WILMINGTON — The response to the Covid-19 outbreak has evolved rapidly — restrictions, guidance, testing policies, and even what we know about novel coronavirus, these things have all changed week to week, even day to day or hour to hour.
One part of that evolving story is testing and its relation to what we know about the total number of Covid-19 cases out there. Another part of the story is how public health officials are reacting to those cases. There’s also a confusing, and concerning, grey area — what we don’t know about how Covid-19 spreads, and how that impacts what restrictions governments are putting (and keeping) in place.
You can also break down the story by thinking about three different types of Covid-19 cases, and the response to each one:
- Confirmed lab tests for Covid-19, leading to self-quarantine and contract tracing
- Probable cases, who have symptoms but don’t get a positive test; these patients are asked to isolate and monitor symptoms, notifying public health officials if those symptoms change
- Mild, presymptomatic, or asymptomatic cases, who may not know they already have the virus, or who may never know they had the virus; because of this, they may spread the disease without knowing it — little is known about how these factors, governments are hoping that general ‘stay at home’ orders will help slow the spread
Testing: The map is not the territory
The state and county have updated numbers of official, confirmed Covid-19 tests daily. It’s a useful tool for gauging the spread of the disease — but it doesn’t fully answer the question: how many cases are out there?
The state numbers published by the Department of Health and Human Services (DHHS) are currently based on positive lab results, either from the state’s own lab or private facilities. This data currently doesn’t appear to include ‘clinical diagnoses,’ situations where a physician determines a patient has (or likely has) Covid-19 but doesn’t sample or test the patient.
According to New Hanover County officials, these cases are still required to be reported, and patients are given the same instructions to self-quarantine as those who receive lab tests. The state may include these numbers at some point in the future, but at the moment it’s not clear how many of these have occurred statewide. (Cases that became more serious, it’s worth noting, would very likely trigger a Covid-19 test).
Cases that went untested?
There’s also the issue of those with Covid-19 who have not been tested or diagnosed by a doctor.
Port City Daily has received over a dozen anecdotal reports of patients who believed they had been infected by the coronavirus but were turned away from Covid-19 testing by urgent care centers or private physicians. Some, who did not have severe symptoms, said were told they did not require testing by public health officials.
One claimed they were told that, because they had not traveled abroad to outbreak sites like China, or domestically to hot zones like Seattle, and had not come in contact with any other Covid-19 patients, that they didn’t need testing. Others, who did travel to potential outbreak zones were also turned away, including one who traveled to New Rochelle (an outbreak site near New York City) and experienced symptoms upon returning but was allegedly turned away by an urgent care facility.
A common theme in their stories seemed to be a lack of available testing equipment, a struggle nationwide. Local urgent care facilities have declined to comment on specific cases, citing HIPAA (federal health information privacy) and stating that evaluations of testing eligibility were up to each physician’s professional discretion. However, many have noted that testing supplies are more readily available now than several weeks ago.
It’s important to note that New Hanover County public health officials have limited testing to those with symptoms, but have not turned away anyone who met the criteria (which included patients who had not had contact with a Covid-19 patient but did have both fever and respiratory issues as well as a negative flu test).
[Note: The best answers to questions about specific symptoms will come from your healthcare provider or from New Hanover County Public Health’s Coronavirus Call Center: (910) 798-6800, open every day from 7:30 a.m. – 6 p.m.]
Mild and asymptomatic cases
Another issue is that positive Covid-19 tests can come from patients with mild or even no symptoms (who are asymptomatic). On Tuesday, New Hanover County confirmed its first case of ‘community spread’ (i.e. an untraceable case linked neither to another patient or travel to a hot zone); the patient reported ‘allergy-like’ symptoms, according to the county.
It’s unknown how many others had similarly mild cases and didn’t report them at all.
Earlier in the outbreak, New Hanover County officials stated that those without symptoms shouldn’t get tested, in part to conserve limited sampling kits. During a March 13 media roundtable, public health officials said a lack of symptoms would probably mean a viral load too low to produce a positive test, even if the person was infected. The county now acknowledges that positive tests are possible without symptoms, but still maintains that symptomatic patients will get more accurate tests.
It is all clear that, as both public health agencies and private physicians and urgent care centers expand their abilities to test, more cases are turning up. That’s important to note to put the numbers in context, because according to public health officials the growing number of cases in North Carolina is due both to the spread of the disease (actual new cases) and increasing ability to test existing cases (increased documented cases).
Phase shift: Containment or mitigation?
From the CDC to the NC DHHS to local public health agencies, there are two distinct philosophies of dealing with Covid-19 (although they are overlapping in some cases).
The first is containment. This means that for every positive Covid-19 lab test, public health officials essentially become detectives conducting an investigation: they trace patients’ steps, tracking where they went, who they came in contact with, and so on. This investigation, called ‘contract tracing’ is designed to stop an outbreak before it starts.
For diseases with short incubation periods, this process is easier, but Covid-19 can take two weeks to show symptoms — meaning public health officials have to cast a wider net.
There’s another problem: limitations on testing means that the guidance from the federal to the state and local level was that only those with pronounced symptoms got tested. The possibility of mild-symptom or asymptomatic carriers also complicates things — it’s easy to imagine a scenario where contract tracing missed links in the chain of viral transmission because some of the infected didn’t show signs of being sick.
In short, it’s a Herculean task. And maybe a Sisyphean one.
That’s where New Hanover County is right now when it comes to contact tracing and containment — on the border of a difficult task and an impossible one.
Hercules? Or Sisyphus?
At the state level, officials have moved from ‘containment’ (contact tracing) to addressing ‘community spread’ with mitigation efforts.
Mitigation, the second philosophy, acknowledges that it’s no longer possible to fully track the disease from patient to patient. In other areas where community spread has become rampant, contract tracing has been treated as a moot point — in Seattle, San Francisco, Chicago, and New York, the next step is lockdowns. This doesn’t mean testing ceases — it remains important — but it transitions from being a tactical weapon against isolated cases to part of a broad strategy against an overall outbreak.
The need to implement these increasingly strict measures has been attributed both to the difficulty in tracking the disease and the failure of residents to adhere to ‘guidelines’ requesting social distancing and hygiene.
Whether called ‘shelter in place’ (as in the original Bay Area shutdown), or ‘stay home orders,’ or mandatory self-isolation, the orders all amount to roughly the same thing — prevent community spread by preventing contact between individuals, with the assumption that a significant portion of the population has or will have Covid-19. The goal, as most government bodies have reiterated throughout the crisis, is to ‘flatten the curve’ — abandoning the idea of containing the virus and instead trying to slow the rate of infection so that, while many residents will contract it, those that need medical care will not all be hospitalized at the same time.
While Wilmington, and North Carolina as a whole, are likely to be placed under some level of stay-home order soon, New Hanover County officials say they haven’t given up on containment.
New Hanover County public health workers are still doing contact tracing for each new case. And, while it may not ultimately stop the spread of the virus, the county hopes it will at least allow public health officials to reach as many people in need of help as possible.
Known unknowns
Local public officials are largely at the mercy of what the CDC and its research partners know about Covid-19 and, right now, there’s still a lot of things about the disease that aren’t known. As the CDC continues to note, “COVID-19 is a new disease and we are still learning how it spreads, the severity of illness it causes, and to what extent it may spread in the United States.”
Currently, the CDC believes most transmission of the novel coronavirus occurs through person to person contact, at a range of six feet and under. The infection is believed to be spread mainly through “respiratory droplets” produced when a person coughs or sneezes — a person can become infected by inhaling these droplets.
However, it may also be possible that “a person can get COVID-19 by touching a surface or object that has the virus on it and then touching their own mouth, nose, or possibly their eyes,” according to the CDC, although this is not currently thought to be the “main way” the disease is spread.
Still, despite that lack of information, public health officials can infer from other outbreak areas that the disease spreads easily and rapidly without containment and, eventually, mitigation. How long those measures will have to remain in place, is probably the greatest — and most painful — unknown to date.
Send comments and tips to Benjamin Schachtman at ben@localvoicemedia.com, @pcdben on Twitter, and (910) 538-2001.
