Julie Wolfson, MD, MSHS is a Birmingham-area parent and pediatric subspecialty physician with training in public health research. The opinions expressed in this perspective are those of the author and do not reflect those of her employers.
Quarantining is such an inconvenience. It means kids missing those key tests or after-school practices and parents missing crucial meetings, shifts or showings.
Quarantining is frankly hard. The fact that any of us are talking about needing to be home for 10 to 28 days is just another feather in the cap of this crazy COVID-laden 2020. But we are seeing the infection rates in our own communities consistently on the rise again. Even though the actual case numbers look like they are dropping, recent changes in the way data are reported make the infection rate even more crucial to be watching now (for more detail, AL.com’s Ramsey Archibald broke down a lot of this last week nicely here). These data meant that over the last few days, the Alabama Department of Public Health (ADPH) risk calculator moved Jefferson County from green (low risk) to dark red (very high risk) [ADPH_COVID19_Risk].
If we want our kids to be in school in person, and for the economy to recover, we cannot leave this to someone else to fix...because there is nobody who is going to swoop in with a golden ticket. The vaccine scientists will admit that even though it will help, it is not a magic bullet – only public health measures can get us back to normal. In other words, this is on us.
Working together as a community includes talking openly about infection without stigma or blame, quarantining when it’s the right thing to do, and working with the system rather than outside of it. Before sending our kids to school if they have one major or two minor symptoms (ADPH K12 Tookit p12 algorithm), we can talk it through with our schools and our pediatricians who are up to date on the guidelines. Even though quarantine means missing out on some parts of the outside world for 10 to 14 days, with infection rates on the rise as they are we are at risk of shutting down again and missing a lot more than 14 days. We still have a chance to do this together, for each other – so that our kids can be in school, and stay in school. But the only way to do this is as a community.
More than ever these days, each step we take has a cascading waterfall of effects beyond what we can see. I will give you a snapshot of how everything we do in these crazy COVID times affects not just the person we see in front of us who has chosen to be in public, but every single person with whom they come in contact. (Out of respect for the privacy of those in our community, the names have been changed and the story represents a combination of a number of stories recounted to me in a number of different personal settings, as a parent of school-aged kids who also happens to be a physician.)
My friend Alex is invested in keeping her kids active and in training for their sports. So, she and her family have listened to advice from coaches they trust. Alex’s daughter, Susan, had her friend Trisha spend the night a couple of days before they got a call. Trisha called to let them know that her COVID test was positive. Trisha had woken up with a sore throat, headache and runny nose the night after she stayed at their house. Trisha’s family called the school, who directed them to their pediatrician. The doctor acknowledged “it could be anything from allergies to a garden-variety cold virus, but we have to be careful right now, so I’ll order a COVID test.” With a positive test, Trisha and her family continued their quarantine.
Trisha’s school explained that they would get in touch with any close contacts, which would be anyone who sat north, south east or west of her in a class or at lunch. But, her pediatrician asked her to think through anyone else who would have been within 6 feet of her, even if they were wearing masks. Trisha thought to call my friend Alex, along with the coach and all the girls on her club sports team. Practices are outdoors, and their coaches have been attentive at making sure the girls stay distanced while there, and masked when not actively playing. Nevertheless, a few of the girls hung out indoors at Trisha’s house a few days earlier to watch a movie and ended up taking off their masks and sharing some snacks.
Sharon sits just in front of Trisha in a couple of classes. She and one of the movie-night teammates, Melissa, both turned out to be COVID-positive. Their schools and pediatricians recommended that Melissa, Sharon and the COVID-negative teammate from movie night - all quarantine.
When Alex and her daughter, Susan, heard from Trisha’s family, they first called the pediatrician. Even though they had no symptoms, the pediatrician sent them for a rapid COVID-test. The test was positive, and the pediatrician arranged for their whole family to get tested. Alex, her husband, and Susan’s sister (Tori) all had negative rapid COVID tests. Nevertheless, their family was now all quarantining along with the other girls' families. Since all of this happened quickly over a weekend, and Susan had not come in contact with Trisha through school, they opted not to let the school know because they wanted to protect their kids from the stigma and rumor mill that had been raging in the new COVID era in school.
A few days later, the girls' coach told Susan and Melissa that he had done some digging. He suggested that if the girls had the fancier COVID test (not the rapid kind), that they could go right back to practice and school if it was negative. Even though it had only been a handful of days, the families got understandably excited to leave the house. They arranged for Susan and Melissa to get PCR tests at a testing center. They were so excited when both girls were negative that they forgot to loop in their pediatricians, or to tell the testing center the full story. Susan (and her sister Tori) and Melissa all jumped back into sports and school, and their parents jumped back into work. They all let out a huge sigh of relief because life could back at least the new version of normal.
Sharon, the contact from school, quarantined from the moment her family was notified. Both of her parents work in the service industry and they worried that staying home would jeopardize the roof over their heads. Sharon’s older brother has a heart condition that puts him at a higher risk of complications from COVID-19 and was studying remotely, having chosen the virtual option...which didn’t protect him from his sister going to school, which she felt like she had to do to have access to the advanced classes she would otherwise miss and change her track.
Trisha’s teammates, Melissa and Susan, both returned to school having “tested out” of quarantine as recommended by their coach (see below). Even though the coach thought he knew know to keep his team safe, he wasn’t up-to-date on guidelines to get his players back on the field while protecting his team and the community from infection. The Centers for Disease Control quarantine guidelines and ADPH Toolkit along with Jefferson County Department of Health quarantine info here have consistent requirements. Once a person has tested positive, they remain in quarantine until at least 10 days from their first day of symptoms (or positive test), and until they have not had any fever for 24 hours (without a medicine like acetaminophen or ibuprofen that brings it down), for a maximum of 14 days.
Quarantine does not end early if someone who tests positive then has a second test that is negative. Quarantine does not end early if someone exposed to an individual who is COVID-positive goes and gets a test that is negative. Tests do not end quarantine. It’s the pits, but only time ends quarantine.
There have been some misconceptions about the meanings of different COVID-19 tests. The real time polymerase chain reaction (RT-PCR) test has been the diagnostic test since the beginning of the pandemic. This tests for actual pieces of the virus and can take some time (1 to 7 days) to provide results, depending on the lab running it. The newer, faster, cheaper rapid COVID-19 test is looking for the COVID-19 antigen. When talking about a virus, an antigen is a protein on the outside of the virus. It is usually this antigen that an antibody made by our bodies searches for to identify the virus, and hopefully weaken or neutralize it. An antigen test looks for pieces of the antigen proteins of the COVID-19 virus using a swab up a person’s nose. This test is done at the point of care in a physician’s office or clinic and can give results in 15 minutes.
The performance of these tests is constantly monitored (FIND performance COVID dashboard). On average, an antigen test is 53% sensitive - so if 100 people have COVID-19 infections, this picks up only 53 of them. The other 47 tests may have looked negative but those people actually had COVID infections. The RT-PCR test is 74 to 84% sensitive. In other words, out of 100 tests, 16 to 26 of them may come back negative, but these have missed the infection. The kicker is, both types of tests are 100% specific. This means that all the samples that are identified as positive for COVID-19 are indeed COVID-19, and not falsely positive. Putting all of these numbers together, both of these tests for COVID-19 are incredibly specific, so if you have a positive test it indicates a real COVID-19 infection. But they both only pick up a portion of COVID-19 cases, so a test that’s negative does not always mean that an individual is truly negative. This is the case regardless of which test is done first.
So, when Melissa and Susan had positive rapid antigen tests, the RT-PCR tests they had afterwards were falsely negative. Neither of the tests is perfect when it’s negative...but if either of them is positive, it’s a real positive that you can count on. Earlier in the pandemic, there was a time when the CDC agreed to a way to test out of a positive, but all of the risks above of a false negative moved the needle to where we are now.
When they went back to school and practice, classmates and teammates became infected. Five days after they returned to school, a boy who sat near Susan started coughing and was COVID-positive. His diabetic father became infected, but before he realized it he had already visited his own mother who was immune-compromised due to treatment for her cancer. Even though Susan’s sister never developed any symptoms either, she had become infected. In turn, her best friend became COVID-positive and had to pull out of school because she was on low-dose immunosuppression for juvenile arthritis. Melissa’s parents became infected, and infected her aunt, uncle and pregnant cousin.
Even though physicians knew early on that the virus had effects on the heart, most of us did not suspect that a whopping 78% of patients would show heart involvement on MRI, and that 68% would still have ongoing inflammation around the heart up to three months later. To boot, this is not just in the elderly – the median age in the study that found this was 49 years. (JAMACardiology MRI post-COVID) Even before these findings came out, national organizations for adult (JAMA Cardiology return to athletics) and pediatric cardiology (ACC_Pediatric_Cardiology_return-athletics) had issued guidelines requiring testing before return to athletics – even for patients who were never hospitalized, including those with mild symptoms. This virus is not messing around. There is so much we are still learning about COVID-19. Why do some completely healthy people end up with amputations and on dialysis, with symptoms that go on for months while others do not?
What makes it even more challenging to work through this together as a community is that there is a developing stigma associated with talking about infection and exposure. The families above are half Democrats and half Republicans, and all making different decisions on a daily basis as to what’s most important for their safety (and sanity). But all of them are members of a community where their kids are friends and teammates. The different ways in which each of them handled a COVID-19 exposure or positive test affected not just the person in front of them, but rippled outward to every person that person saw. We’re all in this together...we’ve got this if we can do this as a community. Let’s try to keep the kids in school. Let’s try to stay open.
Quarantine sucks, but we can do what it takes.