By DR ROBIN ROBERTS, MD
COVID-19 has moved with lightning speed around the globe. From a cluster in Wuhan, China declared on December 31, it has caused over 1 million cases with 50,000 deaths worldwide in three months. In the USA, it’s spiraling; 1059 people died in one day, and it’s yet to peak. The world is at war with an invisible enemy. Armies have been mobilized literally, on every front. The world faces “the disease of all diseases.” To Christian believers, it’s prophesy fulfilled; it heralds Armageddon.
Every day we learn more about COVID-19 at a phenomenal rate. Our medical information databases have long passed gigabits and terabytes, and even petabytes. Scientific research has gone “off the chain.”
We know the virus jumped from animals to human, and it belongs to the corona family of viruses like SARS. It’s deadly. We cracked the viral DNA code in one week, and subsequently, identified proteins as a point to attack. The vaccines have been made. We are moving so fast, even the FDA allowed the scientists to bypass the animal studies and move directly to humans. We know the patterns of the disease in humans; it’s a respiratory attack. Most people will present with common flu-like symptoms and resolve completely. But 10% will get seriously ill requiring hospitalization and about 1 to 3% will die, depending on how many people we get to test in a population.
We felt safe with the early information that the virus spread is by surface contact and droplets when we sneeze and cough. We wondered if it was light enough to linger in the air for aerosol spread. Now we know it does, maybe up to 3 hours or more. Recent studies suggest that up to 80% of the infected persons may initially have no symptoms at all. Add this to our current knowledge of how the disease is transmitted. Frightening!
Now this really throws a spanner in the WHO and PAHO guidelines that have directed our national policies so far. Social isolation, curfews, and border closures remain a mainstay of preventing transmission. We were told initially that routine wearing of mask was needed only for people at risk of being exposed, those having symptoms, or those diagnosed with the virus. Aerosol transmission makes the case that everyone should wear a mask. With a world shortage of masks, the new policies and guidelines propose that we can make our own; even out of scarfs and paper towels. Who would have imagined that COVID-19 would generate a fashion industry of face masks?
COVID-19 has definitely changed our traditional medical approach to treating diseases. And it’s not only the approach for finding a vaccine. We are entertaining using known anti-viral agents, even an old anti-malarial agent. Researchers have thrown out the policies of evidence-based and sound experimental clinical trials. Even the FDA “authorized widespread use of unproven drugs to treat coronavirus, saying possible benefit outweighs risk”. President Trump on national TV “touted hydroxychloroquine as a cure for COVID-19.” Who says you have to be a scientist to validate proof of drug effectiveness and safety? COVID-19 is changing everything and fast! Literally, overnight.
Now this brings me to what I really want to talk about. In the absence of a vaccine and effective Public Health measures, Secondary Prevention has become our main focus – identifying the population at risk and implementing measures to preventing the disease namely, universal hygiene precautions like hand washing, and protective equipment for healthcare providers treating COVID-19 positive or exposed persons. This is the essence of our medical course of action. It’s Public Health at its best. On the face of it, it’s simple and cheap.
Once a person has been diagnosed, you isolate immediately. Apply aggressive contact tracing for anyone and everyone who has been in contact with this positive case. And then isolate them all for the 14 days – the period during which the virus is active for transmission. Depending on the presence and severity of symptoms, suspected exposed persons would be tested formally.
The policies were also quite clear with regards to testing for the COVID-19 virus: ‘who’, ‘when’ ‘how’, and the ‘what’ of the test. This is a new virus; test kits are few and limited. For a cluster in a community, yes - but for a pandemic? No way! The world was unprepared. What made matters worse was the virus is infective before symptoms occur, unlike the SARS virus. The testing sites to identify the virus at its point of entry into humans are in the airways, in the back of the nose and throat. But it takes at least overnight to get the results. Presently only government has the equipment to do the testing. That machine required to do this type of genetic-engineered testing is very expensive. We are fortunate that we have such a lab in the Bahamas, one of the benefits of our HIV research – kudos to Dr. Perry Gomez and his pioneering work.
The other test is quite different. It tests for antibodies. These are protein molecules made by the body’s immune system to recognize and destroy the virus. The immune response is the body’s defenses against any foreign entity like germs – the microorganisms that can invade our bodies and do harm. The problem is that the virus must take a foothold first, the body must recognize and then make the antibodies. This usually takes some 5 to 14 days. This, unfortunately, is the aftermath and so, this test would miss the first days of the body’s invasion when the virus is quite infectious and transmissible. How many people would actually develop an immune response? People who have weak immune systems, like diabetics, senior citizens, people on drugs that suppress the immune system like cancer patients, could have false negative results. So, while the antibody test can be done as rapidly, within 30 minutes, some recent ones that are self-administered can yield results in 10 minutes. Not applicable to detect the onset of infection, these antibody tests are limited, but have the value of determining the prevalence or occurrence of the number of persons in the community who have been exposed and are unlikely to be infected again. Maybe this is the safe group that can go back to work and keep the country and community going; not everyone and everything needs to be locked down. Kudos to Singapore and South Korea for doing this.
Were it COVID-19 a simple flu disorder requiring some over-the-counter meds, in a week of nightly news, it would have been history. Gone and forgotten. But it has stricken, not only people but all our social systems too. Like a lightning bolt wreaking havoc over the globe leaving a trail of death. At the same time, it severely damaged the world’s economy. Stock markets worldwide are experiencing record falls. A global economic is in full bloom, not unlike the 1930s’ market meltdown. Major cities across the world have become ghost towns. Factories have closed. Supply chains disrupted. In addition to the unprecedented demands on the healthcare systems, COVID-19 crippled the governments’ financial forecasts. As businesses are forced to close and people can’t work, there are no tax revenues. Governments must step up to the plate and assure continued viability of businesses and people’s ability to sustain themselves. Deficits will fly through the roof as governments do whatever it takes to stimulate their economies.
This is the challenge, balancing this dilemma: going to work to put bread on the table, pay rent or mortgages versus staying at home to prevent disease transmission to save lives. In our tourism and service-based economy, we are damned if we do, and damned if we don’t.
This discussion proposes that we strike a balance. At the onset, we doubled our public health initiatives, namely contact tracing, social distancing, isolation and quarantine. But now, the time has come to test aggressively, with the goal to test everyone. We must make a national mandate to test everyone. Whatever it takes. If this is what is being said about the government stimulus to reboot the economy, why not make the investment in testing too?
Testing will identify who is safe to go to work and who must be locked down at home. We can set out to do the rapid test on everyone starting with the cities. The new rapid test has an accuracy of 92.8 % on the first antibody response and 98.6% on the next one that remains long lasting. If the recent research is correct, that 80% of infected persons are asymptomatic; a significant number in the population who already have immunity will be identified. They can go to work. All others must stay inside for their recovery period.
The most effective way to control the spread of the virus is through both secondary prevention and testing the population, as proven by the Chinese, South Korean, and Icelandic governments. The UK and the US governments have bought into this too. It’s the race of their lifetime to catch up and save their people and the economy. The UK Health Secretary has set an ambitious target of performing 100,000 test per day in England by the end of April 2020. The BBC outlined the British government’s five-point plan:
• Swab tests for those who already have the virus, to be done by their public health national labs;
• Use commercial partners such as universities and private businesses to do more swab testing;
• Introduce antibody blood tests to check whether people have had the virus;
• Surveillance to determine the rate of infection and how it is spreading across the country;
• Building a British diagnostics industry, with help from pharmaceutical giants
To do this in the Bahamas we must expand our testing capacity. We must partner with all our private labs. We make them accountable. Every test they perform, when, on who, and their results, must be reported to the Public Health authorities on a daily basis. Let’s expand our testing to do both the swab test and the antibody test. Let’s invest in our provider labs too, to help them purchase the testing equipment and supplies. It’s time to be on the offensive with COVID-19. As we double our efforts to contact tracing, social distancing, isolation and quarantine, so too, quadruple our testing. This could take some of the financial burden off the government. I propose that most people would be willing to pay for their tests in the private sector for the expediency and their comfort of mind. I have been isolated at home for 14 days because of exposure to a COVID-19 positive patient. I remain out of action like the other persons on quarantine, not knowing if we are and praying to remain asymptomatic. A rapid test with positive antibodies makes for a different outcomes and assurances.
What else can the government do? The government can leverage the power of country to buy tests in bulk and to access tests kits to purchase directly from the pharmaceutical juggernauts. More convincingly, they are members of the CARICOM. Together, they can leverage the entire 7 million population to purchase in bulk to test the whole English-speaking region, seeking to identify our COVID-19 positive and negative populations and get our tourism-based economy, up and running. By the time we have done this, the vaccines would probably be ready for regular use. The English-Speaking Caribbean leads the world with the highest vaccination rates, slam dunk.
COVID19 will be curtailed only through a shared responsibility and action of the government, the people and full participation of the private sector. It’s time for the government to allow the private sector health services do their part. Let’s prime the country to test every resident. We must win this war, and take our country back!