Ebola—No new cases.  End remains in sight.  2,273 deaths total for this outbreak.

Coronavirus—Most everyone on this list has had a lot of time, and everything is all coronavirus, all the time (so juuuuust a quick reminder that Jeffrey Epstein did not kill himself).  In terms of world events with coronavirus, good chance you are more up to date than me.

My main takeaways this week:

–New York will be a major battleground.  Frankly, the real hope is that other parts of the country can flatten the curve enough to take patients on diversion.  Otherwise, one hospital ship off shore ain’t gonna do it.

–Italy appears to be in the early phases of leveling off, which is optimistic.  Spain is now looking bad though.

–Chloroquine is less impressive in a Chinese study released this past week.  Nothing definitive yet, but go back to your mixer of choice (if it’s not tonic water) for your quarantine cocktail.

–From the front line, testing continues to ramp up.  Here in Indiana, we’ve run at least 2,000 tests in just the last 3 days or so.  I’m losing count, quite frankly.  But it’s more nearly every single day.  We’re working on getting other molecular labs up and going to increase capacity across the state.  We know one big hospital where Covid-19 is actually moving through their lab staff at a pretty good clip this week, so their testing is down.

–Last week, about 10% of each of our runs was positive.  This week, it’s ~20%.  Now, we’re testing a different population, including people who are the “walking wounded”—symptomatic, but not enough to go to the hospital (more on that in a minute).  And as I mentioned, this is kind of expected as we test more people.  But I am really hoping that levels off next week.  That would be the sign that social distancing is working, at least around here (and despite the people you sometimes see flagrantly ignoring it still).  My suspicion remains that overall CFR, once we are better able to determine the denominator, will fall to 1-2% or less.  But still much higher than the flu.

–“Done by Easter” is the most wildly optimistic case.  Two months seems a little more likely.

–EVEN THEN, you won’t be back to “normal” immediately.  Without an effective treatment to keep people out of an ICU (and some of the patient stories circulating are true and horrific), or a vaccine, expect restrictions to be lifted in fits and starts.  In fact, expect them to -come back- a time or two, as quarantine release while the virus is still circulating and a large part of the population has NOT caught it yet will again risk temporary peaks that could swamp the local healthcare system—and “bed’s taken.”  But that will also give time for excess capacity in terms of tents, additional rooms, additional vents to come online, raising the level at which “bed’s taken.”  By the summer, various vaccines and treatments should enter clinical testing.  If one or more is a winner, the world can hit the gas pedal back to normal.  But it will take until Q3-Q4 at the earliest for those treatments to prove it in a clinical trial.

–Jobless claims have been shocking.  Again, I think the virus is the straw that broke a very bubbly camel’s back.  There will be rebound demand on the other side.  If it stretches out over a year though, and it might with various after shock break outs and quarantines, and supply disruptions, not all of those jobs will be coming back immediately.  Nor the demand.  And it’s shocking to me how many businesses have been “nope-ing” on paying their rent right now—that’s not a good sign for a speedy recovery.  Similarly, the unholy amount of money printing just to avoid collapse is a bad sign.  That the economy as a whole was so obviously fragile to an event like this shows that business needs to change a bit from usual.  Redundant supply lines, closer to home for instance.  Also goes to show you that have some savings, be it personal or private (looking at you buyback happy airlines—but others as well.  May you get the zeroed out equity you deserve), is never a bad idea.  Even if interest rate policy means you lose purchasing power in your savings—that just goes to show you that a decade of ZIRP and NIRP is insanity and should never be repeated again.  But I’m no economics expert, and history shows we’re slow learners.

–Back to the medicine, let’s talk about “should I get tested for Covid-19?”

We can’t do that without discussing the Golden Rule of Medical Lab Tests:

If the result of the test will NOT change what you do, DON’T ORDER THE TEST.

So, if you are asymptomatic, you do not need a Covid-19 test.  All of these celebrities running off to get tested, even though they don’t have symptoms, are largely wasting their time.  If you are exposed to someone with KNOWN COVID-19, isolate a bit if you can.  That’s the recommendation.  If you are not symptomatic yourself in 2-5 days, the chances that you were successfully infected start to drop like a rock.  They’re not zero—you can still get sick up to 14 days later.  But that’s pretty rare. 

REMEMBER, THE TEST WE HAVE AVAILABLE WAS BORN AND DEVELOPED FOR PATIENTS SICK ENOUGH TO BE IN THE HOSPITAL.  From a Chinese study of hospitalized patients with CT scans consistent with viral pneumonia, the RT-PCR is about 99% sensitive (think “accurate” for all you non-medical folks).

If you are totally asymptomatic, yeah, a positive would mean something.  That virus isn’t supposed to be around for us to find it.  But the chance that enough virus is around, even for the small amount that needs to make it into the tube for the RT-PCR to find it, is not very good.  Getting tested while you have NO symptoms does not change what you should be doing, and is really just taking a test from someone who may need it more.

Second scenario—you have severe cold or flu symptoms, and think “Oh noes—I’ve caught the corona!”  But you’re not actually sick enough to be in the hospital (like most patients who get this virus).  Should you get tested for it?

Remember the Golden Rule of Medical Lab Tests, and ask yourself how the result will change what you do.

If it’s positive, you’ll tell everyone you got the corona, and they should self-isolate and watch for symptoms for a bit.  Meanwhile, YOU, being the responsible person you are, will also self-isolate until you are fully recovered from the virus in, oh, say, 7-14 days. 

If it’s negative, you’ll…well, probably have the flu.  Are you going into work with the flu?  Are you going around friends and family with the flu?  Probably not, right?  (RIGHT?!?!?!?!)  Turns out the same group of people at risk from bad coronavirus are also many of the same people who should not be exposed to the flu.  So, being the responsible person you are, if the RT-PCR is negative you will…

…still tell everyone you’re sick, and they should watch for symptoms, and then self-isolate yourself until you are fully recovered in, oh, say 7-14 days.

Because here’s the other thing.  The WHO, in its guidelines for coronavirus testing, has recognized that the test is not as sensitive in patients who are not in the hospital with the virus.  You need TWO negative tests, at least 24 hours apart, for the “walking wounded” (patient with cold/flu symptoms NOT requiring hospitalization) to be considered negative for SARS-CoV-2.  Ideally, according to the WHO, one of those was a nasal AND oral swab.  The other should be a “lower respiratory specimen” if possible, “such as bronchoalveolar lavage” (better known as “waterboarding for diagnosis”—I don’t exaggerate much), which I cannot imagine you would do to someone who was not sick enough to absolutely need it.  Regardless, key thing to take away is that the RT-PCR test is not perfect.  It depends on the viral load.  Most testing being done is on a nasal swab in the US (NOT an oral and nasal, which would be better—the CDC started recommending oral and nasal but has backed away to just nasal as swabs run short).  Previous studies have shown that one swab may not be enough to find the virus to get into the test tube:

A pretty healthy percentage of MANY respiratory viruses get missed even by PCR if only one swab is used.

On top of that, we don’t know how much viral load and symptoms are correlated.  Are sicker patients, earlier in treatment, more likely to have more virus?  I dunno (no studies yet), but yeah, probably.  If you show up on day 7 of symptoms, never sick enough to go into the hospital, do you still have enough virus around for PCR to find it?  I dunno.  Maybe?

We have already had cases in our drive through testing here (basically by definition the “walking wounded”) where several people with similar symptoms all get tested in the same car.  One will be positive.  Others will not. 

That positive test is informative—that person has SARS-CoV-2 for sure.  Those negatives—does that mean they DON’T have coronavirus?  Despite same symptoms, living with the now SARS-CoV-2 positive person?  No, they very probably do!  Or at least did.  Or are about to have a whole lot more virus around.  Maybe they had it earlier, with largely milder disease, or their cough is resolving (or they weren’t sneezing nearly as much), so less of the virus has been brought up from the lungs to the nose for the swab to find as the other person.  There are innumerable reasons why a mildly sick person, even with SARS-CoV-2, can have a negative test—even if they have the disease, and ESPECIALLY if only one swab is done.

My point is this:  If you are the “walking wounded”, your test is really only informative if it’s positive.  If it comes back negative, but the symptoms match, and you have a known exposure history, you should probably be tested again, just like the WHO recommends.  Maybe not with the lavage, but another couple swabs wouldn’t hurt.

But that said—will you do ANYTHING different with the test result if you are the “walking wounded?”

No.  Either way, you’ll go home and tough out the disease for 7-14 days.  Tell others you’re sick, and stay away from them so you don’t infect them. 

-So seriously think about whether you even need the test if you are NOT sick enough to need the hospital-.  All you are really doing is providing some epidemiology data on more mild versions of SARS–if you’re positive.  And keep in mind—some of the symptomatic, “walking wounded” negatives, may absolutely still have the virus, even though they tested negative.  My rule of thumb is still to take confirmed cases and multiply by 5, and that is likely closer to the true number of cases present in a country or state.

Now, if you ARE sick enough to need the hospital, YES, YOU SHOULD ABSOLUTELY GET TESTED.  The hospital needs to know where to put you so you do not infect their staff or others.  Some hospitals we have been testing for have only one negative pressure room—they NEED to know who the COVID-19 patients are.  The test is not only MOST accurate in this setting, but the results DO change where you go in the hospital, how closely they watch you for respiratory failure and transfer to an ICU, which ICU you go to, and also tell your doctors that you -probably- don’t have any of the OTHER things that can present that way.  If available, you will be eligible for COVID-19 clinical trials.  So again, if you NEED the hospital for difficulty breathing with your flu/cold symptoms, YES, the test is appropriate.  The delay in testing in the US is that heretofore you needed to check the right travel history boxes or have exposure to someone already known to have COVID-19 as the CDC insisted on its checklist to approve testing.  Now, you just need symptoms and disease severe enough to require your hospitalization.

–Alright.  I’ll climb off my soapbox.  If you are practicing social distancing and taking appropriate preventative measures, your chances of catching coronavirus this week are not very good.  Could still happen, but probably not.  On the other hand, if you’re not doing the whole prevention thing well, your chances of catching coronavirus are good and getting better nearly everywhere in the world.

Love in the Time of Coronavirus:

On hearing Prince Charles was positive for Covid-19:

<Paladin>