During the influenza epidemic of 1918-1920, my great-grandfather, Ralph Norton Mitchell, was in the military. He helped stack the corpses of those who had died from the infection. I shudder to think about what type of personal protective equipment he used. However, his survival reminds me of a feature of all epidemics–some individuals have or develop immunity, and those who have immunity can “do the work.”
Currently, we are nervously watching the tsunami of infection just beginning to strike us, and with the high infectivity of SARS-CoV-2, a significant proportion of the population will likely become infected eventually. Perhaps this will include multiple waves of infection over months or even years, as occurred with the Spanish Flu; however, as we repeatedly hear, most infected individuals have mild or no symptoms. I repeat: most. That’s valuable information.
With limited capacity to test, we have so far not been testing individuals with mild symptoms (even healthcare workers on the front lines–in my experience), and certainly not those who are asymptomatic; however, perhaps that broad testing is exactly the key to climbing out of the pandemic both medically and economically. We need to define as quickly as possible who is immune and move them to the front lines–and get them back to work.
Stay-at-home orders have washed across the country, with exceptions for individuals who provide essential services, yet these orders are completely blind to the workings of the human immune system. Individuals who are immune can “do the work,” and as their numbers increase day by day, like a shadow following the storm cloud of symptomatic cases, they can begin to turn the wheels of our economy once again, and serve on the front lines of care; but we will never know who those people are unless we test them.
Just last week, I had an adult patient with chickenpox in the hospital, and the infection control staff rushed urgently to find my titer results (in employee health) for varicella before I was allowed to see the patient. My point is: we know this stuff already! We check for immunity for many things.
In this pandemic, we are currently charting the frightening growth of confirmed cases, but statistically, we know that so many, many more are infected, with mild or no symptoms. Wouldn’t it be nice to chart the growth of this population of immune individuals as well, and put them to work?
From a medical perspective, I agree, the best thing for mildly sick individuals to do is stay home; however, from an “emergence from the pandemic” perspective, we eventually need to build an army of immune individuals–individuals who are proven to be immune. If we do not test broadly, we will remain ignorant and in fear.
This idea has just emerged in Germany where, it seems, individuals with proven immunity may begin to be issued “immunity passports” or “immunity certificates” (wrist bands, who knows?) to ease the impact of a lockdown. Given our resources and advanced technology, the US should be eagerly jumping on this train. Without broad immunity testing (i.e., antibody titers), we are at risk of experiencing prolonged lockdown and waves of recurrent infection when restrictions are eventually eased. We don’t have to walk in the dark.
We have massively expanded our knowledge of infection and the immune system since my great-grandfather was stacking the bodies of Spanish flu victims. We have the technology to rationally climb out of this pandemic with appropriate caution and with confidence if we test broadly for immunity. May I see your passport, please?
David M. Mitchell is a hospitalist.
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