A scientist at a research institution finds emotions often win over rationality
1. This is not your grandma’s nasal swab test…
The first time I had to get a COVID-19 nasal swab test was May 14, 2020. I know because I was anxious and wrote about it to soothe my nerves. I hate things going in my nose. I used to be a whitewater kayaker, and I was never afraid of flipping upside down, the rocks, the raging rapids. I was afraid of the water going up my nose.
I saw others being tested. There is a COVID screening station in the parking garage. I saw the size of the swabs. I saw the nurse’s arm seemingly disappear into the patient’s nose who often as not gagged and screamed silently during the operation. The test is called a nasopharyngeal swab test, because the swab reaches through the nose, all the way into the back of the throat, into the pharynx.
I work as a Staff Scientist in a research laboratory, which is tucked within the Biochemistry Department, which is tucked inside the Graduate School of… you get the idea. I am a small neurotic cog in a large bureaucratic research university.
When COVID-19 hit, the school decided to shut down around mid-March, except for a skeleton crew who kept things operational. I was part of that crew, responsible for the lab I worked in.
The school decided to open back up and let the first half of the staff start in May. I was to be among that group. To work within this large community of researchers and staff, we all had to get tested and have a negative result (negative meaning no virus detected). I survived the spear-in-the-nose test and got my negative. Cleared for work.
Now in late May and we had a building half-full of people, who all had one negative test. See the problem? Everyone goes home after work, to spouses and children, who are probably not tested, who go out shopping, maybe play with friends, socialize, maybe without masks… and the staff come back to work the next day, perhaps carrying the virus passed on from family or friends.
The test is not useful for very long.
2. Deciding on next steps…
The school’s management had to earn their keep. I mean, what exactly do academic administrators do, other than bloat overhead and force tuition and expenses to skyrocket? COVID-19 made it clear that they had a real job to do. They had to evaluate the risks of the disease, decide how best to manage the pandemic within their academic community, then execute. I know they are very nice people. But seriously. If a football team full of landscaping managers came to mow my half-acre of moss and weeds, I don’t care how nice they are, there is a fundamental staffing problem. Higher education staffing has a fundamental problem. COVID-19 is something difficult to sink MBA teeth into. But after we get through this, they all need to be fired.
I imagine that just on the issue of testing, administrators had to consider multiple conflicting factors. For example, if they waited too long between tests, a newly infected patient would never recall all the people they contacted since the previous test. If they tested too frequently, the school would go broke. They also had to consider what kind of test to conduct, whether they should test individuals or groups, how to monitor the data, how to handle positive results, how to handle privacy, etc.
The sweet spot, perhaps informed by statistics on infection rates and test reliability, or perhaps influenced by Ouija boards and horoscopes, was declared in a school-wide email: a weekly, individual, self-administered nasal swab test.
As rumors of this weekly test began to ripple around my building, anxiety knotted my gut again. I tried to imagine myself twirling a self-administered telephone pole around in my nose, past my gag reflex, far up into the pharynx to tickle my brain. How exactly was I going to do this?
3. Self-administering the swab…
The graduate school where I work is right next to the medical school. I scheduled my test three times with a buggy online app: early morning every week from July until September. Then on the first day of the test, I nervously made my way to the first floor of the medical school.
Stickers on the floor ensured we were spaced at least six feet apart. As we got to the front of the line, a large illustrated sign asked if we had any of the typical symptoms of COVID-19. A no-touch dispenser squirted an alcohol-based sanitizer into our hands. A nurse in a Tyvek gown, mask, and face-shield, stationed at the front, checked that we were masked, had no symptoms, sanitized our hands, and directed us like a maitre’d to the check-in tables, “This way please”.
All the tables were arranged so traffic between stations remained six feet apart. Staff were all gowned and masked and stationed behind plexiglass barriers, and only came out between patients to disinfect the front of the table and the barrier.
The World Health Organization (WHO) recognizes two primary routes for COVID-19 transmission. First are fomites, or surfaces contaminated by a person coughing or sneezing droplets like a lawn sprinkler spraying everything around them. Door handles are a perfect example. Someone sneezes globs onto a door handle. The next person who opens the door gets virus-laden snot droplets onto their hands, then touches their eyes or picks their nose or licks their finger, and now they have the virus. Second is direct inhalation of those droplets. Breathing or speaking causes droplets to spray out and be inhaled by the person next to you. Those droplets are large enough that they fall by gravity within a short distance. The floor then becomes a fomite for those of us who crawl around on the floor and then lick their hands. I’m looking at you, preschoolers. Those transmission mechanisms are the driving force behind the WHO recommendations to wash your hands frequently, to disinfect contact surfaces, to wear masks, and to maintain social distancing.
At the check-in table, a nurse with a laptop asked me for my driver’s license, name, birth date, and address. Then she pushed a button on a tiny printer which spit out a label. The nurse fixed the label onto a small plastic capped tube, then handed it to me along with an individually packaged sterile swab.
Relief! I was so happy to see that swab. It was a couple inches long. Much, much smaller than the nasopharyngeal swab which was long enough to clean both of my ears at once.
The nurse asked me to stand at a marked spot for the next available test station. When one opened up, I shuffled to the next plexiglassed table.
The test nurse asked me to check the information on the label to make sure it was accurate, then remove the cap from the tube and set both on the table in front of the barrier.
Now for the swab. I was told to open the pouch from the stick end, then insert the swab about an inch into the first nostril and begin twirling the swab. Ahhhhh. It felt so nice. This was not some black ops interrogation like my first nasal swab test. This was more like the soft cottontail of a bunny tickling the inside of my nose. Not that I ever… The nurse counted fifteen seconds and asked me to change nostrils. Another pleasant fifteen seconds. And done. Put the swab into the tube, replace the cap, and hand it to the nurse.
Follow the arrows out of the maze of cubicle walls, get another squirt of hand sanitizer from the dispenser, and walk out, relieved. That was nice. My nose felt like it had been to a nasal spa.
4. The tyranny of the test results…
After the relief of the cute mini-swabs, now I’m haunted by the specter of the test results. Nasal swab tests are not for an antibody test. Antibody tests require a blood draw. This would be a test to determine if the RNA within the protein and lipid shell of the virus could be detected. There are several of these tests, most based on a technology called reverse transcriptase polymerase chain reaction, or RT-PCR. The RT part of the test converts all of the RNA, from the many bacteria and viruses and your own cells in your nasal swab sample, into DNA. This RT-made DNA has a sequence that matches, or is complementary, to the original RNA, so is called cDNA. The PCR part of the test specifically amplifies only the SARS-CoV-2 viral cDNA sequences if any are present, and ignores the rest. So, this would likely be a quick test turnaround.
Indeed, the next day, we received an email that said our results were available. The email included a link, which after logging in showed us a lab report confirming the test method was RT-PCR, and the result was negative.
Each week, despite the relief of every negative result, I felt a whiff of lingering anxiety. Did I wash my hands after opening that door with the grimy looking handle? Did I touch my face afterwards? Am I breathing viral particles through the sides of my mask?
And the fine print in the test report wasn’t exactly encouraging. I realize fine print is composed with the legal devil sitting on the writer’s shoulder, trying to imagine the worst possible world and the worst possible people.
The legal devil was saying that positive results could mean infection with the SARS-CoV-2 virus, but doesn’t exclude bacterial or other viral co-infections. Also, that negative results don’t mean I’m clear of SARS-CoV-2 either. A negative result could just mean a contaminant in the swab sample may have messed up the test. It could mean there were just too few viral particles to detect because of improper sample collection, transportation, or handling. It could mean that the virus mutated in the region that the RT-PCR detects, so the test no longer works.
Furthermore, this test according to the fine print was NOT cleared or approved by the FDA, as diagnostic tests must be. Instead this test was authorized for emergency use. Diagnostic tests are normally cleared for use by the FDA after the company has submitted data demonstrating that the very same false positive and false negative results the legal devil was warning about occur at a low enough frequency to be a safe and effective test. But this test I am being subject to is only authorized for the duration of this pandemic which justifies authorization of emergency use — and the legal devil quotes Section 564(b)(1) of the Act, 21 U.S.C. 350bbb-3(b)(1).
I think about the fine print, especially about the emergency authorization. I am anxious each week waiting for the results, and am relieved each time I read “negative”. I can talk myself into being grateful that we are being given a test at all. I can talk myself into being relieved that I have a swab as soft and comfortable as a bunny’s cottontail to gently pad the inside of my nose.
But as I walk, relieved again, from the last test, I think about the latest changes to the WHO’s primary transmission routes for SARS-CoV-2 virus.
They have added aerosols to how the virus can be transmitted directly from one person to another, but over great distances. Aerosols are droplets so small they can drift like cigarette smoke across a room, waft through air conditioning ducts, and deep into the lungs. Right next to where my anxiety nestles in my gut.