COVID-19 update with Dr. Benjamin Marcum

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Myth 10: I already had Covid-19 in November

No, you didn’t.  Probably.

Remember that in medicine the simplest explanation is also the most likely explanation.  We just came through cold and flu season.  Several hundred strains of influenza and parainfluenza and adenovirus and rhinovirus and human metapneumovirus and rotavirus and enterovirus and norovirus and respiratory syncytial virus and yes even other non COVID coronaviruses have just wreaked havoc on us for 6 months – as they do every single year.  Most people have viral infections during the fall and suffer to varying degrees.  Some have asymptomatic infections and just serve as vectors for transmitting these viruses and others have terrible flu-like illnesses that last for weeks, causing all conceivable forms of misery.  We now have the technology to narrow down exactly which virus is responsible for your current form of torment but it is cost prohibitive to do so.  I have the capability to swab your nasopharynx and then send the sample to a lab and identify via PCR (polymerase chain reaction) exactly which nefarious pathogen has invaded your respiratory passages.  Most people don’t want to spend upwards of $150 to determine the specific offending pathogen and are content to know that they have a cold and it will soon pass with supportive care, fever reducing meds, cough suppressants, mucolytics, fluids and rest.  The prescribed course of action does not change regardless of which pathogen is responsible for the current cold.  

Many people think of a cold as mild cough and some sniffles, but symptoms actually range from mild upper respiratory irritation to severe cough, fever and pneumonitis (lung inflammation).  I have heard many anecdotes of patients who had, “the worse cold of my life” in late fall or early winter this year.  I’m sure, for some, their symptoms were quite terrible.  But as a multi-year observer of populations experiencing cold seasons, many patients suffer this way every year.  For me it was 4 or 5 years ago.  I was very sick with upper respiratory symptoms, severe cough, headache, fever… “all the symptoms of Covid-19,” flu swab was negative.  And I got better.  A close friend of our family was traveling from her home in Tennessee to California several years ago.  She fell ill and ended up having been admitted to the hospital with a severe viral pneumonia for several days.  She was in her 30s, healthy with no other medical problems.  Many of you have personal stories such as this or know someone who does.  None of those people who got very sick with a virus had Covid-19.  Many turn out to have influenza despite a negative flu test (false negative rates range from %50 to %80 with some flu tests.)  

“But Doc, how do you KNOW that I didn’t have Covid-19 in November?” 

Well, truthfully I don’t KNOW for sure.  Nothing in medicine is ever 100% certain.  But I can say that it is very, VERY unlikely that SARS CoV-2, the virus that causes Covid-19 was present in our local population at that time.  I can say this with a very high level of confidence for a number of reasons.  

1.) New mutations in a virus occur at a specific place at a specific time and spread from there.  While it is true that we have been unable to identify patient 0 – the very first person who was infected with the virus after it mutated and spread from animals to human hosts, we have been able to identify the first few infected people and it has very clearly spread from a specific location, Wuhan, China.  This occurred in early December.  Viral mutations do not occur simultaneously in multiple locations at the same time.  If the first few patients to have the disease were identified in early December on the other side of the world, it is unlikely to have been in Erath County, Texas the month before.  Certainly if you had a bad infection in late January or early February I can be less certain that it wasn’t due to SARS CoV-2 but still it was unlikely as rates of infection in major metropolitan areas were still quite low at that time. 

2.) Though you may have been very sick, there was no evidence of an infection as contagious and simultaneously as deadly as SARS CoV-2 in our population before now.   Epidemics follow a very predictable pattern of spread.  It’s the pattern we are seeing now.  It begins in a country with huge numbers of cases in large metropolitan areas where people are living in close proximity and then slower, more sporadic spread in smaller towns.  For you to have had Covid-19 in Erath County, based on epidemiological principles, we would likely have already seen huge spikes of infection in major cities and associated spikes in death rates, ventilator use, ICU admissions etc.  Not enough people were extremely sick and dying at the time you had your severe cold to fit the pattern.  

3.)  More people died in China first than anywhere else.  This concept is simple.  Let’s say the mutation did start in central Texas back in November and then some poor infected soul traveled to Wuhan, China and then, in turn, infected many people there, thus igniting the epidemic in China.  If that were the case, the virus would have already had a head start here at home and the severe pneumonia cases would have started piling up here first.  It is too contagious for this not to be the case. The virus started first in China in early December and spread from there.  It simply wasn’t here before that.  We didn’t get three cases in Fort Worth until a three weeks ago, so the likelihood of it being in our county to any degree before that is minuscule. 

4.) People leaving China began the first major outbreaks in other countries.  The outbreaks in Washington State starting around 1/15, Japan and South Korea were all traced back to people who traveled to those places from Wuhan China.  Folks, if it walks like a duck and quacks like a duck, it’s probably a duck.  

“But Doc, can you PROVE I have never had Covid?” 

Well, yes, we could if we had the right tests available.  There are several lab tests we can use to see if your body is currently interacting or has previously interacted with SARS CoV-2.  I’ll discuss three of them.  

1.) PCR.  This is the main test we are using in Stephenville to test for current infection with SARS CoV-2.  It’s a test that identifies a specific RNA or DNA sequence that can say whether a sample has the genetic signature of the virus within it.  We use a nasopharyngeal swab to collect a sample from deep in the nasal passages and then send that to a lab in DFW where the RNA identifying biochemical magic is done and the result is reported back in a few days.  The test is very specific – meaning that if the RNA is detected, you have the virus.  It is not as sensitive as we would like meaning that if the RNA was not detected, you may have a very early infection and have not produced enough viral RNA to be detected or the sample was not collected appropriately or was mishandled.  This test is the most widely available test at the moment and has helped us identify several cases so far.  It’s limitations are the time it takes to report back and the potential for a false negative result.  It is only positive when you are actively shedding viral RNA and is not reliable for saying whether you were infected a month or two ago. 

2.) Molecular testing.  This test is an office based test and has a turn around time of minutes instead of days.  It works on the principle of identifying a specific gene sequence in the RNA of the virus.  A small cassette is loaded with a sample collected from the patient and inserted into a small portable machine in the office and the machine runs the test and reveals a positive or negative result much more quickly.  Again this only works when the RNA from the virus is present, during active infection.  It again, is very specific, meaning a positive is very likely true, but not as sensitive as we would like, meaning there is a higher level of false negative tests than we would like.  But it is fast and we can identify infected people right away which helps us make better decisions about quarantine etc.  Unfortunately this test is very limited in availability at this point.  It was only available for clinical application (not research application) starting Monday of last week.  THR Stephenville (our local hospital) has this test available but I’ll caution you before you decide to go ask to be tested via molecular testing there.  They have a limited amount of single use test kits available and are only able to use them for patients who are sick enough to be admitted to the hospital or transferred elsewhere.  Abbott, who is one of two companies that I know of are providing these tests are currently able to produce 50,000 test kits a day but the Federal Government has, rightly so, directed them to high density populations with out of control spread of the virus.  

https://abbott.mediaroom.com/2020-03-27-Abbott-Launches-Molecular-Point-of-Care-Test-to-Detect-Novel-Coronavirus-in-as-Little-as-Five-Minutes 

They are hoping to produce 5 million tests in the month of April.  We will get more tests in time – but for now supply is limited.  SMSC received our first machine from the other company that I know of making molecular tests, Silaris, today.  We are planning on getting 4 machines and the City of Stephenville has graciously offered to help us get the machines up and running.  Both the City and the County have been working tirelessly and in concert to help the medical community and I am proud and appreciative that I live in Erath County.  Unfortunately we do not have any test kits yet as Silaris has also been directed to send what they can produce to high demand markets but we will get some.  Not sure how many and when but stay tuned.   We are also still aggressively pursuing the Abbott molecular test as well.  

3.) Antibody test.  Evidence of previous infection or immunity to a pathogen remains in our bodies in the form of immunoglobulins (Ig).  Igs are proteins that remember previous infections and remind the immune system to get rid of the pathogen right away if it ever tries to invade the body again.  We can test for those proteins in the blood.  I asked the hospital lab about a week ago if they had an antibody test and the answer at that time was not yet.  I’m not sure if they have been able to access this capability yet.  I did hear today that Clinical Pathology Laboratory in FW (CPL) will be able to do this test on a limited bases in the next few days.  This is the test that you can take to see if you were infected before.  There are a couple of problems, though.  First, there are not enough tests to warrant testing curious well people who were sick in November.  Second, every day we go deeper into the pandemic is another day that puts you at risk for developing infection, whether you are symptomatic or not, and if you have a positive antibody test we are unable to say when you were infected before, just that you were infected before and now show evidence of immunity.  This also brings up the question as to whether you can be infected again.  That remains to be seen.  As time goes, it is clear that this virus will be extensively studied and antibody titres will be followed for years to monitor how immune systems respond and whether we are able to maintain immune memory.  Also, we have yet to see if the virus is able to mutate as fast as influenza which is why some people get flu year after year and the vaccine is constantly working to hit a moving target.  

The intense emotional undercurrent of personal experience is a powerful influence over each of our individual perceptions of reality.  It is easy to read the reports of what people who have Covid-19 experience and it may seem that your recent experience fits the bill exactly.  The problem with falling into that line of thinking is that it does not fit the overall epidemiological narrative and there is a much simpler, much less conspiratorial explanation that is most likely true.  MANY viruses cause patients to be VERY sick every year.  The natural progression of epidemics combined with the likelihood that you had any number of other seriously infectious pathogens, in fact, much more likely rules out Covid-19 as your November or December illness.  It just doesn’t make sense. 

Sorry you were sick, before.  Try to stay healthy, now.  
BAM

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