick Economies

When economies suffer from the impact of deadly epidemics, history demonstrates dramatically that they will not recover until the deadly epidemic is tamed or ended.

A startling example is found in the city of San Francisco in 1918.  That year, when the deadly Spanish influenza pandemic struck, they did what we did, they stayed at home, nearly everyone.  Then as now, it slowed the spread, a tidal wave of death was slowed.  The city was thrilled, feeling the danger was past.  But back then there were no tests, no one had any idea who was infected.  So when San Francisco decided when the danger was slowed that the danger was past, they poured out into the streets and celebrated, threw away their masks!  Within one week, 2000 San Franciscans were dead, demonstrating that the virus did not go anywhere.  People hid from the virus, which as noted, does slow spread, but it cannot eliminate the virus, and offers no protection from getting back together.

We can also do a 1918 comparison.  Take a look at cities in 1918, like San Francisco that stopped the lockdown early to save the economy.   Now take a look at cities in 1918 that decided to stay at home until the pandemic passed, keeping businesses closed for months, even a year or two, longer than the quick to open cities.  One would think opening businesses would spark economic recovery, but check in a few years after 1918, and the early openers had the depressed economies, far worse off than those that waited.

The point is fairly straightforward:  when a deadly virus stalks the land, not only are lives saved by taking steps that keep the virus from spreading, but so are economies.  In fact, the record is convincing, while deadly epidemics rage, businesses cannot succeed.  If we want a thriving economy, we need to stop the spread of the virus.

BOTTOM LINES

  1. We have discussed spreadability of this virus on most of the posts in Real Answers.  Today we take a closer look at whether we have the ability to interrupt the spread of the SARS-CoV-2 virus before it is eliminated by a vaccine.
  2. The answer to this question is yes, we have demonstrated two strategies that work:  Isolate everyone and Isolate the Infected.   The first is our US strategy, it slows the spread, but does not really stop it.  The second is used around the world, 32 countries have achieved almost complete cessation of spread.
  3. As we grapple with saving our economy, our jobs, our livelihoods, it is urgent that we choose the strategy that can interrupt the spread of this virus even as we gather to work and play.
  4. The only proven strategy that can truly interrupt the flow of this virus when we are together is not just testing but:  Testing widely, Testing those most likely to be infected, Tracing all contacts of those who test positive, Isolation of all infected outside the home.

In some nations that have implemented the idea of Isolating the Infected, unemployment can be as low as 3.8% even today, days go by with no deaths, totals of deaths can be kept below 500.  Our choices have led to unemployment going towards 20% and death totals now over 80,000.

We hope our nation embraces the paths that allow us to stop the spread of this virus to the point we can work, play, and live!

To all our health,
Dr. Arthur Lavin

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