Coronavirus Chronicles — The Perhaps Symptomless Disease

In mid-June, the state of knowledge was:

Most of the identified asymptomatic cases are diagnosed by random screening of healthcare workers, and individuals who had been in close contact with COVID-19 cases.

In addition, there is a high number of asymptomatic individuals who have experienced COVID-19-like symptoms in their clinical histories without any diagnostic tests and hospital admission.

The real percentage of asymptomatic individuals and how long they carry the virus is unknown.

Overall, study of the novel coronavirus is in its infancy. Previously we quoted the Centers for Disease Control’s list of recognized possible symptoms. Today’s post picks up on the discussion of back-to-school protocols suggested in late June by the American Academy of Pediatrics (AAP).

According to the AAP document, children, compared to adults, “may be less likely to become infected and to spread infection.” The words “may” and “less likely” are equivocations. It is also possible that, under the right circumstances, children may be quite likely to become infected and to spread infection.

The “less likely” scenario was gleaned from earlier studies which some authorities regard as “small and flawed.” Then, along came a much larger and more rigorous South Korean study that says, according to journalist Apoorva Mandavilli,

Children younger than age 10 transmit to others much less often than adults do, but the risk is not zero.

“Less often” is not great news. Even if a child only transmits to one other person, that individual could could be a “superspreader” who transmits the virus to dozens. That is why for years we have been calling the phenomenon of wildly popular videos a “viral” effect. Maybe nobody pays attention at first, but then an “Internet influencer” — a superspreader — amplifies it.

The thing takes off and explodes, multiplying like crazy and recognizing no limiting authority. The report continues,

And those between the ages of 10-19 can spread the virus at least as well as adults do.

The bottom line here is, to say that children and adolescents are less likely to be symptomatic is meaningless. Studies show that a person’s observable symptoms have little connection with their viral load, or the ease with which they can distribute that viral load to the community. When so many cases of COVID-19 have been transmitted by individuals who appeared, on the surface, to be in peak health, any assurance that a child’s classmates are virtually symptom-free brings no comfort.

Wrapping our heads around it

It is very easy to understand why everybody is confused. If a disease does not have any noticeable effect on a person, how is it even still a disease? If nothing hurts, caves in, or falls off, are you really sick? If an illness does not affect your life in any way, how bad can it be?

The answer is, very bad. For starters, it can make a person unpopular at the Typhoid Mary level. Who wants to be known as the kid who brought in the COVID and wiped out the football team? But mainly, just because someone is asymptomatic today, does not guarantee they will be asymptomatic tomorrow. And that part is hazardously deceptive. A cough is a symptom — but when a child with no cough can simply breathe and be just as contagious as a child with a cough, “asymptomatic” is a distinction without a difference.

Your responses and feedback are welcome!

Source: “A compendium answering 150 questions on COVID‐19 and SARS‐CoV‐2,” Wiley.com, 06/14/20
Source: “COVID-19 Planning Considerations: Guidance for School Re-entry,” AAP.org, 06/25/20
Source: “Older children spread the coronavirus just as much as adults, study finds,” BaltimoreSun.com, 07/18/20
Image by Ministerio da Ciencia/CC BY 2.0

Coronavirus Chronicles — The Seeming Paradox of a Symptomless Disease

The previous post outlined some of the crazy things that coronavirus does when it wants to remain incognito. Childhood Obesity News also touched on the topic of the asymptomatic version of the illness nearly a month ago which, because the news in this field replenishes itself so frequently, already feels like a year.

Since then, multiple institutions began to consider what to do about back-to-school. The American Academy of Pediatrics (AAP) issued recommendations based on certain beliefs:

Although many questions remain, the preponderance of evidence indicates that children and adolescents are less likely to be symptomatic and less likely to have severe disease resulting from SARS-CoV-2 infection. In addition, children may be less likely to become infected and to spread infection.

Anecdotally — meaning in Twitter posts — parents report that their pediatricians are dutifully conveying the information that kids don’t really get it that badly, so the parents should not worry.

Currently, a large number of studies are obtainable as “pre-print,” before being peer-reviewed or published by reputable journals. Granted, some of them sound like science fiction. Back in “normal” times, a lot of this alleged news would have flown right under everybody’s radar. But today, all kinds of reports are out there, seen by the ignorant and the educated alike. In other words, the propensity for reading a headline and going off half-cocked is greater than ever. All that being said, still, the AAP’s ideas seem to have some holes in them.

We are told that, among the symptomatic young, their most likely symptom is intestinal disorder. Who would even know this? What federal agency keeps track of reports of every incidence of diarrhea in children and teens? In the current state of chaos, it is more likely that the medical profession as a whole has only a sketchy picture of what is going on with young people.

The Centers for Disease Control offers a list of potential symptoms that includes fever, chills, cough, shortness of breath, difficulty breathing, fatigue, muscle aches, headache, sore throat, congestion, runny nose, nausea, vomiting, diarrhea, and new loss of taste or smell. Except for that last sign, the others are a dime a dozen. They are conditions a person might have for many other reasons. Pity the parent who has to decide whether to keep a child home or not. Especially when a sore throat is difficult to prove objectively, and the child may not particularly want to go to school.

More unease

An objection can be made to the part of the AAP communique about how children are “less likely to have severe disease.” That is difficult to accept after hearing about Multisystem Inflammatory Syndrome in Children (MIS-C), also known as Pediatric Multi-system Inflammatory Syndrome (PMIS). When kids have heart attacks before they reach puberty, that is not a trend to ignore.

Inside schools, the AAP document suggests ignoring the generally accepted six-foot social distance rule, because:

Evidence suggests that spacing as close as 3 feet may approach the benefits of 6 feet of space, particularly if students are wearing face coverings and are asymptomatic.

Whoa! Other evidence suggests the exact opposite! Even the six-foot rule is deprecated by critics, who say it was established many decades ago, when lab equipment was not sensitive enough to detect how far droplets from a contagious person can travel out into the world. In the section about school bus protocol, the document’s language seems to imply that six feet of distance is an acceptable alternative to masking, although common sense insists that both precautions should be in place.

And by now, it ought to be common knowledge that asymptomatic carriers can spread the virus like a house afire.

(To be continued…)

Your responses and feedback are welcome!

Source: “COVID-19 Planning Considerations: Guidance for School Re-entry,” AAP.org, 06/25/20
Source: “Symptoms of Coronavirus,” CDC.gov, 05/13/20
Image by Susanne Nilsson/CC BY-SA 2.0

Coronavirus Chronicles — What Does Asymptomatic Mean?

As we have discussed, presymptomatic is a descriptor used in retrospect, for a subject who tested positive a while back, but showed signs of illness only after some time had elapsed.

In a nutshell, asymptomatic means the person tested positive for coronavirus more than two weeks ago, but shows no signs of sickness, and may never exhibit any. To be asymptomatic is to have what is called a “subclinical infection,” which typically means not having symptoms observable or detectable through physical examination or laboratory testing.

But in the case of this disease, the old definition is not accurate, because although nothing might be apparent to the naked eye, the person could test positive — if they can even get tested, and if the supplies and equipment and technicians are all in good working order.

In early April, the World Health Organization reported that there had been “no recorded case of asymptomatic transmission anywhere in the world,” an assessment that has since been seriously challenged. Another bit of news about these asymptomatic patients is, for some reason they seem able to shed virus way out of proportion to what might be reasonably expected.

A vast ignorance

It’s been half a year, and nobody really has a lock on how coronavirus spreads. It is estimated that close to half of the people who have it might be asymptomatic. Those are the family members and friends we know and love; the neighbors we don’t want to offend by masking and distancing; the healthy-looking people who shop at the health-food store.

But that is one of the most terrible aspects of this pandemic. We can’t believe the evidence of our own experience. We want, for instance, to gather with the people we have known and trusted and shared the glory of song with for years. But the legendary contagion-affirming events have included devotional group singing.

There was the now-famous March choir practice in Washington state, where everybody seemed okay, but 87% of the attendees got sick. There was the Fort Benning, Georgia, incident, where 142 asymptomatic, negative-testing soldiers started basic training, and then all 142 of them inexplicably turned up testing positive.

In Nashville, Tennesee, comedian D.L. Hughley collapsed onstage during a show. After being treated for exhaustion and dehydration, he told the world, “I also tested positive for COVID-19, which blew me away. I was what they call asymptomatic.” He cancelled further gigs and went into 14-day quarantine, a costly and disruptive proposition for a traveling performer.

A college football team, the LSU Tigers, started holding practices and then 30 of the 115 players had to be quarantined. Reportedly, none of them had anything worse than mild symptoms, and some had none, and nobody was hospitalized. The athletes shared their fate with patrons of the nightclubs in an area near campus known as “Tigerland.” Across the country, several other colleges have reported having athletes and athletic staff members test positive.

The big irony is that a lot of people who worry about catching COVID-19 have already had it. Now, the Centers for Disease Control suspects that the true number of cases could be 10 times as high as any researchers have yet been able to prove. It is possible that as many as 23 million Americans are carrying around coronavirus, and the very great majority are clueless.

CDC Director Robert Redfield told the press,

Researchers examining blood samples from across the country looking for antibodies lead to the health agency’s estimate. Scientists found that for each confirmed coronavirus case, there were 10 more people with antibodies…

This virus causes so much asymptomatic infection. The traditional approach of looking for symptomatic illness and diagnosing it obviously underestimates the total amount of infections.

It becomes increasingly clear that a large percentage of infected humans do not feel bad or show any signs, and knowing that people are asymptomatic is a lot easier than determining that they are not sick.

Another recent development is the phenomenon of “recrudescence.” In a supposedly recovered patient, the virus apparently can conceal itself in the body, undetectable by testing, and then hit that same person again.

Your responses and feedback are welcome!

Source: “High SARS-CoV-2 Attack Rate Following Exposure at a Choir Practice,” CDC.gov, 05/15/20
Source: “8 days after quarantine and testing negative, 142 Fort Benning soldiers test positive for COVID-19,” ConnectingVets.radio.com, 06/01/20
Source: “Comedian DL Hughley COVID-19 positive after fainting onstage,” SFGate.com, 06/21/20
Source: “LSU dealing with coronavirus outbreak to at least a quarter of its roster,” SFGate.com, 06/20/20
Source: “CDC estimates coronavirus cases 10 times higher than what’s being reported,” WSBTV.com, 06/25/20
Image by Jernej Furman/CC BY 2.0

Coronavirus Chronicles — What Does Presymptomatic Mean?

For a number of complicated reasons, some time will pass before science grasps the relationship between children and COVID-19. We are barely starting to detect the foggy outlines of how it affects adults… or at least, some adults, under certain conditions.

But as soon as children are brought into the equation, the picture becomes very murky. The relationship between the disease and its victims seems to operate under a whole different set of rules, and researchers are frantic to make sense of the conflicting signals. At this time, there does not seem to be much solid information to convey about children. At most, we can devote some attention to what seems to be happening with adults, but the details about what’s going on with kids are far from known.

At one stage, a feature of coronavirus journalism was a kerfuffle over terminology, where confusion is understandable because the temporal dynamics of the disease are all over the map. Two words that have been bandied about extensively are presymptomatic and asymptomatic.

Timing is everything

Some victims are obviously sick quite soon, but others give no clue. Apparently, “presymptomatic” is a time period that may last as long as two weeks. That is considered the outside limit on when they “should” develop discernible symptoms. And yet, many do not seem to have anything wrong with them. Looking like anybody else — looking, in fact, just like healthy people — they walk among us, because they are us. But make no mistake, a presymptomatic person can contain a boatload of virus, and actively (though unknowingly) spread it around.

But if they don’t develop symptoms, if they feel okay and look okay and are not febrile or in pain — while testing positive — the person then graduates to “asymptomatic.” They have the virus! They just don’t have the aches or the disordered gut or any of the other variegated multitude of possible symptoms.

Eric Topol, M.D., of the Scripps Research Institute, echoes the sentiment. “We know presymptomatic people are highly infectious, and they’re responsible for a lot of the virus’s spread.” Journalist Markham Heid cites evidence that presymptomatic people may be even more likely to transmit the disease than those who have symptoms, maybe because we don’t shy away from them.

Appearances can be deceiving

The concept to hold onto is, whatever they are called, they can be very infectious during any stage of the disease process. A second and equally important concept is to maintain compassion. If a person has no symptoms — and some have never even been caught running a fever! — they don’t know they are sick. They might be blamed for not wearing a mask just in case they have the COVID, but they can’t be blamed for not knowing they caught it.

Ed Taboada, Ph.D., who knows about molecular biology and evolutionary biology, explains that even when people go on to develop actual symptoms, they are paradoxically carrying the highest viral loads during the presymptomatic stage. The clear message here is that a hale and hearty demeanor can be one of nature’s little deceptions, and no one should be trusted.

They might just be having an incubation period, and even though they do not feel personally inconvenienced, the disease might very well be quietly multiplying inside them. Taboada says,

There is one often-cited study […] in which they ascribed an estimate of 44% of secondary infections to contacts that occurred during the index case’s pre-symptomatic stage. As per the paper: “We observed the highest viral load in throat swabs at the time of symptom onset, and inferred that infectiousness peaked on or before symptom onset…”

Same information, different phrasing:

We now know that COVID-19 patients have the heaviest viral load — and appear most infectious — at the onset of symptoms, not at the end. People who haven’t yet developed any symptoms, and therefore wouldn’t show up in the CDC’s temperature checks, are responsible for more than 40% of the virus’s spread. And only about 45% of cases early in an infection will develop a fever.

Your responses and feedback are welcome!

Source: “What You Need to Know About Asymptomatic Spread of Covid-19,” Medium.com, 06/10/20
Source: “What is the evidence of asymptomatic transmission of COVID-19 where symptoms NEVER manifested?,” Quora.com, 06/22/20
Source: “The CDC Lost Control Of The Coronavirus Pandemic. Then The Agency Disappeared,” BuzzFeedNews.com, 06/24/20
Image by Florida Guidebook/CC BY 2.0