By JOHN T. LITTELL, MD
Several times a day, on every possible news outlet, we are bombarded with updates as to the new number of “cases” of COVID-19 in the U.S. and elsewhere. News analysts then use these numbers to justify criticisms of those who dare to reject the CDC’s recommendations with regards to mask wearing and social distancing. It is imperative that all Americans - and especially those in the medical profession - understand the actual definition of a “case” of COVID -19 so as to make informed decisions as to how to live our lives.
Older Americans remember all too well the dread they experienced when a family member was diagnosed with a “case” of scarlet fever, diphtheria, whooping cough (pertussis), or polio. During my career in family medicine, including several years as an Army physician, I have cared for patients with chickenpox, shingles, Lyme disease as well as measles, tuberculosis, malaria, and AIDS. The “case definition” established for all of these diseases by the CDC requires the presence of signs and symptoms of that disease. In other words, each case involved a SICK patient. Laboratory studies may be performed to “confirm” a diagnosis, but are not sufficient in the absence of clinical symptoms.
Having now been privileged to care for sick patients with COVID-19, both in and out of the hospital setting, I am happy to see the number of these sick patients dwindle almost to zero in my community – while the “case numbers” for COVID-19 continue to go up. Why is that?
In marked contrast to measles, shingles, and other infectious disease, “cases” of COVID-19 do NOT require the presence of ANY symptoms whatsoever. Health departments are encouraging everyone and anyone to come in for testing, and each positive test is reported as yet another “new” case of COVID-19!
On April 5, 2020, a small number of state epidemiologists (Council of State and Territorial Epidemiologists (CSTE) Technical Supplement: Interim-20-ID-01) came up with a “surveillance” case definition for COVID-19. At the time, there was uncertainty as to whether or not completely asymptomatic persons could transmit COVID-19 sufficiently enough to infect and cause disease in others. (This notion has never been proven and, in fact, has recently been discounted – cfr “ A Study on the Infectivity of Asymptomatic SARS-CoV-2 Carriers, Ming Fao et al, Respir Med, 2020 Aug – available online through PubMed 2020 May 13, as well as recent reports from the WHO itself). The CSTF thereby justified the unconventional case definition for COVID-19, adding “CSTE realizes that field investigations will involve evaluations of persons with no symptoms and these individuals will need to be counted as cases.”
Hence, anyone who has a positive PCR test (the nasal swab, PCR test for COVID Antigen or Nucleic Acid) or serological test (blood test for antibodies –IgG and/or IgM) would be classified as a “case” – even in the absence of symptoms. In our hospitals at this time, there are hundreds of former nursing home residents sitting in “COVID” units who are in their usual state of good health, banned from returning to their former nursing home residences simply because they have TESTED Positive for COVID-19 during mass testing programs in the nursing homes.
The presence of a positive lab test for COVID-19 in a person who has never been sick is actually GOOD news for that person and for the rest of us. The positive test indicates that this person has likely mounted an adequate immune response to a small dose of COVID-19 to whom he or she was exposed – naturally (hence, no need for a vaccine vs. COVID-19).
It is important as well to understand that the presence of lab testing is not the ONLY criterion that the the CDC uses to established a diagnosis of COVID-19. The presence of only 1 or 2 flu-like symptoms (fever,chills, cough, sore throat, shortness of breath) - in the absence of another proven cause (e.g., influenza, bacterial pneumonia) is SUFFICIENT to give a diagnosis of COVID-19 – as long as the patient also meets certain “epidemiological linkage” criteria as follows:
“In a person with clinically compatible symptoms, [a “case” will be reported if that person had] one or more of the following exposures in the 14 days before onset of symptoms: travel to or residence in an area with sustained, ongoing community transmission of SARS-CoV-2; close contact (10 minutes or longer, within a 6 foot distance) with a person diagnosed with COVID-19; or member of a risk cohort as defined by public health authorities during an outbreak.” Note that the definition of a “risk cohort” includes age > 70 or living in a nursing home or similar facility.
So, in essence, any person with an influenza- like illness (ILI) could be considered a “case” of COVID-19, even WITHOUT confirmatory lab testing. The CDC has even advised to consider any deaths from pneumonia or ILI as “Covid-related” deaths – unless the physician or medical examiner establishes another infectious agent as the cause of illness.
Now perhaps you see why the increasing number of cases, and even deaths, due to COVID-19 is fraught with misinterpretation and is NOT in any way a measure of the ACTUAL morbidity and mortality FROM COVID-19. My patients who insist upon wearing masks, gloves and social distancing are citing these misleading statistics as justification for their decisions (and, of course, that they are following the “CDC guidelines”). I simply advise them, “COVID-19 is NOT in the atmosphere around us; it resides in the respiratory tracts of infected individuals and can only be transmitted to others by sick, infected persons after prolonged contact with others”.
So you may ask – why are we continuing to report increasing numbers of cases of COVID as though it were BAD news for America? Rather than as GOOD news, i.e, that the thousands of healthy Americans testing positive (also known as “asymptomatic”) are indicative of the presence of herd immunity – protecting themselves and many of us from potential future assaults by variants of COVID?
Why did we as a society stop sending our children to schools and camps and sports activities? Why did we stop going to work and church and public parks and beaches? Why did we insist that healthy persons “stay at home” – rather than observing the evidence-based, medically prudent method of identifying those who were sick and isolating them from the rest of the population - advising the sick to “stay at home” and allowing the rest of society to function normally? And, while we witnessed the gatherings of protestors in recent days with little concerns for COVID-19 spread among these asymptomatic persons, most certainly many are hoping that the increasing “case” numbers for COVID-19 will discourage folks from coming to any more rallies for certain candidates for political office.
Fear is a powerful weapon. FDR famously broadcast to Americans in 1933 that “We have nothing to fear, but fear itself”. I would argue that we have to fear those who would have us remain fearful and servile and willing to surrender basic freedoms without justification.
John Thomas Littell, MD, is a board-certified family physician. After earning his MD from George Washington University, he served in the US Army, receiving the Meritorious Service Medal for his work in quality improvement, and also served with the National Health Service Corps in Montana. During his eighteen years in Kissimmee, FL, Dr Littell has served on the faculty of the UCF School of Medicine, President of the County Medical Society, and Chief of Staff at the Florida Hospital. He currently resides with his wife, Kathleen, and family in Ocala, Florida, where he remains very active as a family physician with practices both in Kissimmee and Ocala. To learn more, visit johnlittellmd.com
June 14, 2020