23 March 2020 Blog Post: COVID-19 Update
As readers are probably all well aware at this point, COVID-19 cases have skyrocketed in the United States and now stand at 42,839 with 522 deaths (1.21% mortality rate but likely an underestimate given where we are in the epidemic) and 295 recovered. As I have expressed in previous posts, this total caseload is undoubtedly an underestimate and remains so now. More likely 40-80,000 cases was the total disease burden in the US a week ago, not currently.
At Santa Monica Primary Care we have begun to receive coronavirus test results back from our commercial lab provider, LabCorp. The amount of time for test returns has been widely variable ranging from 24 hours to 9 days to obtain results. We have had positive tests (indicating active coronavirus infection) in about 15% of the tests we have run to date. This is significantly higher than the the 10% positive testing rate that our Surgeon General has discussed among patients tested with a “high likelihood” of positive results.
In Los Angeles County, public health officials have, for all practical purposes, given up any attempt for viral containment. This is documented in The Los Angeles Times article. In addition to lack of testing, the County also lacks staff to trace the source of a positive test and to inform close contacts who may have been exposed.
I think we can do better. The key to doing better can be found in the basic principles of Epidemiology and outbreak containment. At its core there are two strategies: #1 – Therapeutic countermeasures (e.g., vaccines and antiviral medications) and #2 – Public Health interventions (e.g., infection control, social separation, and quarantine). Given that we have no proven therapeutic countermeasures against coronavirus, we must rely exclusively on Public Health interventions. But the key to infection control… is disease surveillance. In other words: test, test, test.
Simply because the Public Health infrastructure around us has given up on their core mission does not mean that we need to suffer the same. So in our clinic, we have continued to test. Maybe not test, test, test given the lack of kits but at least test. I’ve been asked, ‘how did you get test kits?’ I did not ‘get’ them. Two and a half months ago anybody who had even audited a first year Epidemiology class could tell that this pandemic was coming. So first I asked our LabCorp representative to set aside some viral test kits for our office. After much cajoling, phone calls and persistence – we got a handful of kits.
But our office tests for other viruses in our usual clinical practice. We have point of care flu tests and we send throat and nasal swabs out for viral PCR testing all the time. We compared the swabs sent by LabCorp to what we had in the office, looked at old papers on Middle Eastern Respiratory virus surveillance techniques and concluded that we could fashion our own test kits. LabCorp, to their immense credit, told us to send what we could and, if usable, they would run it. The kits work, as evidenced by positive results exceeding the national average.
I believe a negative coronavirus test is an immensely important result. It allows somebody to care for an elderly parent, neighbor or dependent. It reassures the patient themselves that the cough and slight fever they have may indeed be the common cold, or influenza, or something else – but not coronavirus. Could it be a false negative? Of course it could be. Is it likely to be a false negative? Not likely. Equally important, a negative test also tells an individual that they have NOT had the infection, and remain susceptible and should remain vigilant since there is no vaccine, no treatment.
Similarly, a positive coronavirus test is also critical information. An infected patient can double down on their quarantine knowing definitively that they could very well spread this infection to others. They can inform close contacts and do their own disease surveillance, even if only among a small group. They can act as ambassadors of the efficacy of restrictive interventions: social distancing, travel restriction, quarantine, and case isolation. Could it be a false positive? Of course but this too is not likely. But exception handling in the middle of an outbreak should not be our focus.
In 2007, Lawrence Gostin and Benjamin Berkman of Georgetown University Law Center wrote the following during the H5N1 pandemic threat:
“Surveillance is the backbone of public health, providing the data necessary to understand an epidemic threat and to inform the public, provide early warning, describe transmission characteristics and incidence and prevalence, and assist a targeted response. Surveillance strategies include rapid diagnosis, screening, reporting, case management reporting, contact investigations, and the monitoring of trends.”
And, if a physician is quoting two lawyers, it is probably now clear that we are rudderless in an extraordinary time.
𝗦𝗶𝗴𝗻 𝗨𝗽 𝗳𝗼𝗿 𝗢𝘂𝗿 𝗡𝗲𝘄𝘀𝗹𝗲𝘁𝘁𝗲𝗿
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