Warning – very long article: A reflection on my sad COVID19 experience and ordeal re my official retirement as an international ref

 

‘Malta somewhat failed me’ – was it due to rigidity? fear to be novel? stubbornness? remaining obstinate? being inconvincible? or am I wrong in my perception?

 

Part A – Shocked by a Positive PCR Test Result

I was due to fly out to Ireland on Sunday 8^th August 2021 to officiate and even represent Malta as an international referee in the FIBA basketball Championships to be held in Dublin. These were to be my final games as an international referee as the age limit for referees in FIBA is set to 50 years and since I turned 50 last December, the last international refereeing licence expired at the end of the 2020/2021 season, namely 31^st August 2021. Thus, the projection was that the end of August would see me closing off my 25-year international career (1996-2021). Additionally, as regards the number of refereed official and fully competitive international matches (considering only official club cup competitions and national team competitions and disregarding all international friendly matches), I was on the 496-game mark and my forthcoming retirement stage in Ireland should have also led me to reaching the nice 500-game mark. Essentially, I did not need to carry out any prior PCR test in order to travel to Ireland as my full vaccination (an AstraZeneca double dose in my case) was enough to be able to board the plane, fly and be in Ireland. However, I went for another (the 32^nd for me, up till that day, since November 2020) PCR swab test early on Friday 6^th August.

Late evening on the same day, I then received an email with the COVID19 test result stating ‘Detected’.

  I was totally shocked and had no real idea how such a result may have been possible (I was feeling no, and never then felt any, symptoms whatsoever and was running a minimum of 8kms daily in the previous 3 months, including a 10km run just an hour before that same Friday morning’s PCR test (with no variations, which are common in case of illness or disease, in the heart rate counts recorded in every session on the heart rate monitor)). However, I took instant responsibility and immediately left our summer residence (and wife and son) to isolate myself alone in our permanent residence.

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Part B – Ready to carry out my civic duty, but……….

In brief, along the course of the following day (Saturday 7^th August) I was contacted, rightly so, by public health officials notifying me of the need to quarantine.

I had no issue to carry out my civic duty to stay in quarantine if I really was positive and I was of any threat to be infectious to others.

In the meantime, I took a first follow-up PCR test on Saturday 7^th August morning. Had this swab test, or any of the other three subsequent (Saturday 7^th to Tuesday 10^th), resulted positive, I would have had no problem to accept the fact that I was unfortunate to be positive in such a much-awaited period in my international refereeing career. But when the first, and later, swab tests came out negative, added with the fact that I was not feeling the least of any symptom whatsoever and was even easily carrying out in-house intense HIIT and tabata workouts (with no hindrance whatsoever, no breathing issues or any abnormal heart rate results), my concern started increasing on asking whether there may have been some sort of mistake in the Friday 6^th August PCR specimen analysis and/or if the consecutive number of negative results might be an indication of myself not actually being any threat of being infectious. I started thinking, taking the first scenario above, what if, say, the specimen was analysed incorrectly on Friday or was maybe contaminated at the testing centre or merely a case (even if the chances are minimal but the chance still exists, as even documented as shown later) of a false-positive result? My concern was, should I suffer unjustly in having to renounce from going to my final retirement tournament, an event that is very important in one’s career and also may be termed an honour even for the Malta sport fraternity which I have represented with pride and integrity in all the past years?

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Part C – Thoughts of ‘is it better maybe not to be vaccinated?’ + 4 consecutive negative results, 24 hours apart

  Forgetting, for the moment, the possibility of a false-positive result on Friday 6^th August, I communicated (through a series of emails between Saturday 7^th and Thursday 11^th August) the following facts with the Superintendent for Health. The positive test result on Friday 6^th August came out with a CT count of 34. Those who are savvy to the technicalities know that a CT count of 34 is factually a borderline result to negative and this can have either of two options:

• either the virus was on me for a while and was dying or dead at the time of the Friday PCR test; or
• the PCR Friday test is indicating the beginning of the disease.

  The Superintendent had stated, in one of her three short replies, that: “When a positive test results, it means that you have COVID-19. It does happen that the test is negative on repeat tests but that is not a guarantee that you didn’t have Covid or that you are not infectious.”  

Whilst accepting (as it is logical and I am not one to deny the stark truth) the remark that a single subsequent negative test might not catch the virus, the fact was that I then carried out four (4) consecutive tests, 24 hours apart, and all of these 4 PCR tests resulted negative.

  Thus, with these four -ve results in hand and the fact that no trace of the virus was detected in the four following days, my limited logic on the matter deduced that, if I was positive with a CT 34 count on Friday 6^th, then there was only one plausible option, namely that (if I was really positive on Friday 6th) the virus had been on me for a while (unknown to me due to the presence of no symptoms whatsoever) and that it was either in the very last stages (left-over bits from being killed by my immune system) or outrightly were dead virus (which still may show on the PCR test). With this is mind (namely if the virus was in the last stages or dead (thus the CT34 count)), then it is not the same situation as it (the virus) being in the initial stages. My limited knowledge deduced that science states that infected people appear to be most infectious before they develop the symptoms and early in the illness and not at the end.   If I was really positive, then I was maybe unfortunate in having gone for the PCR test on Friday 6th August during the very last stages of the virus detection. Yet should I, if this was the case, then had to suffer unjustly in that quarantine was started when I was maybe less or unlikely to be infectious? Just thinking: Had I had earlier symptoms or gone earlier in the previous days/week for a PCR test, this would have been different as then (had I been diagnosed immediately as positive) the quarantine period would have commenced many days before.

In a sense, (even if I am totally and absolutely in favour of vaccination), in this case it would have been maybe better had I not had a full AstraZeneca vaccination cycle (my second and last dose was on 18^th May) as I would probably have had immediate symptoms leading me to the correct quarantine period!

Note: My wife and son had also to succumb to 14 days of mandatory quarantine as I was honest to declare that they were in contact with me in the 48 hours prior to the positive test (I believe this is the correct duty but I ask (after observation), did/does everybody declare all the close contacts? or has this been abused so that one (possibly even prominent persons) is not caught in the close contact quarantine and can continue, unperturbed, with daily life and even public appearances?) Honest persons will have the right answer. Anyway, for record purposes,  both my wife and son carried out swab tests during the mandatory quarantine and all tests resulted negative as well.

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Part D – Kindly offered another chance to retire but………!!!

By Tuesday 10^th August (following my 4^th consecutive (with a 24-hour period between tests) negative test result), not much could still be done to safeguard my participation in the FIBA championships in Ireland and so any participation in Ireland was definitely out.   Yet, FIBA, the European basketball body, clearly understanding and knowing the moral and agonistic importance of any retiring event and after getting to know of my ordeal re the Ireland championships, were immediately in contact and were ready to offer me an exceptional and not-normal further, last chance possibility in the final tournament window in the week starting 15^th August 2021. In fact, I was officially kindly provided (and am grateful to who did so in my regard), on Monday 9^th August, with the opportunity of a referee slot for a FIBA Group A Championship in North Macedonia which would have the need for me to travel out of Malta very early on Saturday 14^th August, just a handful of hours from the end of a 7-day quarantine period (if granted) ending on 23:59 hours of Friday 13^th August. This would have basically meant that I would immediately have had to go to the airport at the end of the requested reduced quarantine period. FIBA could not offer later possibilities as there were no other scheduled games till the end of August when my age limit comes into effect and my refereeing license officially expired.   I admit that I understood from the outset that this (the granting of a 7 day quarantine period) might be a difficult decision for the person/s involved, mainly the Superintendent for Health in this case, as it is may not have been part of the norm; yet I honestly think that my request for a reduced 7-day quarantine period (based on 4 consecutive negative tests and followed by three extra ‘precaution buffer’ days to Friday 13^th August) was not presumptuous or arrogant and also made whilst not posing risks re infection to society.   In fact, I had not requested to immediately have my quarantine terminated after the four negative PCR tests (the last one on Tuesday 10th) but had also suggested that I carry out another three extra isolation days (till Friday 13th) as an added precaution (another sort of added buffer to even put (in my opinion) the Superintendent’s mind at rest re any infectious risk (if there was any)), even if medical journals and statements conclude (see below) that the risk was practically immediately non-existent.

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Part E – The final decision + no effort to adopt a personalised approach

  The Superintendent for Health replied to my request by stating: ‘I am very sorry about your situation but this is science and laws are based on science. Labs have their quality control so one cannot assume positive tests are the result of contamination Quarantine is 14 days despite any negative results.’   I noted the statement “this is science and laws are based on science”. I have full and utmost respect for the benefits of science and, of course, I can never be cocky in thinking of having more knowledge than others who specialize on the matter. However, I did also ponder at depth and carried out extensive research during this sad isolation ordeal. Of course, laws are also very important to manage a society. However, we all know well enough and are also aware that the same laws may, at times, need to be interpreted according to different scenarios and cases. One also needs to be logical and reason out that cases differ and so law will be, rightly so, interpreted differently. Also, the Public Health Law states that the Superintendent has the power to ‘make, vary or revoke orders‘, thus a personalized approach may also be allowed according to law.   I was aware and under the impression that the Superintendent for Health (and any other, if any, decision makers in such instances) generally adopt a one-size-fits-all approach, yet I was still confident that one might finally accept to consider a personalized approach (i.e., based on repeated testing) which has also been suggested, after all, in scientific papers, such as citing some:  

“approach is based on the assessment of the viral load of each isolated patient (i.e. personalized approach), and isolation ends when the viral load drops below a certain threshold value, which is associated with a low risk of further spreading the pathogen (He et al., 2020).”

  The viral load can be measured by reverse transcription polymerase chain reaction (PCR), which can be used not only for diagnosing infection but also in determining when to end the isolation period (eLife 2021;10:e69340).

“in the personalized approach using PCR tests, isolation ends after obtaining a given number of consecutive negative test results (eLife 2021;10:e69340).

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Part F – A rigid, one-size-fits-all approach despite scientific conclusions

Despite all these efforts, communications, research and references even to scientific material, the apparent final decision, unfortunately, adopted by the Superintendent for Health was to be ever so rigid and opt for the application of a one-size fits all approach!!!

The final reply I received from the Superintendent for Health, on Wednesday 11^th August, was short and blunt: “This is policy and legislation in place – all positive cases need to do 14 days isolation” 

Such a final decision taken without (in my humble opinion) allowing for any chance of a personalised approach:

• based even on humane or emotional recognition and a slight understanding of and empathy towards this being a genuine special case;
• also based on scientific reasoning and on the assessment of my viral load measured by the PCR tests and where quarantine may be acceptable to be ended when the viral load drops below a safety value obtained after a number of consecutive negative test results (4 negative tests in my case) even if I had put forth certain (in my opinion) clinical and epidemiological evidence indicating that I was unlikely to be infectious through being:
  • totally asymptomatic;
  • had no known previous exposures;
  • had a high, borderline CT 34 count in the initial PCR swab test on Friday 6^th August swab test; and
  • having tested negative in subsequent PCR tests, not once, but on four consecutive days as from Saturday 7^th August to Tuesday 10^th August.

  Further to all the above points presented in my various communications, I also then put forth a further reference to two extremely recent and interesting documents which I believed presented added value. (This was of course made without pretending that I am an expert as I can never be cocky and expect to be more knowledgeable than those who should be specialists in the area and should have and demonstrate the right professional acumen). However I think that even a casual reader might be able to understand some of the medical literature and interesting points from these two documents (some excerpts of which below):

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https://www.hpsc.ie/a-z/respiratory/coronavirus/novelcoronavirus/guidance/outbreakmanagementguidance/PCR%20weak%20results%20guidance.pdf

Guidance on the management of weak positive (high Ct value) PCR results in the setting of testing individuals for SARS-CoV-2 – V1.5   7^th July 2021

 “In general terms, a high Ct value/low viral load result in an asymptomatic person is more likely to represent residual RNA detection of no public health or infection prevention and control (IPC) significance.” p.6 “Confirmed detection of SARS-CoV-2 RNA at high Ct value in a person tested on the basis that they had no symptoms or other clinical features at the time of sampling may represent:

• A person with residual RNA detectable more than 10 to 14 days after onset of infection. [Unlikely to be infectious];
• A true false positive.” P.7

“Further evaluation should include a repeat sample. This sample is generally taken on the second day after the initial sample (for example, if the initial sample was taken on Monday the repeat sample should be taken on Wednesday)…If the Ct value remains high/viral load remains low on the repeat sample, the person may generally be considered as a remotely acquired infection and non-infectious at the time of testing. If self-isolation/transmission based precautions and contact tracing were initiated they can be stood down and the person need no longer self-isolate.” P. 8 “In the event that an asymptomatic person who has vaccine protection…and the CT value is high/low viral load, it can generally be assumed to represent residual viral nucleic acid unless they are symptomatic. Under these circumstances asymptomatic people do not need to restrict their movements.” P.9

“A very good PCR assay with a specificity of 99.5% can still generate 5 ‘RNA detected’ results in a cohort of 1000 individuals without the infection.” p.10

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https://www.health.gov.on.ca/en/pro/programs/publichealth/coronavirus/docs/contact_mngmt/management_cases_contacts.pdf

Management of Cases and Contacts of COVID-19 in Ontario – August 11, 2021 (version 13.0)

  “False positive results may occur…..if there was no prior high risk exposure and where incidence of COVID-19 is low, it may be recommended to seek immediate confirmatory testing following a molecular POCT positive result, as symptoms might be due to other causes (e.g., a circulating respiratory virus other than SARS-CoV-2).” p.14 “Investigations of Potential False Positive/False Negative Results: Where there is concern of a false positive or false negative result based on an unexpected test result relative to the clinical and epidemiological information of the case, it is advised to recollect a specimen for repeat testing as soon as possible.” p.14

“The repeat test on a subsequently collected specimen is not considered more accurate than the initial test; however, the combination of the two results provides additional context for interpreting the initial result.” p.15

“In situations where a false positive laboratory result cannot be confirmed based on the laboratory investigation, but there is clinical and epidemiological evidence that the individual is unlikely to be currently infectious (e.g., high Ct value, asymptomatic, no known exposures, and immediately re-tests negative), public health case and contact management may be discontinued.” p.15

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Part G – Outrightly ruling out the existence of ‘false-positive’ results!

My reduced 7-day quarantine request was also based on the assumption and decision taken by the Superintendent that the first PCR test was not a ‘false positive’.

The stand taken by the health authorities was one whereby the possibility of a false-positive result was not even factored in the slightest of ways.

A remark put forth by the Superintendent was “labs have their quality control so one cannot assume positive tests are the result of contamination”. Whilst accepting such a remark, assuming and respecting the expertise of the source,  I humbly

do not think we can outrightly ignore that there may still be a remote chance of ‘false-positive results’

resulting from say some accident (contamination or otherwise) during sample collection at the testing centres or possibly an unfortunate swap of samples in the lab (according to certain people in the business, these unfortunately have happened and may also occur as everybody is human and liable to lapses in focus).   My reply to the Superintendent was asking whether one is therefore outrightly ruling out the possibility of a ‘false-positive’ test?

I still honestly admire and have high regard to the excellent (and difficult yet very commendable) work carried out by all involved in the health sector, including the same Superintendent and other decision makers who surely did not have an easy job, since the start of the COVID19 outbreak months ago.

I am also confident in the quality control carried out in the approved labs by the dedicated personnel. It is also a fact (and I agree) that PCR tests are regarded as the gold-standard to detect the virus, but it is also true that they are not perfect and the test outcome depends on when the test is performed. Also being highly sensitive, PCR tests can also show false positives (as even documented below).  

Nothing in life is perfect and everything and all of us (myself included) can be liable to a mistake.

  Additionally, my perception was that even in analysing positive and negative results, there was what I termed a ‘two weights, two measures approach’. The Superintendent stated that a positive result is surely reliable and there can be no mistake. (Unfortunately, this is not totally accurate as studies have shown that a small (even if slight and modest) percentage of error is always possible). Then what about a negative test? Does one follow the same reasoning? However, I am not stupid and clearly accept and adhere to the Superintendent’s expert opinion (based also on scientific documentation which is logical and cannot be denied) that there is a possibility of a mistake in a single negative test.

But then, what are the chances of a mistake in two consecutive negative tests? And further then, three or even four consecutive negative tests?

  I believe that it is clearly logical that the probability outcome that one is infectious is now extremely low, not to say inexistent, after a series of four negative tests like in my case. This increased my disappointment at the decision taken to adopt a ‘safe-defensive’ stance, cutting a straight line, without really looking deeply into the merits of a possible personalised case. I was initially very confident that logical reason, based also on scientific tests and probabilities as well as scientific and medical grounds added with a sense of rightfulness will finally triumph. However the end of the road was bleak as the Superintendent resorted to a generic safe approach whilst relying ‘ad verbatim’ to policy and legislation when even there, there are also references that allow the Superintendent to ‘make, vary or revoke orders’ or grant ‘special permissions’.    

Part H – Conclusion – Lest mistakes are recognized and learning takes place so that the same mistake is not repeated again.

 

My only solace is that I put forth my case and request in total honesty and sincerity and all that was stated is 100% true, authentic and genuine as I believe in earnest in integrity and veracity.

  I am not hiding the fact that I was very disappointed (to put it mildly) with the generic ‘one-size fits all’ decision but, ultimately, my conscience (and internally I) can still be at peace in that I tried my best, by being truthful and genuine, to make the authorities aware that this may really have been a special case and I never tried to fool anybody. Despite this emotional and negative moral setback, I still can somewhat be at peace internally in that I tried to convince through honesty and authenticity.

Ultimately, love it or hate it, I have to accept the ultimate decision and I hope that the decision maker/s are totally comfortable and at ease with their final verdict.

Being open in my thoughts, I also allow for the possibility that maybe (hope I am not) I am being biased or acting like one ‘putting my head in the sand’. I welcome any explanations to make me aware if could be also that I am in the wrong and my perceptions and assumptions above are not correct. After all, my life motto is ‘learning never stops’ and will welcome with open arms to learn of and correct any mistakes.   As I said before, it seems that after even proudly, and with no regret, representing and working, at times quite persistently, to raise the national sporting reputation abroad and carrying Malta’s colours in dozens of important sport arenas with immense satisfaction and for a long number of years,

I feel that part (but a decisive one at this juncture) of Malta somewhat failed me in my last step after I gave so much to it.

even if I think that I was not being unreasonable or posing any infectious risk/threat in asking (as explained above) for a reduced 7 day quarantine, an added second possibility to savour my last and final much-awaited retirement stage after a 25-year career was also put down the drain.

The damage (in my perception) is now done and there is no going back. My intention in making all this public is merely so that, I hope, lessons are learned and no single other person surely will have to pass through such a similar ordeal.

If anything, as regards decision makers in such cases, if the final decisions can be tweaked and corrected, then let it be so. In that case, my ordeal and emotional suffering, at least, will serve so that mistakes may not be repeated but become essentially a source of learning.  

I will conclude in the same manner I ended two of my communications with the Superintendent for Health namely with a reference to a very interesting and truthful quote by Chief Justice John Roberts, which any true decision maker should NEVER shy away from:

 “Legislative novelty is not necessarily fatal; there is a first time for everything.”

(White, B. (2012). Judicial Politics, Chief Justice Roberts’s Legacy, and the National Federation of Independent Business v. Sebelius Decision. The Justice System Journal, 33(3), 367-372.).

I hope that one would be ready to act outside a safe comfort zone and be ready to even take novel decisions (and not much of the same generic one size fits all) so that the same mistake is not repeated elsewhere or anytime.

I dearly wish that nobody would have to pass through the same experience and ordeal I faced in the past weeks.

I may forgive but I am not denying that I feel, and probaly will remain, hurt and very disappointed in that what I deemed as a logical, plausible, safe (even if not part of the norm) and genuine solution was outrightly dumped even behind the pretence that ‘this was never done’. True leaders, as per the great quote above, do not remain in a safety zone (the latter would not make them great but only standard leaders) but are ready for a first time in everything. I still have full respect and am grateful to the positive work done by the same Superintendent for Health (who did not, at times especially in 2020, have an easy job and much responsibility fell on her shoulders) and other related decision makers and all the health workers (who are also the real heroes at the frontline) in the last months. There is no denying that great work was accomplished and all deserve the right merit for the correct decisions taken. But, as explained above, nothing in life is perfect and each one of us is not infallible and liable to mistakes, knowingly and unknowingly, even totally innocent ones.

Lest mistakes are recognized and learning takes place so that the same mistake I experienced is not repeated again.

 

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Addenda;

Below: My four consecutive negative PCR test results – Saturday 7th August to Tuesday 10th August

 

 

 

  PS: I also even tried to press my case elsewhere, at top decision making level (as even, I believe, if the chief public health officer has most responsibility, it is always the Government that is to be held accountable), and make contact (with the intention that maybe there can possibly also be a sort of mediator in the matter) with the Honourable Deputy Prime Minister and Minister for Health, Dr Fearne, but my five emails addressed to two different email accounts (namely christopher.fearne@gov.mt and chris@chrisfearne.com) and dated Saturday 7th, Sunday 8th, Monday 9th, Tuesday 10th as well as Thursday 12th August (although apparently recorded as delivered) remained unanswered and not even acknowledged.

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