Why COVID-19 and other infections are not “just a virus”

Unless you haven’t listened to any news for the past 8 weeks, you are well aware of the “challenge” the whole world has been confronting over what some do call “just a virus”; and you know that it has caused much critical illness and death, leading to “public” and private anxiety.

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” In a very short period, health care and society have been severely challenged by yet another emerging virus. Preventing transmission and slowing the rate of new infections are the primary goals.

However, the concern of COVID-19 causing critical illness and death is at the core of public anxiety.”

JAMA, March 11, 2020 “Care for Critically Ill Patients with COVID-19”
“just a virus”

You’ve probably visited your doctor or your child’s doctor for an acute illness that started suddenly or over a few days. Likely the symptoms included some combination of

  • fever and/or chills
  • sore throat, runny nose, and/or sneezing
  • cough
  • joint and/or muscle aches
  • vomiting with or without diarrhea
  • rash
  • redness with or without drainage from the eyes
  • headache and a general miserable feeling
This illustration depicted a 3D computer-generated rendering of a whole influenza (flu) virus with a light grey surface membrane, set against a white background. The virus’ surface proteins, hemagglutinin (HA) and neuraminidase (NA), were depicted in light and dark blue, respectively. HA is a trimer, which is comprised of three subunits, while NA is a tetramer, which is comprised of four subunits, with a head region resembling a 4-leaf clover. CDC/ Douglas Jordan, public domain

And you were probably told that you or your child had “a virus”,or viral infection, followed by one or more of the following phrases-

  • there is no treatment but it will go away
  • the treatment will not cure it, but it will help the symptoms
  • it has to run it’s course
  • it resolves without treatment
  • you caught it from someone else
  • it is contagious
  • the symptoms will go away, but it stays in your body
  • you may get it again
  • you won’t get it again
  • there is a vaccine to prevent this
  • there is no vaccine to prevent this
This image depicted a Centers for Disease Control and Prevention (CDC) scientist interacting with her Caliper LifeSciences’ Zephyr Molecular Biology Workstation, working with samples to be tested using a real-time PCR machine, known as a themocycler (see PHIL 22904), in order to identify the various types of poliovirus contained therein. The data from this analysis is stored in a computer, while the software further analyzes the data before being reviewed by a scientist. The themocycler can vary the temperature, which is important, for PCR requires multiple test rounds at different temperatures. In the instrument, viral RNA is copied into DNA and then the DNA is amplified. Specific probes bind to the DNA, in order to determine what type of polio present. One hundred ten labs around the world can run this assay, and can tell if an isolate contains polio, or not, and if so, what kind.CDC/ Holly Patrick, MS, MPH

And finally, you may have heard a phrase I hope you never hear, and I hope we doctors never use again-

“It’s JUST a virus.”

Why it’s never “just a virus”

The quote at the beginning of this post is from an article in the Journal of the AMA . Unless you haven’t listened to any news for the past 8 weeks, you are well aware of the “challenge” the whole world has been confronting over what some do call “just a virus”; and you know that it has caused much critical illness and death, leading to “public” and private anxiety.

But we shouldn’t have been surprised. Viruses have been around probably as long as humans have, we just didn’t know much about them until the past century or so. After all, viruses are made of genetic material DNA or RNA, like us and animals; when viral DNA/RNA invades our bodies and enters our cells, they start reproducing (replicating), causing disease. (This is a simplified explanation of what viruses do.)

Transmission electron microscopic image of an isolate from the first U.S. case of COVID-19, formerly known as 2019-nCoV. The spherical viral particles, colorized blue, contain cross-sections through the viral genome, seen as black dots.CDC/ Hannah A Bullock; Azaibi Tamin
How do doctors know it’s a virus?

Until fairly recently, viral infections were diagnosed by typical symptoms and characteristic physical exam findings, especially fever and rash, and many are still diagnosed that way. Then laboratory scientists developed tests for some viruses, which help confirm the diagnosis , important when a treatment is available. The tests can also be used to know if someone is or is not already immune to a disease, if a vaccine is available.

So what infections are caused by viruses?

Lots of them are, but fortunately most are not nearly as serious as the novel coronavirus that causes COVID-19, or the 2 previous coronavirus outbreaks, SARS and MERS. You’re probably quite familiar with some of them. Here’s what I think is an easy to understand way to categorize them.

This illustration provides a 3-dimensional (3D) graphical representation of a tightly packed, icosahedral, poliovirus particle that consists of 60-copies each of capsid polypeptides, designated as pink VP1 (viral protein1), green VP2, purple VP3, and though not shown here, VP4. This particle was composed of units of four capsid polypeptides, which interact in groups of five, resulting in a viral particle that has, what is referred to as 5-fold (pentameric), and 12-fold symmetry. Note the deep canyon on the capsid’s surface surrounding the apex of each pentamer of the virus. The canyon, together with the pentamer apex, is used as the site for capsid binding to cellular receptors.CDC/ Sarah Poser

categories of viral infections

This is how they behave without previous vaccination or treatment (when available) .This is not an exhaustive list, just some of the most common. These all spread person to person.

Short duration, followed by life-long immunity
  • measles
  • mumps
  • rubella
  • polio
  • hepatitis A
Short duration, followed by short-lived immunity
  • RSV- respiratory syncytial virus
  • influenza
  • rhinovirus (common cold)
  • coronavirus
Persistent infection, life-long carrier of virus, virus inactive at times, not always passed to other people
  • HSV-herpes simplex virus
  • VZ-varicella/zoster (chicken pox-shingles)
Persistent infection, life-long carrier of virus, virus always active and can be passed to other people
  • HIV/AIDS-human immunodeficiency virus
  • Hepatitis B
  • Hepatitis C
  • HPV-human papilloma virus
Viruses that spread from animals to humans
  • Avian influenza
  • Rabies
  • West Nile virus
Viruses that spread from animals to humans-and sometimes then to other humans
  • yellow fever
  • coronavirus
  • Ebola
Centers for Disease Control and Prevention (CDC) activated its Emergency Operations Center (EOC) to assist public health partners in responding to the coronavirus disease 2019 (COVID-19) outbreak first identified in Wuhan, China.
How serious are viral infections?

How serious a viral infection is depends on how you want to define “serious”. Even a “mild” illness can be a major problem if it’s you or your family that is sick. With a mild illness, you still may feel too sick to work or go to school, which you should not do anyway, so not to transmit it to other people.

The above classification is quite simplified, a framework for looking at infections that you’ve probably heard of. They range from the common cold, with no risk of death, to HIV/AIDS and rabies, which are always fatal without treatment.

People with the short duration infections usually recover but some carry risk of progressing into life threatening respiratory events, due to RSV, influenza, and now the coronaviruses. Polio frequently left its victims paralyzed for life and measles can cause permanent deafness.

The herpes virus and VZ virus cause recurrent outbreaks of painful skin sores. . Hepatitis B and C viruses can lead to chronic liver disease and liver cancer. HPV causes benign warts but also cancer of the cervix.

This illustration, created at the Centers for Disease Control and Prevention (CDC), reveals ultrastructural morphology exhibited by coronaviruses. Note the spikes that adorn the outer surface of the virus, which impart the look of a corona surrounding the virion, when viewed electron microscopically. In this view, the protein particles E, S, and M, also located on the outer surface of the particle, have all been labeled as well. A novel coronavirus, named Severe Acute Respiratory Syndrome coronavirus 2 (SARS-CoV-2), was identified as the cause of an outbreak of respiratory illness first detected in Wuhan, China in 2019. The illness caused by this virus has been named coronavirus disease 2019 (COVID-19).CDC/ Alissa Eckert, MS; Dan Higgins, MAMS
“the challenge of emerging virus”

I hope that we all learn from this pandemic. I hope both physicians and patients take viral infections more seriously and appreciate the complexity and challenge they represent. We share something important with them-DNA, the genetic material that creates health as well as disease. Viruses aren’t static; like us they change and adapt.

We have vaccines that can dramatically reduce our risk of getting several of these diseases and I hope more people will use them. We have a few drugs which combat these diseases; fortunately some have been life saving, like those for HIV/AIDs.

Healthy lifestyles offer protection against infections of all kinds but we frequently overlook their value. You may be tired of hearing them but they include

  • hand washing- often and thoroughly
  • cleaning and disinfecting frequently touched surfaces
  • water and sanitation facilities
  • safe food handling and cooking practices
  • wise sexual practices
  • staying home when sick
  • limiting contact with animals and preventing insect bites
  • immunization

sharing the HEART of health

For this post I reviewed sections of the textbook Fenner and White’s Medical Virology, Fifth Edition , made available online free at ScienceDirect.com specifically to help medical professionals navigate the COVID-19 challenge.

You might want to check out some less technical references at these links.

Overview of Viral Infections

Viral Infection

Except for the cover photo, the pictures in the post are from the Centers for Disease Control and Prevention website, and are in the public domain.

Screening medical tests- desirable or distracting-updated

To make an intelligent decision about your own screening, you need a physician who reviews your past and current medical history, your family history, and your health goals.

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This post has been updated June 11, 2021

Both doctors and patients have mixed emotions about diagnostic tests done to screen for disease. We physicians want to help patients stay healthy, prevent disease, and treat problems early and effectively.But the time spent counselling, ordering, performing, and reviewing these tests means less time available to manage patients’existing medical problems.

I agree with Dr. William Zinn, family physician in Boston, who wrote

“Keeping track of the ever-increasing health maintenance requirements and cancer screening sometimes make it hard to remember why the patient came to the office in the first place.”

JAMA, January 7, 2020

For patients the issues are similar. While they want to stay healthy, prevent disease, and get treated promptly, they don’t like the inconvenience, time away from work, cost, and sometimes discomfort the tests require.

What are screening tests?

A screening medical test is done to uncover a disease or disorder in a person who may or may not be a risk for it and who otherwise feels well and has a normal exam. Suppose we are considering screening a group of people for disease X. Let’s start by dividing them into 3 groups.

  • Those with no symptoms, feel fine, at average risk of health condition X.
  • Those with no symptoms, feel fine, at increased or high risk of condition X.
  • Those who have symptoms suggestive of condition X, or have had other testing that suggests they might have it

Screening for X in groups 1 and 2 might be appropriate, based on medical guidelines, physician judgement, and patient preference. For group 3, with symptoms of condition X, testing would be considered diagnostic; a doctor would test for X, and possibly other conditions that the symptoms suggest.

Diagnostic vs Screening

That might seem like a picky difference, but there are several implications for both doctors and patients.

Documentation- The medical record needs to reflect accurately why a test is being ordered and done. This is necessary for billing because inaccurate coding can make doctors and clinics liable for fraud. Also, the government and other payers are starting to judge doctors’ quality of care based on medical record audits of care given or not given, and why.

Interpretation and Follow up-A test is rarely interpreted in isolation. The history and exam together with the test lead to a diagnosis.

Reimbursement– Most if not all insurances, including Medicare, reimburse differently based on whether a test is diagnostic or screening. And this usually determines how much the patient pays for each. Screening tests are usually covered 100% while diagnostic testing may require a deductible or copay .

A Country Doctor Writes blog explains this dilemma in detail –

But because in the inscrutable wisdom of the Obama Affordable Care Act, it was decided that screening colonoscopies done on people with no symptoms whatsoever are a freebie, whereas colonoscopies done when patients have symptoms of colon cancer are subject to severe financial penalties.

read more at this link

This link at FamilyDoctor.org helps explain

Health Insurance: Understanding What It Covers

Cervical cancer screening frequency also now takes into account a woman’s HPV, human papilloma virus, status. Go here to learn

When should a woman begin cervical cancer screening, and how often should she be screened?

a microscope image of a cell infected with HPV

A koilocyte is a squamous epithelial cell that has undergone structural changes as a result of infection by human papillomavirus (HPV). This image of a koilocyte shows human ectocervical cells (HEC) expressing HPV-16 E5 oncoprotein, and immortalized with HPV-16 E6 and E7 oncoproteins. Formation of koilocytes requires cooperation between HPV E5 and E6 oncoproteins. The cell culture is stained with hematoxylin and eosin (H&E).National Cancer Institute \ Georgetown Lombardi Comprehensive Cancer Center, Ewa Krawczyk, public domain

Does disease screening make a difference?

Screening tests don’t prevent disease although they may be helpful for health maintenance or improvement. They may prevent progression or complications of a disease, but don’t prevent it’s onset. They may not even prevent death from the disease, although we like to believe they do. Screening may diagnose the disease before symptoms develop, so the patient lives longer with the disease, but not affect the eventual outcome.

Doctors can now offer patients another option that is more accurate than the stool blood test and less invasive than colonoscopy.

Stool DNA testing looks for certain DNA or gene changes in cells that can get into the stool from polyps (pre-cancerous growths) or cancer cells.  It may also check for blood in the stool. For this test, people use a take-home kit to collect a stool sample and mail it to a lab. Cologuard® is the name of the stool DNA test that is currently FDA-approved. This stool test needs to be done every 3 years.

So when should we offer screening tests?

If there is a clear benefit to patients from an effective treatment available to make a difference in the disease course or

If knowledge of the condition helps the patient and family make choices about managing the condition’s likely course or the need for family members to be screened

If the test is reliable enough to identify most people with the disease without falsely identifying people who don’t have it. The scientific terms for this are sensitivity and specificity.

When the benefits clearly outweigh the risks and costs.

a mammogram image
a mammogram revealing a breast cancer image source- National Library of Medicine, Open-i

How to decide for yourself

These are just some of the factors involved in deciding when to undergo screening tests. To make an intelligent decision about your own screening, you need a physician who reviews your past and current medical history, your family history, and your health goals. Then the doctor can make recommendations based on your needs and desires with the help of expert guidelines published by medical organizations who carefully review the medical literature.

Review the graphics in this post for recent guidelines from professional organizations and discuss with your physician. Help your doctor help you by scheduling a health maintenance visit rather than bringing it up when you are there sick or for chronic care. These discussions deserve your physician’s full attention.

further information from the National Institutes of Health.

To Screen or Not to Screen

¿Hacer o no hacer pruebas de detección?

exploring the HEART of health maintenance

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