“Reporting probables is a way to identify the disease burden in communities.” -Sherri Recker, PCHD Director of Nursing
“Reporting probables is a way to identify the disease burden in communities.” -Sherri Recker, PCHD Director of Nursing

PUTNAM COUNTY — Last week’s announcement by the Putnam County Health Department and the Ohio Department of Health regarding the use of “probable cases” in monitoring the COVID-19 pandemic aroused a deluge of skepticism and outrage. The alert, posted Thursday on the PCHD Facebook page, prompted a number of respondents to negatively weigh in on the motives of the health department and the ODH.

At the eye of the storm lies the disconnect between laboratory-confirmed cases — the reporting of individuals known through laboratory testing to have contracted COVID-19 — and those probable cases wherein healthcare workers strongly suspect the sick they are treating are suffering from the virus.

Likely contributing to the criticism are a number of factors: the unfounded belief the probables would be tallied in with confirmed cases (they’re not; they’re expressed separately), economic anxiety, continuing downward trends in statistical models estimating the number of people affected, and an ongoing general uncertainty due to the novel nature of this virus. Additionally, there is an understandable misconception as to how pandemics are traditionally monitored world-wide and nationally.

Historically, the World Health Organization, as part of its Global Influenza Programme, instructs health organizations on the monitoring of influenza pandemics, a process which includes surveilling for probables. In the 2017 update to the WHO Guidance for surveillance during an influenza pandemic, a key system feature of monitoring pandemics includes “… surveillance of Influenza Like Illness and Sudden Acute Respiratory Illness cases, systematic laboratory testing of a sample (emphasis inserted) of cases, clinical data and qualitative indicators.”

As the novel coronavirus is not influenza, the WHO, spurred on by a scarcity of tests, updated its case definition of COVID-19 on March 20 to include probables as part of an ongoing effort to contain the spread of the outbreak.

And the decision to include probables as part of reporting on the pandemic in Ohio and the rest of the country comes not solely from WHO practice, nor from recommendations by the Centers for Disease Control, and not self-servingly from the ODH.

“The decision actually came from the Council of State and Territorial Epidemiologists; they put that out,” reported Putnam County Health Commissioner Kim Rieman. “The Ohio Department of Health is making the decision to count probables based on what this group is recommending.” (For a Primer on CSTE click or tap here)

In determining probable cases in the United States, PCHD Director of Nursing Sherri Recker said the process does have governance, that there are criteria in place detailing who can make such a report, and under what circumstances.

“With probable cases, when there’s a lab-confirmed case of covid, the health department does a contact investigation,” Recker said. “In the process of that investigation, (the covid-positive individual) may have close contacts; family members, co-workers, or people working in healthcare. So then let’s say that those contacts develop symptoms. After they’re exposed to what we later know is a confirmed case, and they develop symptoms, a person like that would be considered a probable case. So we’re looking at symptomatic contacts of positives. That would now be classified as a probable case.”

As to who does the reporting, Recker advised the county health departments, through the course of their investigations and working with physicians and hospitals, serves as the clearinghouse for the information provided to the ODH.

As to why, Recker quickly pointed out what is clear to healthcare workers on the front lines of the pandemic.

“Reporting probables is a way to identify the disease burden in communities,” she said. “Because there are cases of covid that aren’t lab confirmed, this is a way to identify people who have probably been exposed to the disease and developed symptoms as a result of that.”

In short, understanding what is probable helps those working to aid the sick and prevent further illness fill in the gap between what is all but certain, and what is proven.

“They’re working on getting more testing supplies, and testing is getting better in our community, but we’re not to a point, either locally or nationally, where we can test everybody yet,” Recker said.