In the early days of a pandemic, time is of the essence. Taking action quickly can make a difference in the number of lives saved or lost. As an epidemiologist and an associate professor in the infectious diseases division at the University of Louisville in Louisville, Ky., Forest Arnold, D.O., helped lead a response to the COVID-19 pandemic that made the school’s hospital a pioneer among the state’s health care institutions.
A West Virginia School of Osteopathic Medicine (WVSOM) Class of 1997 alumnus who was born in Michigan and spent his childhood in Charleston, W.Va., Arnold developed an interest in infectious disease during his third- and fourth-year rotations. Following an internal medicine residency at the University of Tennessee, he received an infectious diseases fellowship at University of Louisville Hospital and has remained with the facility ever since.
In March, when the COVID-19 pandemic was declared a national emergency, Arnold’s team, under the direction of Dr. Julio Ramirez, took over a research building and rapidly established a testing location, becoming the first such site in Kentucky’s most populous city and outpacing even the state laboratory in Kentucky’s capital, Frankfort. Arnold said such speedy action was possible because his division already had a research lab, providing familiarity with the logistics of testing, and because the university’s virology lab was one of the few in the nation where SARS-CoV-2 — the virus that causes COVID-19 — was distributed from the “index patient,” or the first individual in the U.S. with a confirmed case. The hospital’s research affiliation with other area medical facilities helped, too.
“Before the pandemic, we had relationships with the other hospitals in Louisville to study pneumonia,” Arnold said. “In mid-March, we spoke with their chief medical officers and told them we were ready to start doing 100 coronavirus tests a day, with each hospital getting 10 tests. They sent us their samples, and at the end of each day we sent reports of who was positive. At one point, one of the hospitals had an outbreak among its employees, so we started testing them as well, and then we expanded to nursing homes.”
As the pandemic continued and coronavirus testing became faster and more readily available, the number of testing locations increased, as did the number of tests that could be performed each day. But in the earliest days of the still-ongoing public health crisis, University of Louisville Hospital was the region’s primary diagnostic site.
“We did it for about two months, until everyone else was able to get off the ground and start doing it themselves,” Arnold said.
In addition, Arnold served as the lead author of two publications related to the pandemic. In an effort to help physicians around the world identify possible COVID-19 cases based on radiological results, he took the lead in creating an online library containing CT scans and chest X-rays of 15 COVID-19 patients and five “lookalike” patients.
“In the beginning of the pandemic, when the testing was slow, it was difficult to tell who might have it and who might not,” Arnold said. “I thought that if patients were coming in and getting CT scans or X-rays, then maybe the physician could see whether the patient’s X-ray was consistent with coronavirus even before the test came back. It was a way to educate physicians about what was coming, because in a severe coronavirus patient, the sooner you intervene, the better the outcome.”
Despite the subsequent availability of quick-response testing, libraries such as University of Louisville Hospital’s can still be useful, Arnold said.
“Even now, we sometimes see false negative swabs, so it’s nice to be able to see the imaging and compare it to what you’re looking at,” he said. “For example, we recently saw a patient whose family member had COVID. Her swab was negative but her X-ray looked like coronavirus, so I was confident that she had been isolated appropriately. If the context is right and you know what COVID looks like on an X-ray, it can aid your clinical diagnosis.”
Arnold also published research comparing the ability of 3-D printed nasopharyngeal swabs to detect COVID-19 with that of commercially available swabs. Staff from the University of Louisville’s engineering and dental schools had collaborated to design and manufacture swabs using 3-D printers, incorporating feedback from Arnold. But because the effectiveness of the swabs still needed to be determined, Arnold devised a study.
“At that stage of the pandemic, swabs were one of the things everyone was running out of,” he said. “So we printed them and I asked a group of patients, most of whom were known to be COVID-19 positive, to agree to be swabbed with the 3-D printed swab and a regular swab at the same time. We compared the results and found a 90 percent agreement. Since then, the state of Kentucky has contracted with us to have several thousand swabs on hand.”
Arnold’s radiological library and swab study were both published in the University of Louisville Journal of Respiratory Infections and are available online.
Arnold, who has written a book about his experiences during the pandemic, said the sheer magnitude of the COVID-19 pandemic sets it apart from previous epidemics.
“It’s on a grand scale that we haven’t had before. Epidemiologists are in charge of coming up with the policies that determine how a hospital responds: Who do we test? What instructions do we give about personal protective equipment? What do you do when you have employees who are positive? And because this is a pandemic of mammoth proportions, answering those questions has been a massive undertaking.”
As thankful as he is to be able to take an active role in helping organizations, and individual patients, navigate these uncertain times, Arnold also remains appreciative of the osteopathic medical school that started him on his journey.
“We’re an academic hospital, and working with students has helped me realize how great a medical education I got at WVSOM,” he said. “I’ve seen that knowing the anatomy is such an important part of taking care of patients, and getting that information front-loaded in the first two years was extremely valuable.”