2022 begins year three of the SARS-CoA- 2 pandemic.
2021 ended with 68 million US cases, and 855,000 deaths. This occurred in the setting of shut downs, mask mandates, vaccines, and therapeutics including monoclonal antibodies for IV infusion for high risk individuals, and in the outpatient and inpatient setting, novel use of standard therapeutics. In spite of these modalities, 2022 is on track to have a higher number of cases than 2021. Businesses have been devastated, school systems disrupted, education of our children forever impacted, and a healthcare system overwhelmed. With no end in sight, I would like to take the opportunity to offer my perspective and my concerns.
Throughout the evolution of the pandemic, I have tried to constantly review available resources and published data to form my approach to prevention, diagnosis, and treatment. This has been problematic because it involves multiple state and federal agencies with contradictory messaging and media sources spotlighting talking heads as experts with opinions that are not always based on data or science that have confused everyone.
On Dec. 30, 2021, the National Institutes of Health (Dr. Anthony Fauci) and the Kentucky Department of Health released their most recent recommendations for high-risk, non-hospitalized mild to moderate COVID-19 patients. The Omicron variant is the predominant variant in many states including Kentucky. It has markedly less susceptibility to currently available monoclonal antibodies infusions, and for this reason both entities no longer recommend the use of these agents and they are no longer being shipped or available.
On Dec. 22 and 23, 2021, the Food and Drug Administration issued emergency use authorization for two new antivirals to help combat COVID-19, but realistically they are in short supply until early spring with 720 total doses allocated to the state of Kentucky and none currently available in our area.
This leaves us with our current standard therapeutics along with mitigation or prevention. Federal and state public health recommendations are the use of masks in the appropriate setting, social distancing, COVID-19 vaccines, and mass testing using the novel approach to place the capability to test in the general public’s hands with self-administered, at-home tests.
COVID-19 vaccines are still the best defense we have to slow the spread of the virus, but current data suggests they may be less effective against Omicron compared to previous strains. The CDC has now gone on the record that natural immunity offers the best immunity. The problem is you have to have had and survived COVID-19 disease to acquire natural immunity. Not a great option.
Now let’s focus on our last resort: mass testing. Let me give an example of mass testing. How effective would it be to have women do a pregnancy test daily, and if they were negative assume they were safe to proceed normally with sexual activity? This means I’m not pregnant today, so I will not be pregnant tomorrow. Does this not sound like a bad idea?
In essence, this is what we are doing with mass COVID-19 testing with rapid antigen and PCR screens, but in my view, this is dangerous as well. Rapid and PCR screens are used for diagnosis, to assess need for treatment, opportunity for work return, attend school, and board a cruise ships. If this is an effective method to assess positivity rates, why do we currently have a cruise ship out to sea with a COVID-19 outbreak with all passengers screening negative prior to boarding? Why do employers struggle with outbreaks in the work place in spite of readily accessible testing?
In healthcare test results are but a piece of a puzzle. Rarely are they diagnostic without a clinical scenario within which a test result matches the complaint. Consider a patient with intermittent chest pain. Gallstones are a common asymptomatic condition but clinically can cause chest pain. An ultrasound of the gallbladder confirming stones, will not save the life of the patient presenting with ischemic heart disease, if it were assumed the abnormal test is the diagnosis. The wrong test, and the wrong diagnosis.
Let us discuss COVID-19 testing. Available literature as well as personal experience suggest as high as 20 percent of rapid antigen screens result in a false negative from people with early symptoms who indeed do have COVID-19 and are contagious. PCR testing can have as high as 3-5 percent false negative in early disease presentation. Knowing this, in our practice, our approach, our practice assumes that any symptomatic person with suggestive COVID-19 symptoms is positive and given appropriate initial treatment regardless of a positive or negative test. We initially were doing PCR on negative Rapid screening, which reinforced the fact 20% of negative rapid screens were coming back positive PCR screens. No longer are we doing rapid tests unless we need an immediate result for some reason.
Let us now consider mass testing in the home with home test kits: if the available literature is correct it suggests that home tests by some manufacturers can have as high as 40 percent false negative early in the disease process. This is a dangerous platform from which decisions are based for the safety of interaction with others at work or school.
Now I ask, why do you think this disease is out of control, rampantly spreading through our society? In my opinion, the use of indiscriminate rapid testing contributes to the problem rather than being a viable solution.
Where does this leave us? First, if you are not vaccinated do so until we have better options for prevention and treatment. Second, be diligent about washing your hands, and limit physical interaction when you can’t control your environment. Wear your mask in indoor, high-concentration, high-risk environments. If you have symptoms of COVID-19, do not rely on a negative test to make you believe you are not infected. Contact your primary care provider for advice and potential evaluation. Approximately 90 percent of patients presenting to our practice with symptoms of viral upper respiratory disease ultimately have positive confirmation of COVID-19. The common cold and influenza are both rare in the current setting. If you have symptoms, please be responsible and take them seriously as a threat to you as well as others.
