I haven’t written in some time. Earlier this month I got sick, and I think it was covid, although, as I’ll explain, I can’t be sure one way or the other. This experience has made me think a lot about what all those unconfirmed cases mean for us - for individuals, and for public policy. Here are my thoughts.
The Problems With Not Knowing
As of Thursday I became eligible for a covid vaccine booster. Georgia is offering Pfizer boosters for people who have been vaccinated with Sinopharm, in part to facilitate travel outside of Georgia to countries which do not accept Sinopharm as fulfilling vaccination requirements. I’m not sure if I need the booster though, because I might have had covid.
Georgia is now offering a “Green Passport” which lists the dates and types of your vaccinations, the dates and results of your last PCR and antigen tests, and whether you’ve had a confirmed recovery from covid. I downloaded my “Green Passport” and it does not list me as having a confirmed recovery from covid. This could at least potentially impact my future ability to access certain facilities here.
A new (but not Nu) covid variant has been identified by South African health authorities. I feel obliged to point out that this does not necessarily mean that South Africa is particularly dangerous or is incubating virus strains - South Africa apparently has one of the most sophisticated and transparent monitoring programs in their region, and perhaps in the world, which means that the strain could have come from anywhere but SA was the first to identify and report it. I’m not sure how worried I should be about this Omicron strain, because I’m not sure if I had covid.
I pride myself on making good decisions under conditions of uncertainty, but this situation is straining even my capacity to feel comfortable with not knowing. In fact, at this point in the pandemic - after two years of twists and turns, of everybody being wrong all the time, of disaster after disaster - I find it hard to feel certain about anything. I find anxiety creeping into my daily life. This month - in which I might have actually had covid - has been the worst for me since early 2020, when all we knew was that people were dying horrible, horrible deaths in numbers that our institutions could not cope with.
Did I Have Covid?
The basic facts of my case are that I came down with covid-like symptoms starting on November 4th. My wife had the same symptoms and we decided one of us would get a covid test - no point testing both of us since we probably had the same thing, right?
Right?
Anyway, I tested negative that day. Was this too early to test? Theoretically if you’re symptomatic the PCR should be positive. But here’s a paper that says that PCR tests have a median false negative rate of 38% on the first day of symptoms!
I struggled through online classes the next day, reassuring my students that my covid cough couldn’t be covid because I’d tested negative the previous day. By the end of the day I had a fever, which would last for a week. As far as illnesses go, this wasn’t the worst - I’ve definitely had worse flus - but it wasn’t pleasant either. Fever, chills, cough. I took ibuprofen and paracetamol and ambroxol (a basic cough medicine, which has also been shown in preliminary studies to have potential for fighting respiratory infections maybe including covid).
I wasn’t particularly worried during this time since I’d tested negative for covid. But then my wife lost her sense of taste and smell. She tested positive for covid on the 11th. I went back for another test on the 13th - by which time my symptoms were almost entirely gone. They gave me a PCR test *and* a rapid antigen test. Both were negative.
So this is where my uncertainty comes from. What are the odds my wife had covid symptoms including loss of taste and smell and a positive PCR test but didn’t actually have covid? Very low. What are the odds my wife had covid and I had flu at the exact same time? Also seems pretty low.
I’ve heard of some couples where one partner gets covid and doesn’t infect the other. It’s at least possible. Especially since we’re both fully-vaccinated, and since (to fight allergies) I have two HEPA filters in my apartment - one in my bedroom and one in my living room, it’s at least possible that I could have avoided catching covid. But this all just seems like way too much of a coincidence to believe.
The most likely scenario in my mind is that I had three false negative tests. Maybe because I was vaccinated my viral load was too small to be detected by PCR. Maybe the guy who did the Nov. 4th PCR didn’t put the swap deep enough in my nasal passages, and maybe by Nov. 13th I’d completely cleared the virus from my system. These feel like rationalizations, but I guess they’re plausible.
In retrospect, I guess I should have done a PCR test on one of the days when I was much too sick to even think about leaving the house. I just wasn’t familiar enough with the literature about PCR false negative rates, and a lot of other stuff was going on, and I didn’t think ahead about the implications of potentially having an unproven case of covid.
Perhaps it bears mentioning that the neighbor who drives my kids to school also had a positive covid diagnosis, and one of the clerks in the little grocery store in our building where I buy my Borjomi had a positive diagnosis - so that’s at least two known possible vectors for where our probably-covid cases could have come from, and more circumstantial evidence that this was covid rather than a flu.
Finally, I should say that medically we all seem to be fine. I have a bit of a residual cough but my fatigue seems to have worn off (by the way, sorry for the month-long hiatus in writing) and my bloodwork shows that the markers of infection I had have gone back to normal. My wife can taste and smell again. No long covid symptoms with anyone, so that’s a plus.
On the other hand, as I mentioned earlier, it’s been rough in terms of the anxiety of not knowing. Of worrying that every cough or twinge or random body ache was a sign of a rare-but-fatal complication of covid. I’m not sure that a positive covid test would have ameliorated this, to be honest. I think I felt better when I thought I had a bad flu than after I’d recovered but convinced myself I’d actually had covid.
Missing Cases
Until now, the question of missing cases was abstract. I’d been looking at my covid numbers and sort of casually multiplying “confirmed cases” by three in accordance with results from that one antibody survey in Tbilisi last year.
But here’s a household with five people - myself, my wife, my two children, and my mother-in-law. All of us had symptoms of some kind of respiratory illness. All of the adults are fully-vaccinated with Sinopharm. Only one person had a positive PCR test but it’s logical to assume that actually all five of us in fact had “mild” covid cases - “mild” meaning symptomatic, but not requiring emergency treatment.
A while back I wrote about vacationing in Bakuriani and how our driver had already had covid so we felt safe hiring him. It turns out he didn’t have PCR-confirmed covid either - he was just certain based on symptoms and contacts that he’d had it. I wonder how many people are like us: people who have had contact with covid-confirmed people, who had symptoms of covid, and who either didn’t get tested or got tested but had false negatives.
This problem must be especially acute in the regions of Georgia where medical care is less easily available than it is in Tbilisi or Kutaisi. The covid testing site in Kutaisi is about two blocks away from my apartment, and if you have any covid symptoms at all the tests are free, funded by the government. Is there a comparable site in Zestaponi? Samtredia? Marneuli?
I wonder how many people get sick and don’t want to leave the house to go to such a testing site while sick. How many people, like me, finally go when they feel up to taking a walk, only to get a negative test.
I can’t help but think that the “we’re catching a third of cases” rule of thumb I’ve been using could be on the low end. Maybe we’re catching a third of cases in the largest city in the country… and maybe we’re catching a fifth of cases, or even less, in rural areas. Of course, as a basic sanity test, we must be catching more than a fifth of cases nationwide, because the official case count shows that 22.5% of people in the country - that is, more than one in five Georgians - have had confirmed cases. So if we’re catching one in three nationwide, that means 67.5% of Georgians have actually had covid. If we’re catching one in four, it’s 90%. That is to say, we could be rapidly approaching the point where everyone in Georgia has either had covid or had a vaccine, or both. I think it would be good to know which scenario is closer to the truth, but I’m not seeing any further attempts to do antibody surveys.
I also wonder how many people who tested but got false negatives are out there spreading covid around. Imagine if I’d gone to a grocery store - or to work, if I wasn’t working remotely - thinking “I have a cough but it’s definitely not covid”. Imagine how many people I could have infected if I’d relied on a false negative PCR test result.
That reminds me: teachers who teach in person are apparently still getting PCR screening tests approximately every two weeks. Why? What’s the point of screening when PCR tests are only positive for a few days out of the infection period? What’s the point of screening when you can have a cough, headache, and fever but still have a negative PCR result? This makes me think that vaccine mandates are pretty much the only way to go, and all this PCR screening stuff is just theatre. I’m willing to be proven wrong on this but the only study I could find suggested that you’d need to PCR test people every two days to detect and contain outbreaks with any degree of reliability. Here are their results - note that PCR screening every 14 days has less than a 25% chance of picking up symptomatic cases before symptoms show up (graph C), or picking up asymptomatic cases at all (graph D):
I guess catching 20% of a- or pre-symptomatic cases is better than catching 0% of these. I don’t want to give in to the all-or-nothing polarization or the pandemic burnout that seem to be plaguing the discourse. I just wonder if this is the right thing to be focusing on, or if it’s giving us a false sense of security without much actual benefit.
Solutions
I’ll probably opt for a booster even though I think I’ve had covid. Can’t hurt, right? I might wait and see what the deal is with Omicron, and if strain-specific boosters become available. I’m also not sure if I’d want to do a Pfizer or stick with Sinopharm. Honestly I’m leaning towards Sinopharm now for various reasons. We know it’s highly effective at preventing hospitalization and death. I think it even protected my 72-year-old mother-in-law, who apparently made it through covid with fewer symptoms than I had. We also know side effects are much less frequent than with Pfizer, and when they do occur they’re much milder.
The booster will take care of my Green Passport problem too. I won’t have to prove I’ve had covid if I’ve had three shots. For people who are unvaccinated or vaccine-hesitant, though, the general problem of not being able to confirm a covid diagnosis will restrict people from accessing spaces even if they’d be safe, and this seems like a flaw in general with covid passports.
On the level of public policy, I’m not sure what to say about this. In terms of testing, I can’t ask for much more than the Georgian government funding a testing site a three minute walk from my house that does free PCR and antigen tests, and yet even that wasn’t enough. A doctor from the government called my wife after her positive diagnosis to check in, but other than that no effort was made to get us to isolate, to trace our contacts, or to do anything to prevent us from spreading the illness to others. I guess that stage of the pandemic is over, and this is just one more thing that the government has given up on.
Of course if you’re only catching 20-30% of cases - even when people are getting tested a lot - then contact tracing is pointless. I just wonder when the Georgian government stopped trying to get people to test and isolate. Was it a response to a wave that made it infeasible? Or was it part of the general collapse in the government’s covid response that has precipitated this seemingly endless series of waves?
I think the government could do better about communicating to people that they need to test and isolate, and also when testing and isolation should be done. I’ve been obsessively following covid for almost two years and even I didn’t know that PCR tests have in the neighborhood of a 38% false negative rate on the day of symptom onset. That seems like a pretty big deal, and as I mentioned above it calls the efficacy of screening protocols into question in a big way.
But what I think we need the most is a solution to the apathy of covid fatigue. I worry that talking about it will spread it, so I’ll just say: I’m tired. I’ve gone to great lengths to protect myself and my family - and we seemingly got covid anyway, although I guess we all had mild cases so I guess it turned out okay. I want to be able to stop thinking about and worrying about covid. On the other hand it is clear that covid is not done with us, and soon enough we’ll have variants that can break through natural and vaccine-acquired immunity, and if too many people stop worrying about covid then that will undoubtedly make the problem worse. We need to find an equilibrium where we’re taking reasonable precautions as individuals and as communities, but also we’re all able to let our guards down a little and start rebuilding a sense of normalcy in our social and professional lives. And that happy medium seems out of reach in a society where not only are people completely polarized around the extremes of either “do nothing” or “do everything”.
The question of whether I had covid seems like a microcosm of this problem. The precautionary principle would seem to tell me to assume I didn’t have covid and so I’m still susceptible to covid and should take exactly the same precautions as before. And yet. If I’m double-vaxxed and probably recovered from covid, can’t I relax a little? And unfortunately, like Georgia itself - which went all-out with prevention in the first wave, only to almost completely give up thereafter - it seems like those of us who expended the most initial effort to understanding and avoiding covid are now suffering the most from pandemic burnout. I feel a sense of responsibility to keep up precautions, but I’m so tired of worrying about every trip to the dentist or the grocery store. Of worrying about what my kids will bring home. Of wondering if I should shave my beard because beards make masks less effective. I feel like at least if I knew I had covid, for sure, that I could relax for a couple of months.
Alas, there is no rest for the weary.
Hi Neal. Thank you for another great article.
And I’m happy to hear you and your family have recovered well.
Regarding the uncertainty. Have you considered doing an antibody test?
When you have Covid, your body develops antibody against both the s and n protein.
But the western vaccines like Pfizer only develop antibodies against the s protein.
So if you test and have antibodies for the n protein, you can know that you had an actual Covid infection.
I’m not sure how exactly the sinopharm vaccine works though. I think I remember that it was the inactivated virus.
So perhaps it creates antibodies against both proteins.
But perhaps it’s worth looking into this to get some certainty.
It won’t be usable for the certification, but at least you will know for yourself.
"I wonder how many people get sick and don’t want to leave the house to go to such a testing site while sick. How many people, like me, finally go when they feel up to taking a walk, only to get a negative test."
Isn't this everybody? I was convinced I had COVID in March of 2020. There was not a chance in hell I'd go to some clinic where other people who thought they were also sick would wait around to get tested. Since COVID is as contagious as chicken pox, why in the world would the health care system herd people into crowded locations for testing? Wasn't that a main contributor to the spread of it?
I doubt any of the tests have actually ever worked. And when the history of this pandemic is written, I believe that the PCR tests not actually working, and the forcing of people into cramped unventilated testing centers, will both be view as main reason for the rapid spread of the pandemic.