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.

Spreadability

We are in the last half of April, and once again the seasonal influenza virus is disappearing, as it always does in April.  It is worth taking another look at the annual CDC maps of the comings and goings of the influenza virus at this time.  Here is the link, https://www.cdc.gov/flu/weekly/#S5.  Simply scroll down to the yellow and brown map of the US.  Take a look at it today and see how many states are in hatch marks or yellow, really most of the nation.  This indicates states where the influenza virus is either only active in certain localities in the state (yellow), or not very common anywhere in the state (hatch marks).  Now click on the rewind button many times just above this map, til the cursor goes all the way to the left, then hit play and watch the United States turn brown by week 4.  You will be watching how a virus appears in a nation, then spreads to every state and essentially every city, town, and village in the nation, in this case the seasonal influenza virus, reaching every corner of America by February 1, 2020, now disappearing.

The SARS-CoV-2 virus spreads just as well as this seasonal influenza virus. In fact, if current measures are accurate, it spreads 4 times more broadly than the seasonal influenza virus.  This is based on the fact that each person with the seasonal influenza virus spreads it to an average of 1.4 people, but for the SARS-CoV-2 virus that number is 5.7, about 4 times more.

So it comes as no surprise that the maps of the United States where each town is red if COVID-19 is present, and more red the more it is present, have shown our nation, the entire nation, turning more and more red.

And so we have the essential paradox of the spreadability of our enemy, the SARS-CoV-2 virus that causes COVID-19:  This virus has spread across our entire nation AND we have slowed the spread of this virus by lockdown, keeping it from exploding exponentially everywhere.

Again, an exponential rise is when 1 case becomes 2, becomes 4, then 8, then 16.  That’s 4 repeats, go 20 repeats and 1 case becomes 1 million cases, if we only double each time.  But even so, that is an exponential rise.  A non-exponential rise is let’s say a nation has 500 new cases every day, always 500 cases, never more, never less.  The difference is enormous, exponential rises explode, a constant non-exponential rise simmers.

And so once again, the lockdown across the world has kept the increase in the number of people with COVID-19 from exploding exponentially, but has not stopped the virus from spreading across the nation.  This means that even though our hospitals may not be sinking under an exploding rate of increase, the virus remains in all our communities.

Therefore, as stated in several earlier posts, when we inevitably leave our homes to go to work or play, the SARS-CoV-2 virus has not gone anywhere, like the seasonal influenza virus has.  It is still in every town.  And when we gather again, it will pick up spreading right away.

If we catch all the little fires of spreading SARS-CoV-2 virus, and put every fire out right away, we might be able to avoid igniting an exponential rise, the sort of rise viruses are built to create.

But as readers of Real Answers know very well by now, the only way to catch those fires when they are small is to:

1. Screen all for symptoms and test those with symptoms suggestive for COVID-19.
2. Find a process to sample all those with no symptoms and test that sample, to statistically detect small outbreaks of COVID-19.
3. Find everyone who has been within 6 feet and longer than 15 minutes, of everyone infected with COVID-19 (Contact tracing) and test them.
4. Isolate all with COVID-19 so they cannot spread the virus, to anyone, including their families, until they are no longer contagious.

Do these steps and the small fires are put out before they rage into huge firestorms.Do not do these steps and the virus will find a way to go exponential again.

Dr. Thomas Friedan, once director of the CDC and a master of controlling the spread of tuberculosis which he was extremely successful in accomplishing advises that these steps be taken if we have any hope of preventing that deadly return to exponential spread of COVID-19 after opening the economy:

• Don’t even start until the number of new cases declines for 14 days in a row.  (In E Asia, the rule is more like, only after there are NO new cases for 14 days)
• Demonstrate actual ability to track, that is know, 90% of all contacts of all who have tested positive
• A period of time when no health care worker contracts COVID-19 infection
• And, ample rooms for those with mild COVID-19 infections to stay until no longer contagious.

You will note this program is right in line with the 4 point program outlined above.  The extra recommendation is crucial, a nation simply cannot succeed in controlling the spread of COVID-19 using the putting out the small fires as they emerge, if the large blazes are still blazing.

A note on tracking contacts of the infected.  One study estimates an infected person has an average of 45 direct contacts.  Dr. Friedan estimates the US would need 300,000 contact tracers to find all these contacts, test them, and isolate those contacts infected.   As of now, the CDC has 600 contact tracers, and state and local health departments have about 2,000.

Crowded versus Isolated Rooms

Tragedy has dramatically demonstrated how the SARS-CoV-2 virus spreads best, as all viruses do, when people gather.

The lockdown demonstrates that when people spend most of their time in rooms with few people, the number of new cases slows.

But during the lockdown, four examples of what happens when people spend time together demonstrate the SARS-CoV-2 virus maintains its ability to spread wildly bringing death in its wake:

• Bursts of infection after gatherings.  In Atlanta, GA, just two funerals gathered enough people to ignite a town wide outbreak that has brought this small town to its knees. Yesterday, we found that places that held large rallies to protest the lockdown were followed by spikes in COVID-19 infection.
• Workplaces with many people in close contact- the premier example is the pork processor in South Dakota, which until yesterday, was the nation’s largest outbreak in a single site.
• Nursing homes- this setting combines lots of people staying together all day and all night and extreme risk of death from infection.  This results in 20% of the deaths from COVID-19 in the United States happening in nursing homes.
• Prisons- this setting places people in cramped contact continuously, in very large numbers.  This has led to the nation’s #1 largest outbreak in a single site now in Ohio, in an Ohio prison.

These patterns bear enormous implications.  One actuarial analysis found that citizens of states resisting slowing the spread of the SARS-CoV-2 virus face a 30% increased risk of losing life from this infection.

These experiences make it very, very clear that, as with all viruses, gather together and you increase the risk of infection.   Stay apart, and you reduce the risk of infection.    So, again, as long as the SARS-CoV-2 virus remains around us, we can only gather and not see explosions in infection with the ability to know where the new outbreaks are first happening and isolating them.

Severity

COVID-19, for now, is the #1 most common, leading cause of death in the United States

Many people have talked about how so many other problems kills so many more Americans than COVID-19, and they are right, sort of.

We know that tobacco kills about 500,000 people every year, which is far more than COVID-19 has killed in America so far.

But a serious review on this subject in the NY Times recently offers a clearer view.  https://www.nytimes.com/2020/04/18/health/coronavirus-america-future.html

The disease COVID-19 first appeared in the United States in late January, 2020, so it’s been hurting us for only 3 months.  And given the failure to test in any way that could give us an accurate count, the official number of deaths, about 1,800 a day since April 7, 2020, is a low estimate.   But now compare COVID-19 to the great killers of America- heart disease and cancer.  Heart disease kills more people than any other disease in America, and it kills 1,774 Americans a day.  Cancer is a close second, but it kills us at a rate of 1,641 deaths a year.

Tobacco kills about 500,000 of us a year, but that is via some deadly disease, mainly heart disease and cancer, but even so, tobacco’s daily count of death is 1,370.

On a day by day basis, COVID-19 now kills more Americans than heart disease, cancer, or tobacco.  And that is during the days when we are heavily locked-down, isolated, staying at home, with this SARS-CoV-2 virus as held in check as much as we can.

More on the SARS-CoV-2 attack on the kidney

A recent post on Real Answers briefly noted that the SARS-CoV-2 virus is now showing an ability to destroy kidney function, at the very least, temporarily.  It is too soon to know whether the virus actually infects the kidneys, or whether in severe cases when lung function is attacked directly by the infection the kidneys drop their function in reaction to the stress, or either way, if the loss of kidney function is temporary or permanent.

What we do know, however, is that 20-40% of all people sick enough with COVID-19 end up requiring renal dialysis because their kidneys have ceased working adequately (https://www.nytimes.com/2020/04/18/health/kidney-dialysis-coronavirus.html).

This fact has led to an enormous surge in the demand for dialysis machines, and the fluids and tubing they need to work.

Testing

Beyond the imperative of doing enough testing to know who is infected, so we know how we are doing, and achieve the ability to control the spread if we venture back to work and play, there is complexity in the whole world of testing.  Here are some thoughts that will hopefully reduce any confusion about what testing is.

Currently there are two types of test being used and discussed:

• A test to see if you have live virus in you- that is, are you infected and contagious at the time of the test
• A test to see if you once were infected

Are you infected now?  The SARS-CoV-2 virus PCR test is the way to know

The test being used to answer this question here and around the world is a test to see if you have live SARS-CoV-2 virus in your nose or throat.

To do this test, you need to swab your nose or throat and see if there is any evidence for the SARS-CoV-2 virus on that swab.

Many of us have heard terms like PCR, RNA, genetic testing mentioned when talking about this test, here is why.  Remember all viruses are basically packages of a bit of genes wrapped in a protein coat?  Well, every virus has a unique bit of genes and a unique protein coat.  The test to see if you have a virus in your nose or throat tries to see if the unique bit of genes in the SARS-CoV-2 virus is present.  All genetic bits in all of life come either in the form of DNA or RNA.  We have both in our bodies, where DNA is the basic blueprint gene.  In the  SARS-CoV-2 virus, the little bit of gene material in the virus is all RNA.   So the test for the virus being present looks for  SARS-CoV-2 viral RNA.   One virus only has a tiny, tiny amount of RNA, so to see it, the test copies any  SARS-CoV-2 viral RNA a zillion times, in effect amplifying the amount of viral RNA on the swab so we can detect it being present or not.

The technical term for that amplification process is PCR, which stands for polymerase chain reaction.   The polymerase is the enzyme that makes zillions of copies of the viral RNA, and the chain reaction is what multiplies the copying, amplifying it so we can see if the RNA is there or not.

This test can fail.

What if the swab misses where your virus is sitting? That is a false negative, the test says you are fine, but no, you are infected.

What if the test says it found the RNA of the SARS-CoV-2 virus on your swab, but you are not infect.  That is a false positive, test says you are infected, but no, you are fine.

Every test has false negatives and positives, see below for more on this point.

Were you once infected?  The antibody test is the way to know

Most of the time someone has a germ infect them, their body makes a whole lot of antibody to that germ.  The antibody is used to kill the germ and/or clear it out of the body.  Antibodies are proteins only made by one type of cell in our immune system, the B-cell.  Every antibody is shaped like the letter Y, and the upper part of the Y, the V-shaped part, is created to cling to one, and only one type of molecule, usually another protein.  So, if you have antibody to the chickenpox virus, that means the upper part of that Y-shaped antibody will only attach to a protein in the protein coat of the chickenpox virus.  Remember, a virus is a bit of gene wrapped in a protein coat.  We just read that every virus’ bit of gene is unique to that virus, so is each virus’ protein coat.

A germ with its antibody on it has a huge target for your immune system to utterly destroy that germ.

So in the antibody test, we take blood and see if your blood has antibody that will only attach to the protein coat of the  SARS-CoV-2 virus.

This test can fail.

The blood test might say you have no antibody to the  SARS-CoV-2 virus, but you were infected.  This is another example of a false negative, the test says you were never infected, but you were.  This can happen even if the test is done perfectly right, because not everyone makes antibody that can be measured after an infection.

The blood test might say you have antibody to  SARS-CoV-2 virus, but you were never infected.   This is another example of a false positive, the test says you were infected, but you never were.  This can happen by error in the testing process, but errors are part of all testing processes, unfortunately.  Or it could happen by cross-reactivity, see below.

The Reality of Error

We like to think all our medical tests ring true.  I know I wish it were so.

But some tests ring truer than others.  The pregnancy test rings pretty true.  If it glows positive, you usually are pregnant, and if you have a negative test, you usually are not pregnant.  But we do know it is not always correct.

Some tests have a surprising degree of inaccuracy.  These are actually designed to overcall situations.  How could that be?

It turns out if you measure anything, even how wide a box is with a ruler, error will there with your attempt to make an accurate measure.  It is a fact in all measures, and it is a fact in medical measures.  And a balance is always present between minimizing false negatives and positives.   Let’s say you are screening for if you need glasses.   Someone has to set a level of performance for your eyes, exceed that level and the doctor says you don’t need glasses, fail to reach that level and the doctor says, go see the eye doctor.   But the key point is the level at which normal is set is picked by someone.   That someone, or group of experts, often will set that level low, to avoid telling anyone that they are fine when they are not, that is the goal of minimizing false negatives.  But anytime you do that, you boost the number of people told their test is not normal, and with that comes a boost in false positives.  That’s why so many, so many, people have the experience of a screen telling them there might be a problem, only to go to the specialist, the eye doctor in this example, and finding out all is well.

The only situation in which there are no false positives or negatives is when the group of people with the problem and the group without the problem always have different test results.

Imagine a test to see if you have blue eyes, not a very helpful test, but let’s see how it might work.  Well, it turns out no one with brown eyes has blue eyes, so they would always come up negative for this test.  And people with blue eyes would always come up positive on this test, no overlap, no false positives and negatives, for brown and blue-eyed people.  (But of course, what about hazel-eyes that vary day to day…)

The Complexities of Germs and Our Immune System

Now, add to the fact that false negative and false positives are a fact of life for most medical tests, that infections present their own complexity, hinted at above.

Take the germ.  Any test that tries to swipe a germ from a spot on the body, in this case, the case of COVID-19, we swipe the throat or upper nose, may or may not get the virus on the swab, even if it’s there.   That can happen if the virus is concentrated on one spot in the nose, and the swab just happens to miss that spot.  Or, it can happen if the virus was in the nose on Tuesday, but the swab was done the following Saturday by which time the virus had burned down to the lungs, so the lungs are loaded with SARS-CoV-2 virus but the nose is empty of it.

Now, take the antibody.  Let’s say you just got over COVID-19, and now you get tested for the antibody to the  SARS-CoV-2 virus you just had in you.   Maybe your body hasn’t cranked up production of your antibody to the level the test can detect it yet.  Or, maybe your body cleared out your SARS-CoV-2 virus by using other immune strategies your T-cell has concocted, like swarming infected cells with immune cells, and not resorting to antibody production.

Or, let’s say you never had COVID-19 and your antibody test comes back positive.  As noted above that can happen simply by an error in the machine and process, and as we have seen every measure risks inaccuracy.  Or, it could be the antibody test will find antibodies that stick to all sorts of coronaviruses, not just the  SARS-CoV-2 virus.  And we know about 25% of the common colds I’ve had, and that everyone has had, are old, old coronaviruses, so we all probably have some antibodies to some coronaviruses even if we never have been infected with THE SARS-CoV-2 virus.  We have seen this error in some antibody tests that were then deemed unusable.

How do the Tests for Live Virus and for Antibody Actually Perform?

No one knows for sure.

Some centers are reporting the false negative rate for the swab looking for the virus at about 30%.  That would mean about 1/3 of Americans tested by swab and told they do not have COVID-19, actually do.  But these are spotty reports, we don’t actually have information from looking at the swab’s test performance that can reliably answer this question.

And the antibody test is so new, we really have no idea on how many times its results will be right or wrong.

Still, the swab for virus and the blood for antibody, are giving us some information, and the use of the swab for virus test in E Asia has proven to be accurate enough to stop spread by accurately finding out who is infected.

BOTTOM LINES

1. The SARS-CoV-2 virus is highly contagious, 4 times more contagious than seasonal influenza virus.
2. The SARS- CoV-2 virus is dangerous.  It causes far more destruction to the body than the seasonal influenza virus.  It can destroy the lungs, impair the heart, and now appears to play some role in shutting down the kidneys.  We have flu epidemics every winter, but have never seen any of our major cities, or our small villages decimated like with this disease, not since 1918.
3. So it is time to end all pretend that the SARS-CoV-2 virus is like the flu, it simply is not, it is a threat beyond any humanity has faced from a germ since World War I.
4. In the United States, whenever people gather, spikes in infections and death follow.  This has happened following gatherings for funerals, for protests, for work.  And in nursing homes and prisons.  Really for any reason enough people get together.
5. So how to get back to work and play before this virus goes away- on its own, by a powerful drug, or by vaccine?   Only if we are in a status where the number of infections is close to none, so that when the inevitable flares happen, we can control the spread.  And this can be done only be testing enough people and their contacts so that we can isolate enough of the infected to slow the spread.
6. Testing comes in two types now.  Swabs to find live virus to see if you are infected now, and blood tests for antibodies to see if you had it in the past and recovered.  We do not know how well either test performs, it is simply too early on to know, but people should know they have errors.  At the same time, they the swab for virus test is accurate enough, proper use with enough people tested has stopped the spread of this virus in many nations.

And so America, Ohio, our neighborhoods face a deadly infection that spreads so rapidly and well.   Our nation is in the plateau of a massive explosion of an all out exponential rise in cases in our nation, the largest outbreak of the disease of any nation in the world to date.  If and when this explosion settles to the point we can think about going back to work, all these points will have to be kept in our mind, to see when we are called to come back to work and play, if we really have the plans in place to detect new hot spots and to actually contain them.

To your health,
Dr. Arthur Lavin