---------------------------------------We stopped using the test based strategy as all were PCR + for more than 3-4 weeks and infectivity at that point was not clear. We started IgM/IgG testing in-house last week and require IgG + in addition to 14 days OOW from onset of symptoms and 7 days symptom free to RTW. Since last week, we have been drawing serology on all PCR COVID+ healthcare workers to validate our testing and to assist with RTW decisions.
We also started drawing serology on HCW with classic COVID-19 symptoms in addition to the PCR. Yesterday we had a positive IgM on a nurse with classic COVID-19 symptoms ( cough, SOB, fever, loss of smell/taste) but had two previous negative PCR from our screening clinic.
Today, we opened up IgG testing to all HCWs in the organizations and offer 100 appts per day in our TMH clinic. We hope this testing will allow us to identify how many of our HCW may have had asymptomatic infection and how many are susceptible. We reiterate to our HCWs that a positive IgG does not indicate the amount or duration of immunity or if they are protected from reinfection.
Our Infectious Disease physicians plan to conduct a retrospective study on IgG testing of healthcare workers once we have a large enough sample. We have already scheduled over 2500 for IgG testing and are hoping for at least 5,000 by July. We included data points such as history of exposure, perform aerosolizing procedures, work in high risk unit, history of symptoms but never tested, and random selection of HCWs.
Will be happy to share results with this group.
JoAnn Shea, APRN, MS, COHN-S
Director, Team Member Health and Wellness
Tampa General Hospital
Office: 813-844-7692
Cell: 813-789-3441
From: MCOH-EH <mcoh-eh-bounces@mylist.net>On Behalf Of William.Scott
Sent: Thursday, April 23, 2020 1:58 PM
To: 'Swift, Melanie D., M.D., M.P.H.' <Swift.Melanie@mayo.edu>; 'MCOH-EH' <mcoh-eh@mylist.net>
Subject: Re: [MCOH-EH] Use COVID antibody results for return to work management?
Hi Melanie. Thanks for the feedback at this strange time. I totally agree. Our institution after further discussion with myself, ID and Medical Director of Lab were able to convince our Quality Medical Officer that we did not want to use the PCR method for the reasons mention. Instead he will wait until we have AB (IgG) testing on asymptomatic HCWs since the rational is easier to explain and better at determine past exposure and immunological response. But again we are not sure of neutralization of infection and future protection.
Bill
William Scott, MD, MPH, FACOEM
Clinical Assistant Professor, Carle Illinois College of Medicine,
Clinical Assistant Professor, University of Illinois College of Medicine at Urbana-Champaign
Head, Occupational & Envionmental Medicine & Employee Health
Carle Foundation Hospital, Carle Physician Group.
O 217-383-5383
M 217-372-4819
From: Swift, Melanie D., M.D., M.P.H. <Swift.Melanie@mayo.edu>
Sent: Thursday, April 23, 2020 8:19 AM
To: William.Scott <William.Scott@carle.com>; 'MCOH-EH' <mcoh-eh@mylist.net>
Subject: [EXT] RE: Use COVID antibody results for return to work management?
_______________________________*****EXTERNAL EMAIL SOURCE*****Bill, We are hearing a lot of institutions grappling with this and the desire to test asymptomatic employees is understandable. It’s prompted by an awareness of asymptomatic spread.
I would caution you to consider test frequency. A negative PCR test today does not ensure the person won’t be positive in another 2 days, which begs the question of why start doing it unless you plan to continue testing every few days.
If you find a positive PCR in an asymptomatic person, I think you are obligated to use the test-based strategy for RTW. The non-test-based strategy is to return them after 7 days from symptom onset. Pretty hard to calculate if there are no symptoms!
Melanie
Melanie Swift, MD, MPH
Medical Director, Mayo Clinic Physician Health CenterAssociate Medical Director, Occupational Health Service
Senior Associate Consultant
Assistant Professor of Medicine
Division of Preventive, Occupational, and Aerospace Medicine
Phone 507.284.2560
_______________________________
Mayo Clinic
200 First Street SW
Rochester, MN 55905
www.mayoclinic.org
From: William.Scott [mailto:William.Scott@carle.com]
Sent: Monday, April 20, 2020 2:16 PM
To: 'MCOH-EH'
Cc: Swift, Melanie D., M.D., M.P.H.
Subject: RE: Use COVID antibody results for return to work management?
Thanks for opening up on this discussion. I agree with many of these point. We are about ready to start Ab testing HCWs in our institution but we do not know how yet to interpret the testing. We hope like in other viral IgG responses there will be protection.
Additionally my institution will start test asymptomatic HCWs via PCR (since it is readily available now). How would one dealing with asymptomatic PositivePCR COVID-19. Do you take then off work/isolate for stand 7 days (CDC guideline) or let them work with masks?
Curious what other would do?
Bill
William Scott, MD, MPH, FACOEM
Clinical Assistant Professor, Carle Illinois College of Medicine,
Clinical Assistant Professor, University of Illinois College of Medicine at Urbana-Champaign
Head, Occupational & Envionmental Medicine & Employee Health
Carle Foundation Hospital, Carle Physician Group.
O 217-383-5383
M 217-372-4819
From: MCOH-EH <mcoh-eh-bounces@mylist.net>On Behalf Of Swift, Melanie D., M.D., M.P.H. via MCOH-EH
Sent: Monday, April 20, 2020 1:15 PM
To: 'mcoh-eh@mylist.net' <mcoh-eh@mylist.net>
Cc: Swift, Melanie D., M.D., M.P.H. <Swift.Melanie@mayo.edu>
Subject: [EXT] Re: [MCOH-EH] Use COVID antibody results for return to work management?
_______________________________*****EXTERNAL EMAIL SOURCE*****Good question and one we are all grappling with I think. We have a tool available, but aren’t quite sure if/how/when to use it.
- About 80% of COVID-infected individuals develop IgG by day 14, and almost 100% develop it by day 30.
- Some people with a new positive IgG still have detectable viral RNA by PCR in nasopharyngeal swabs.
- The PCR can’t tell whether that viral RNA represents viable, replication-competent virus; so we have to assume a person who is PCR-positive may be still communicable.
- We don’t yet know whether a positive IgG always represents neutralizing antibody and thus presumptive immunity.
- One study, in preprint and not peer-reviewed, found that 2 macaques who had recovered from COVID-19 and developed IgG were rechallenged 28 days later with the same strain and remained asymptomatic.
- Promising but a far cry from feeling comfortable that we can declare someone immune.
- We don’t know how durable any immunity, if present, lasts.
So my personal take on this is:
- IgG is not helpful in determining safety to RTW.
- IgG may be helpful diagnostically, especially when an individual was not tested with PCR early in their illness course, and now appears to have late complications of COVID-19. The virus may be only replicating in the lower airway and nasal PCR could be negative. An IgM or IgG that was positive would help make the diagnosis.
- If we find evidence of neutralizing antibodies and durable immunity, and we have a vaccine that is in short supply, the test could help us develop a vaccine prioritization.
- If we find evidence of neutralizing antibodies and durable immunity, and we have another wave of hospitalized patients, IgG could help us identify HCP at lower risk, and this could be used in some sort of cohorting strategy.
My 2 cents only,
Melanie
Melanie Swift, MD, MPH
Medical Director, Mayo Clinic Physician Health CenterAssociate Medical Director, Occupational Health Service
Senior Associate Consultant
Assistant Professor of Medicine
Division of Preventive, Occupational, and Aerospace Medicine
Phone 507.284.2560
_______________________________
Mayo Clinic
200 First Street SW
Rochester, MN 55905
www.mayoclinic.org
From: MCOH-EH [mailto:mcoh-eh-bounces@mylist.net]On Behalf Of Thorne, Craig
Sent: Monday, April 20, 2020 12:01 PM
To: 'mcoh-eh@mylist.net'
Subject: [MCOH-EH] Use COVID antibody results for return to work management?
Good afternoon everyone,
I am curious about current opinion on how you plan to use COVID antibody results for return to work management?
At this point in the pandemic, we are not requiring home isolation for exposed essential HCWs regardless of their source of exposure.
Given all the literature about the uncertainties with COVID antibody testing, a discussion about this on this list serve could be interesting.
Thank you,
Craig Thorne
Craig D. Thorne, M.D., MPH, MBA
Chief Medical Director, Occupational Medicine and Business Health ServicesYale New Haven Health System
Cell: 203-687-5281
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