Dear Readers:

This past week has resulted in a very pessimistic mood in America. Regarding the economy and COVID-19, the media shifted from "things are looking pretty good" to "Oh, my God-the sky is falling and it is because we dared to start opening up the country for business!" The main news cycle has been about the rising Florida case incidence for positive COVID-19 testing; the same for Texas and some other states.

This past week the office has been inundated with calls from not just patients but health brokers, employers and business owners seeking testing for themselves, employees, and family members. My sense is folks are starting to panic and the panic could quickly get out of control.

This pandemic has been different for America on many fronts. The one that has me the most concerned is that people aren't consulting with their doctors- they are just trying to jump to the front of the line at the lab because they were informed such testing exists. My goal in writing this newsletter is to remind everyone that a lot of what is driving individual behavior in this situation is "other people's agendas". The job of your doctor is to make a rational analysis of the facts as presented and provide a rational approach to disease diagnosis and management. For this situation, as in any other analysis of disease, we need to understand probabilities as well as the role of testing to confirm the presence of disease.

For my office I wish to explain our present review of the situation and my general recommendations. I can only test actual established patients. I cannot test friends, coworkers etc. Those individuals should be directed to speak to their personal physicians.

If you are not symptomatic with fever and additional symptoms of an infectious disease, I do not recommend any form of COVID-19 testing. If you are ill and suspect or know of COVID-19 exposure, we are testing such cases in the parking lot. We are performing the nasal PCR viral test. I am looking into a rapid turn around COVID-19 antigen nasal test but it isn't available to us presently.

We are designating a time window each day for such cases. I would ask that you call the office and explain your symptoms and signs so we can plan appropriate testing. If you are concerned you are very ill (markedly short of breath for instance) it would be prudent to present yourself to the emergency room for a thorough evaluation. I am not routinely advising antibody testing. The literature if full of scientific articles explaining the poor sensitivity and specificity of such testing. I feel it is the Center of Disease Control and State Health Departments job to perform surveillance antibody testing on contact cases in order to further understand the infectivity as well as the morbidity and mortality associations of this illness. This will take years of data collection to gain a full picture of this ongoing story.

Many are upset that everyone isn't wearing a mask at all times. My approach to this novel virus is not different than any other highly contagious respiratory virus. Annually, each of us are exposed to tens of infectious viruses and bacteria, including the more common seasonal corona viruses, influenza, rhinovirus, and para-influenza. Any of these can result in death with the common final pathway being Acute Respiratory Distress Syndrome. The CDC is estimating one half to three quarter of a million hospitalizations from influenza this year with an annualized mortality that (at present) is 1/5 to 1/2 the number of US COVID-19 deaths. A question to ask ourselves is- going forward are we going to indefinitely put this much social pressure on society out of concern of all the infectious illnesses that summarily surpass the mortality statistics of COVID-19 at its worse?

I just read a 12 case series for autopsies of COVID 19 death from Journal of American Medicine and ARDS was the cause of death in all of the cases. Contrary to early opinion articles- There isn't a "mystery and unique pathway to mortality from COVID-19. When there is an index of suspicion that an individual is acutely ill with a contagious infectious condition, we take appropriate precautions. The mortality statistic per incidence of infection for this virus is quickly diminishing as collect antibody data is updated in the general population. This has been reported but the media doesn't really share this information.

So regarding how hard to shelter ourselves and when to consider getting tested for a diagnosis of COVID-19, I would like to point the following facts:

In my view what this means is, despite all the attention and focus on a rising number of cases, especially for Florida, your day to day probability of contracting this illness in the general public is extremely remote. Mortality expectations are not certain to rise. It remains true that intimate contact is where the likelihood of contracting infection lies. That means from your loved ones, your homes, friends, confined groups like bars, public demonstrations, nursing homes, hospitals, urgent centers, emergency rooms, and medical offices where sick people are presenting. Your risk is not from walking by or near asymptomatic (and in all probability not viral shedding) people. Rather as shown in case series reports early on (nothing has changed) from the known contacts that you might spend significant time interfacing with. The "mask" cover-up is distracting the population at large of these facts. I haven't seen one recommendation to mask at home yet if you follow the data logically that would be a more prudent recommendation. Because people aren't always in tune with their health status it makes sense for service workers who face innumerable customers to have physical barriers (like windows or Plexiglas) between them during check out and payment procedures. Meticulous cleaning makes sense.

Regarding protection- a half worn, flimsy surgical mask from China, where the straps break off or your nose isn't covered, is not protection. A bona fide N95 fitted mask and eye protection or an actual physical barrier offers significant protection. If you are a person with active cancer, low immunity from medications, diabetes, or poor nutritional status you should keep yourself isolated when reasonable and minimize your time in public. The 12 autopsy cases referenced earlier had cancers or other significant poor prognosis illnesses.

If you learn that someone you know casually (like at work or in your neighborhood) has contracted COVID-19 you should simply monitor yourself for any symptoms of respiratory infection. Calling to have a test done in the absence of symptoms is not helpful. There is a high false negative test rate. This means you could test negative but still be harboring or developing a more significant viral load and future infectivity as well as potential for real illness. The presence of virus in your nose without symptoms does not confirm your casual contact was the source of your infection.

I have already written in the Wall Street Journal "letters to the editor " about a case of a person who, despite being a full month past symptomatic presentation,still showed PCR nasal testing positive for the virus. This same person would demonstrate at least IgM antibodies using antibody testing as well. There is no reason to believe persistent positive testing results meant the person was any longer contagious. It simply meant that the PCR testing is highly sensitive for measuring genetic evidence of the virus' presence and that as we get well from infection our immune system uses antibodies to sequester and clear the pathogen. None of these responses are new or novel to the medical or scientific community. It simply isn't appropriate nor easy to explain all this to the general public.

The main symptoms of this virus include fever (temp 100 or higher), shortness of breath cough and sore throat. Yes, there are other potential symptoms including GI upset, diarrhea and vomiting and rarely loss of sense of smell but usually with some of the other three primary symptoms. If you develop symptoms, I recommend prompt contact with your physician for evaluation both to try confirming a diagnosis (and rule out other treatable diseases which are still highly likely to be present). Letting the doctor know you are ill with acute infectious symptoms allows us to properly prepare for evaluating you while maintaining a safe environment for ourselves and our staff.

Raymond Kordonowy MD