What University of Iowa doctors are learning about coronavirus — and what more they want to know

IOWA CITY, Ia. — Dr. Daniel Diekema has worked to understand viruses for a quarter century. He’s never seen a challenge like COVID-19. 

There are more uncertainties surrounding this new coronavirus than known facts, said Diekema, director of the Division of Infectious Diseases with University of Iowa Health Care. For scientists trying to predict its behavior, slow its spread and eventually find a cure, it’s like assembling a jigsaw puzzle that has no edge pieces.

“This one is more dangerous so far,” Diekema told the Register, comparing COVID-19 to previous respiratory syndromes.

“It’s extremely important that we have the patience and the will to maintain these kind of shelter-in-place policies. I understand that the economic and social disruption that is associated with this is devastating. But I think there’s some pretty smart economists that have looked at, over the long term, we’ll be happy that we were able to bend the curve, even with the short-term pain that’s involved.”

Diekema has been working at UIHC since 1998 after three years spent in Maine. His role involves preventing disease, diagnosing it and even caring for those who become infected.

In times like these, he finds himself on the front line of his profession. And Diekema knows one thing that many people may not want to hear: There’s no panacea for a pandemic.

Diekema is one of the experts who helped Dr. Bradley Ford develop a method for testing for COVID-19 on-site. UIHC began running the tests March 20. That procedure has allowed its medical staff to ease the burden on the State Hygienic Lab while also learning more about the coronavirus that has spread worldwide, responsible for more than 72,000 deaths as of midday Monday, 25 of them in Iowa.

Here’s what Diekema, Ford and their colleagues have discovered so far, and what they want people to know about COVID-19.

Developing a way to test

Ford is the medical director of clinical microbiology at UIHC, heading a laboratory of 25 people. He knew early on that COVID-19 was going to present a unique challenge and that his staff needed to be at the forefront of efforts to test in Iowa.

But it wasn’t until March 7 that the Food and Drug Administration issued an “emergency use authorization” allowing smaller labs such as UIHC’s to work on developing a test. Ford said he placed an order for the myriad materials needed — from DNA and RNA reagents to swabs and viral transport media — that same day.

It helped that Integrated DNA Technologies had much of what Ford sought. The State Hygienic Lab provided samples. Both entities are in nearby Coralville.

“Not only did we have the right people in town, but we had a high-complexity lab that’s authorized to do the work, a lot of people with relevant experience and all of the instruments that the FDA happened to specify as necessary for doing the test,” Ford said.

“It’s really a homegrown effort here.”

Within two weeks, Ford’s lab was able to replicate results that the State Hygienic Lab was getting, so he knew his lab's testing would work. That meant that results that once took 24 to 36 hours to retrieve could now be done in as little as four.

Ramping up the testing

Ford’s laboratory staffers started working at 3 a.m. and were running COVID-19 tests until 5 p.m. He is expecting to expand those efforts in time, but for now can conduct 100 to 200 tests each day.

UIHC is limiting testing to people who are showing symptoms of COVID-19, where the results are needed to make clinical decisions. The faster turnaround time is especially important when testing medical workers, who are needed now more than ever.

“That gives us a better ability to either intervene quickly or make sure that health care providers can get back to work if they don’t have COVID,” Diekema said. “If they find a cluster in a long-term care facility, for example, a rapid turnaround time helps to get interventions in place.”

The Iowa Department of Public Health announced Sunday that more than 40% of the state’s COVID-19 deaths have been associated with outbreaks in long-term-care facilities.

Diekema said the U.S. missed its chance to conduct widespread testing of the population before COVID-19 arrived. Now that it’s here, he said the prudent course of action is to treat it in a similar manner to any flu outbreak: Assume that younger, healthier patients who are reporting symptoms have the virus and make them self-quarantine until they have recovered. There’s no need to test unless their condition worsens. But the lack of the ability to test large segments of a community means statistics about how many people actually have contracted COVID-19 are less accurate.

How highly contagious the virus is

The COVID-19 tests are primarily being used for diagnosing the disease, but Diekema has been struck by one phenomenon he’s seeing. It reinforced what he already believed about how highly contagious this coronavirus is.

“When we get a positive test, it’s very, very positive,” Diekema said. “Every test has a limit of detection. The positives that we’re seeing are just thousands-fold higher than that. And what that tells me is that when people have symptoms of this virus, they’re shedding a lot of virus in their upper respiratory tract.”

Diekema said COVID-19 appears to manifest itself most significantly in the nasopharynx, the area that connects the mouth to the nose. That development is a contrast to SARS, a respiratory illness that appeared in 2002 and was contained by 2004, with fewer than 800 deaths.

That is why anyone who is sneezing or coughing is particularly dangerous. Diekema also believes that’s why the virus is able to live so long on hard, flat surfaces, where it can easily infect people who unknowingly rest their hand on a contaminated spot and then touch their face.

“(The COVID-19 test results) mean it’s very likely to be highly contagious in terms of, when (infected people) shed droplets or droplets settle on surfaces. They’re probably fairly high in number and that may be one of the reasons there’s such high rates of community transmission,” Diekema said.

“When people get really sick from it, it is a two- to three-week illness. They might have mild symptoms for a week, then shortness of breath. They may need to be hospitalized and then the recovery, once it gets that severe, it can be long.”

MORE:The latest on this week's Iowa COVID-19 news, including more business closures

Will warm weather stop the spread?

Diekema said it’s too early to make that conclusion. It’s assuming that COVID-19 will behave like previous human coronaviruses, classified as types 229E, NL63, OC43 and HKU1. These are more akin to the common cold and have been circulating in the the human population for years, meaning most people have been infected by one or more at some point in their lives.

“In terms of the current pandemic, the problem is that we have a completely non-immune population. And so to a certain extent, without mitigation measures like the physical distancing and sheltering in place, it’s just going to run through the population until there’s a sufficient number, call it herd immunity,” Diekema said.

“We’re not sure how long immunity lasts for this. Most people assume that there’s going to be at least some degree of immunity after infection, but how long-lived that will be, how complete it will be, is still unclear. The natural history, without doing anything, of a virus like this, it will just tear through a community, infect somewhere between 30% and 70% of the population depending on a lot of variables in terms of population density, and then it would tail off and periodically reappear.”

When will it be safe to go back outside?

Diekema said the clearest way to define the end of the pandemic won’t come until much more testing is available. Then, he said, he would look at two indicators that the virus is subsiding.

“Once we start seeing the number of hospitalized patients with confirmed COVID level off and start going down, and the number of ICU patients leveling off and going down, that might be a sign that we’ve started to flatten the curve,” he said.

“But I think there’s a very good chance that several months later you’ll get a second bump in the number of cases. You’d still by then be much more prepared. You’d have all your policies in place. You can test all the people that you want to test. So I think that second peak, if there is one, would be much less disruptive than this first one.”

Ways to hasten the end of the pandemic

Diekema said the next game-changer in the quest to understand and treat COVID-19 will be a serological survey to determine how many people in a community became infected, whether or not they even realized it. That would help identify the antibodies that formed in the serum of those infected. That, in turn, could lead to a quick test people could perform at home, as well as a means to treat those who are seriously ill from the coronavirus.

On Wednesday, the FDA gave approval to a North Carolina-based company for the first serological antibody blood test. Diekema said UIHC will work on a serology project in collaboration with the State Hygienic Lab.

In the meantime, he said, the surest way to avoid COVID-19 is to remain in your homes while the scientists do their work.

Mark Emmert normally covers the Iowa Hawkeyes for the Register and is assisting with hospital coverage with the coronavirus pandemic. Reach him at memmert@registermedia.com or 319-339-7367. Follow him on Twitter @MarkEmmert.