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Editorial

Aggressively find, test, trace and isolate to beat COVID-19

Larissa M. Matukas, Irfan A. Dhalla and Andreas Laupacis
CMAJ October 05, 2020 192 (40) E1164-E1165; DOI: https://doi.org/10.1503/cmaj.202120
Larissa M. Matukas
Departments of Laboratory Medicine and Pathobiology, and Medicine (Matukas), University of Toronto; Division of Microbiology (Matukas), Department of Lab Medicine, and Department of Medicine, St. Michael’s Hospital, Unity Health Toronto, Department of Medicine and Institute of Health Policy, Management and Evaluation (Dhalla), University of Toronto; Unity Health Toronto (Dhalla), Toronto, Ont.; editor-in-chief (Laupacis), CMAJ
MSc MD
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Irfan A. Dhalla
Departments of Laboratory Medicine and Pathobiology, and Medicine (Matukas), University of Toronto; Division of Microbiology (Matukas), Department of Lab Medicine, and Department of Medicine, St. Michael’s Hospital, Unity Health Toronto, Department of Medicine and Institute of Health Policy, Management and Evaluation (Dhalla), University of Toronto; Unity Health Toronto (Dhalla), Toronto, Ont.; editor-in-chief (Laupacis), CMAJ
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Andreas Laupacis
Departments of Laboratory Medicine and Pathobiology, and Medicine (Matukas), University of Toronto; Division of Microbiology (Matukas), Department of Lab Medicine, and Department of Medicine, St. Michael’s Hospital, Unity Health Toronto, Department of Medicine and Institute of Health Policy, Management and Evaluation (Dhalla), University of Toronto; Unity Health Toronto (Dhalla), Toronto, Ont.; editor-in-chief (Laupacis), CMAJ
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  • RE: Strategically sequence asymptomatic COVID-19 patients
    J. R. Stone [BSc, MSc, PhD]
    Posted on: 21 October 2020
  • 7,000 active COVID cases in Canada is the spark that could ignite the second wave
    Anne Andermann [MD DPhil CCFP FRCPC]
    Posted on: 10 September 2020
  • Posted on: (21 October 2020)
    Page navigation anchor for RE: Strategically sequence asymptomatic COVID-19 patients
    RE: Strategically sequence asymptomatic COVID-19 patients
    • J. R. Stone [BSc, MSc, PhD], Professor, Department of Biology & Origins Institute, McMaster University

    An editorial call was published recently for aggressive testing on asymptomatic as well as symptomatic COVID-19 patients1. This prudential rallying cry should be carried further, amplified by strategic asymptomatic patient genome sequencing.

    The current pandemic has spawned tremendous research on SARS-CoV-2 and its clinical manifestations. Patients can be categorised into at least three groups on the basis of pathogenic effects. Some patients follow the stereotypical, severe path, predominantly involving respiratory trauma and ultimately arrest; these patients often are high-risk members in populations, elderly, frail or immunocompromised individuals. Some patients are asymptomatic, experiencing no maladies despite having tested positive; these patients often are low-risk members in populations, young, healthy individuals. Some patients follow an atypical, milder path, involving less common symptoms, such as nosmia1,2, ageusia2 or paresthesia; scant data are available about these individuals, although olfactory and gustatory dysfunction prevalence is greater in young-age cohorts and, so, low-risk patients2.

    Asymptomatic and atypical-course patients warrant investigation1. Asymptomatic health care providers particularly should be studied to determine why they seem to be resistant despite ample opportunity for SARS-CoV-2 infection or, for those that tested positive, what halted the viral perpetration to COVID-19. Asymptomatic patients provided the first fundame...

    Show More

    An editorial call was published recently for aggressive testing on asymptomatic as well as symptomatic COVID-19 patients1. This prudential rallying cry should be carried further, amplified by strategic asymptomatic patient genome sequencing.

    The current pandemic has spawned tremendous research on SARS-CoV-2 and its clinical manifestations. Patients can be categorised into at least three groups on the basis of pathogenic effects. Some patients follow the stereotypical, severe path, predominantly involving respiratory trauma and ultimately arrest; these patients often are high-risk members in populations, elderly, frail or immunocompromised individuals. Some patients are asymptomatic, experiencing no maladies despite having tested positive; these patients often are low-risk members in populations, young, healthy individuals. Some patients follow an atypical, milder path, involving less common symptoms, such as nosmia1,2, ageusia2 or paresthesia; scant data are available about these individuals, although olfactory and gustatory dysfunction prevalence is greater in young-age cohorts and, so, low-risk patients2.

    Asymptomatic and atypical-course patients warrant investigation1. Asymptomatic health care providers particularly should be studied to determine why they seem to be resistant despite ample opportunity for SARS-CoV-2 infection or, for those that tested positive, what halted the viral perpetration to COVID-19. Asymptomatic patients provided the first fundamental breakthrough toward drug development during the AIDS pandemic, revealing that some victims were resistant to their HIV perpetrators; asymptomatic COVID-19 patients might contain mutant angiotensin-converting enzyme (ASE2) receptors. Research on atypical-course patients might reveal that these individuals possess robust immune systems that stifle virus population growth, yielding only the non-severe symptoms, which sometimes appear in early-stage severe patients, or, if they tested negative, important parameters relevant to infection dynamics and rRT-PCR-test timing specifications. Virus population habitats and growth rates within patients, which are determinants for success with nasopharyngeal swab testing and its timing, remain underexplored; knowing how these determinant-factors vary among patients is vital for accurate forecasting, especially for including in predictive models false negative rates.

    Finding, testing, tracting and isolating patients are essential to curbing the pandemic. But sequencing patient genomes – strategically – would provide equivalently essential, complementary data, vital to public health and, so, should be ramped-up immediately.

    Show Less
    Competing Interests: None declared.

    References

    • Larissa M. Matukas, Irfan A. Dhalla, Andreas Laupacis. Aggressively find, test, trace and isolate to beat COVID-19. CMAJ 2020;192:E1164-E1165.
    • Yan CH, Faraji F, Prajapati DP, Ostrander BT, DeConde AS. Self-reported olfactory loss associates with outpatient clinical course in COVID-19. Int. Forum Allergy Rhinol 2020;10:821-31.
    • Agyeman AA, Chin KL, Landersdorfer CB, Liew D, Ofori-Asenso R. Smell and taste dysfunction in patients with COVID-19: a systematic review and meta-analysis. Mayo Clin Proc 2020;95:1621-31.
  • Posted on: (10 September 2020)
    Page navigation anchor for 7,000 active COVID cases in Canada is the spark that could ignite the second wave
    7,000 active COVID cases in Canada is the spark that could ignite the second wave
    • Anne Andermann [MD DPhil CCFP FRCPC], Medical Specialist in Public Health and Preventive Medicine, McGill University

    While we were caught off guard in March when COVID cases spiked in Canada, there is no excuse this time around. We are far from COVID herd immunity, antibody tests are not reliable indicators of protection, approval of a vaccine is months away, so we are left with the same arsenal of public health measures to prevent and protect us from the second wave, which may be even bigger and longer as our Canadian winter approaches.

    To prevent outbreaks that can lead to the second wave, each new diagnosis of COVID (i.e. index case) requires rapid intervention and containment at the source since up to 1 in 5 secondary cases may have no symptoms leading to undetected ongoing spread. All close contacts of the index case must therefore isolate for 14 days and ideally should be tested for COVID (i.e. “Ring Testing”). In school settings, for instance, isolating for 14 days and immediately testing all household members of the index case is important to identify secondary cases among siblings or parents to identify other classrooms and/or workplaces at risk. For each classroom exposed, isolating for 14 days and testing all teachers and students on day 5-7 post-exposure (i.e. the peak incubation period) will further identify secondary cases but even those with a negative test still need to complete the 14-days and be retested if symptoms develop. Due to ongoing exposure to the index case, at the end of the 10-14 days isolation period (or longer if the case remains symptomatic), the en...

    Show More

    While we were caught off guard in March when COVID cases spiked in Canada, there is no excuse this time around. We are far from COVID herd immunity, antibody tests are not reliable indicators of protection, approval of a vaccine is months away, so we are left with the same arsenal of public health measures to prevent and protect us from the second wave, which may be even bigger and longer as our Canadian winter approaches.

    To prevent outbreaks that can lead to the second wave, each new diagnosis of COVID (i.e. index case) requires rapid intervention and containment at the source since up to 1 in 5 secondary cases may have no symptoms leading to undetected ongoing spread. All close contacts of the index case must therefore isolate for 14 days and ideally should be tested for COVID (i.e. “Ring Testing”). In school settings, for instance, isolating for 14 days and immediately testing all household members of the index case is important to identify secondary cases among siblings or parents to identify other classrooms and/or workplaces at risk. For each classroom exposed, isolating for 14 days and testing all teachers and students on day 5-7 post-exposure (i.e. the peak incubation period) will further identify secondary cases but even those with a negative test still need to complete the 14-days and be retested if symptoms develop. Due to ongoing exposure to the index case, at the end of the 10-14 days isolation period (or longer if the case remains symptomatic), the entire household should be retested (i.e. “Serial Testing”) before the index case returns to school.

    Rapid identification of index cases, 14-day isolation of contacts with ring testing and serial testing are proven approaches to prevent COVID outbreaks. Preventing disease spread and further lockdowns requires close attention to local epidemiology. Areas with no new cases, no ongoing hospitalizations, and ideally no active cases for several weeks, should cautiously resume school and work activities while maintaining high rates of testing.

    These are stressful times and in the context of a pandemic, trauma-informed public health is needed. Different people have different life circumstances, different health concerns, different family structures, different risk tolerance thresholds. A nuanced and flexible approach offering in-person and remote learning and working options creates an atmosphere of trust, safety, choice and control, which are key elements of a trauma-informed approach. The Canadian economy will recover more quickly by containing COVID, being patient and waiting until few to no active cases in a given region, reducing travel that could import cases, and enabling people in COVID-free zones to safely get back to business.

    Show Less
    Competing Interests: None declared.

    References

    • Larissa M. Matukas, Irfan A. Dhalla, Andreas Laupacis. Aggressively find, test, trace and isolate to beat COVID-19. CMAJ 2020;10.1503/cmaj.202120.
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Canadian Medical Association Journal: 192 (40)
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5 Oct 2020
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Aggressively find, test, trace and isolate to beat COVID-19
Larissa M. Matukas, Irfan A. Dhalla, Andreas Laupacis
CMAJ Oct 2020, 192 (40) E1164-E1165; DOI: 10.1503/cmaj.202120

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Aggressively find, test, trace and isolate to beat COVID-19
Larissa M. Matukas, Irfan A. Dhalla, Andreas Laupacis
CMAJ Oct 2020, 192 (40) E1164-E1165; DOI: 10.1503/cmaj.202120
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