Since the first appearance of COVID-19 in the St. Louis region in early March, the community has expressed impatience with the amount of information about cases reported by public health agencies. The problem is partly endemic to a democracy with protections for personal privacy; public health agencies are limited in what they can report, even during a pandemic when information can save lives.
In this pandemic, the problem has been compounded by a chaotic testing situation, with tests being performed by public and private facilities. To address this problem, St. Louis County Executive Sam Page issued an executive order requiring private companies to immediately report the results of all COVID-19 tests, positive and negative. Public health agencies have experienced difficulty in getting timely reports from private testing facilities, particularly of negative test results. Negative test results, when compared to symptomology, can provide important information.
The good news about a pandemic is that, as it spreads across the world, the disease becomes better known. While the St. Louis region is new to the struggle against COVID-19, other communities have struggled against it for months. Researchers have had an opportunity to move into those communities and make more detailed reports on COVID-19 and its impact. What the community wants to know about COVID-19 in St. Louis but is having a difficult time learning in real time is being reported about other communities. There is every reason to expect that their experiences are not only relevant to what is happening here but also predictive of what will happen here.
The Centers for Disease Control and Prevention’s Morbidity and Mortality Weekly Report is providing a series of reports from the front line of COVID-19 response. Since these researchers have been granted permission to ask more detailed and invasive questions than local public health officials (in a democracy) may ask in real time, these reports contain valuable clues about what to expect and how to respond.
In its April 3 report, the CDC discusses a COVID-19 outbreak at a senior independent and assisted living community in the Seattle, Washington area, where the first case of COVID-19 in the United States was reported. By the way, that case was reported on January 19, when a 35-year-old man presented to an urgent care clinic in Snohomish County, Washington, after traveling to visit family in Wuhan, China. Many people in St. Louis who had symptoms consistent with COVID-19, such as a dry cough and fever, last year persist in believing they had COVID-19. Given the highly contagious nature of the virus and its devastating effects, especially on older people and people with certain health conditions, if someone in St. Louis had COVID-19 last year, we would have started responding to this disease last year, not this March.
The CDC report on the senior independent and assisted living community in the Seattle area has a more complete set of data about a more limited group of tests than we have seen in St. Louis, and important lessons can be drawn from this report.
Among 142 residents and staff members tested for this study, three of 80 residents (3.8%) and two of 62 staff members (3.2%) had positive test results. A fourth resident, who had negative test results in the initial phase, had positive test results 7 days later. The three residents who tested positive had no symptoms at the time of testing. Both of the staff members who tested positive reported symptoms.
The message is clear: symptoms are an unreliable indicator of whether someone is infected with this virus. Screening for an isolated symptom – like the temperature checks to be admitted into certain public spaces such as St. Louis City Hall – provides only an illusion of protection from contagion.
Not only does the absence of symptoms not guarantee health, but the presence of symptoms also does not prove infection. In this study, symptoms were reported by 42% of residents and 25% of staff members who had negative test results. These uninfected people reported the same symptoms – fever, cough, shortness of breath, sore throat, chills, body aches, malaise, headaches, and diarrhea – that are synonymous with COVID-19 infection.
The message is clear again: symptoms are an unreliable indicator of whether someone is infected with this virus. While telling people to stay home if they feel sick is good guidance in any event, it will keep home many people who are sick with something other than COVID-19.
This report confirms the advice perhaps best stated by Dr. Ngozi Ezike, director of the Illinois Department of Public Health, on March 15 when there were only 93 COVID-19 cases in Illinois. By April, the state would be reporting more than 1,000 new cases every day.
“At this point, it is best to assume that the coronavirus is circulating in your community and you should take the same precautions when interacting with other people that you would when interacting with someone who has tested positive for COVID-19,” Dr. Ngozi Ezike said.
“This may seem like an extreme step, but this is how we reduce the number of new cases and prevent the health care system from being overwhelmed.”
The corresponding author for this CDC report is Alison C. Roxby, aroxby@uw.edu.
