key: cord-0784191-491s2ezz authors: Fatteh, Naaz; Sutherland, Glen E.; Santos, Radleigh G.; Hamilton, Maxine; Jacob, Joseph; Patel, Alexander title: Healthcare Understanding of COVID-19 Antibody date: 2022-01-10 journal: Health Policy Technol DOI: 10.1016/j.hlpt.2022.100598 sha: 87fec42b750e9cdd072213ac742a0b4d65581e56 doc_id: 784191 cord_uid: 491s2ezz OBJECTIVE: : The SARS-CoV-2 pandemic has shed light on the difficulties in spreading uniform information. We rely on national and international organizations to provide scientifically accurate information to the public at large. With so many different sources of information, often not scientific, there appears to be an incomplete understanding of many aspects of SARS-CoV-2 infection. We sought to gain information about healthcare worker understanding of the implications of a positive serum COVID-19 antibody test result. We identified a broad range of responses among all categories of healthcare workers in our facility. Most notably we found that there was not complete understanding that there can be asymptomatic spread of COVID-19 infection. METHODS: : We provided health literacy and opinion questions to the healthcare workers of our facility. RESULTS: : Upon analysis of the data, we identified many differences in level of understanding among our healthcare workers. CONCLUSION: : We identified a lack of consensus on important details leading to potentially growing uncertainty with respect to SARS-COV-2 antibody. A diminished health literacy with respect to antibody testing could potentially suggest future issues with understanding the importance of vaccination benefits. Many questions have arisen in light of the new viral pathogen, SARS-CoV-2 (COVID-19) being introduced to the human population. With hope waning that the pandemic could be controlled with social distancing measures, the next steps for the Public Health system were to be able to determine the true prevalence of disease. In theory, it was felt that this would help governments make decisions about returning to normal life. The Johns Hopkins University Center for Global Health Security has carefully outlined information about COVID-19 serology or antibody testing. Questions raised include: which is the most accurate antibody test to use, is there a specific antibody level that correlates with immunity and if so, how long does immunity last (3) . The concept of an immunity passport has even been raised as a way to -clear‖ someone to return to work (5) . Since vaccines have become available, the question initially arose as to whether to vaccinate those with a positive antibody. At present the recommendations are to provide vaccination to all citizens who wish to receive it regardless of prior infection status due to concerns for waning immunity after infection. Hepatitis B is a model for using antibody status as a determiner for when post exposure prophylaxis or vaccination is needed (10) . There has been confusion in interpreting the antibody levels with Hepatitis B with respect to understanding who qualifies for vaccination. The Centers for Disease Control has provided guidance to assist healthcare workers about the different variations of serology results, and the correct interpretation of Hepatitis B serologies (8) . It is notable that initially the same confusion had arisen with Sars-CoV-2 antibody test results, especially since quantitative testing is not readily available. There is a reduction in levels of neutralizing antibodies in 2-3 months (6) . This would suggest a decrease in natural protection occurring after that time frame. Vaccination has continued in a schedule put forth by the CDC, but there is also considerable hesitancy on the part of many people with respect to safety and potential side effects of a new vaccine. Among the healthcare worker population who have previously been infected, some feel that they do not need to be vaccinated as they will have long lasting natural immunity. According to the CDC, asymptomatic or presymptomatic transmission is well documented. The risk of transmission from asymptomatic patients appears less than from symptomatic patients, but it is not zero. For example, in the Singapore study, the risk of secondary infection was approximately 4 times higher among contacts of symptomatic patients versus asymptomatic patients. In order to reduce community transmission of SARs-CoV2, the CDC recommends partnering with public health practitioners, healthcare providers, pharmacies, employers, and faith leaders. The CDC repeatedly recommends promoting high vaccination coverage rates, along with rigorous mitigation strategies ( masking, distancing, improved ventilation, and disinfection) along with appropriate quarantine and isolation practices, in order to prevent and control outbreaks in high risk settings. (14) With SARS-CoV-2 infection, total antibody levels have been shown to increase within 2 weeks after symptoms develop as seen with other viral infections (7) . After a viral infection, antibodies are produced and of those, some of them are neutralizing and can offset the infectivity of the virus (9) . High titers of SARS-CoV-2 IgG detected by ELISA have been correlated with the presence of neutralizing antibodies (13) . In a review of SARS-COV-2 diagnostic tests, PCR testing and antibody testing timeline was reviewed showing the IgM and IgG tests can become positive as early as 2 weeks, overlapping with positive PCR testing for a few weeks (11) . There are many commercially available molecular assays, including rapid tests which should mean that the time for result is less than one hour. There is variable false negativity (4). There is no defined national protocol available for which test to use, and even less information available about comparison of results. Within the same healthcare system, employees may obtain lab testing from different locations based on their insurance. These tests may not be comparable. Despite the numerous available tests and studies looking at the presence of different antibody value ranges, the actual degree and duration of protection conferred by a positive SARS-CoV-2 antibody is felt to be approximately three months. From our own personal experience working with SARS-COV-2 infected patients, we understand the significant psychological impact that the SARS-CoV-2 pandemic has had on healthcare workers at all levels. This has been seen with prior Infectious Disease outbreaks such as SARS (Severe Acute Respiratory Syndrome) (16) . In a paper looking at the psychological impact on healthcare workers caring for patients with SARS, about 10% of the respondents had experienced high levels of posttraumatic stress symptoms since the outbreak had begun (16) . We feel that some of the stress with respect to our current pandemic may be due to a lack of understanding of the pathophysiology of SARS-CoV-2 with respect to testing and understanding what result suggests immunity. The purpose of this study is to gauge the understanding of healthcare workers about antibody testing. The antibody test has two components, SARS-CoV-2 IgM for acute infection and SARS-CoV-2 IgG which typically indicates immunity. We can take the information we glean from this study and potentially apply it to the general population to direct educational resources to ensure understanding of the SARS-CoV-2 viral testing and implications of results. We distributed a questionnaire to employees of Broward Health Medical Center, a large teaching hospital, between the dates of March 9, 2020 and May 30, 2020. Questionnaires were distributed to all willing employees. These were employees involved in both direct patient care and those who did not have hands-on patient care. Both groups worked in the hospital. We identified these as health care and non-health-care workers. We contacted the head of each department to assess the best time to meet with the largest number of people in each department. The surveys were handed out to the group and handed back to the researcher when completed. Also, questionnaires were handed out to those who, when asked, stated they had not received a questionnaire previously. There was a statistically significant association (p < 0.0001) when considering all categories, with physicians and residents selecting -yes‖ at higher rates (92% and 90% respectively) compared to the overall sample (56%). There was a statistically significant association (p < 0.0001) when considering all categories, with physicians and residents correctly selecting -yes‖ at higher rates (58% and 80% respectively) compared to the overall sample (36%). There was a statistically significant association (p < 0.0001) when considering all categories, with physicians and residents correctly selecting -yes‖ at higher rates (92% and 93% respectively) compared to the overall sample (70%). There was a statistically significant association (p = 0.0006) when considering all categories with environmental services and transportation correctly selecting -yes‖ at lower rates (5% and 4% respectively) compared to the overall sample (22%). Regarding Question 6, there was a statistically significant association (p < 0.0001) when considering all categories, with environmental services and transportation selecting -yes‖ at lower rates (21% and 17% respectively) compared to the overall sample (37%). There was a statistically significant association (p < 0.0001) when considering all categories, with environmental services and transportation correctly selecting -yes‖ at lower rates (47% and 21% respectively) compared to the overall sample (87%). Regarding Question 8, there was a statistically significant association (p = 0.0004) when considering all categories, with Category B3 selecting -yes‖ at higher rates (80%) and transportation at lower rates (21%) compared to the overall sample (63%). There was a statistically significant association (p < 0.0001) when considering all categories, with physicians and residents selecting -yes‖ at higher rates (87% and 98% respectively) and transportation at lower rates (42%) compared to the overall sample (70%). • When grouping the literacy questions together, Physicians and Residents answered correctly at significantly higher rates compared to the majority of other categories while Transportation were more likely to have answered correctly at significantly lower rates. The physicians and residents may have been receiving more training with respect to this topic. • Nurses had low knowledge with only 21% knowing that positive IgM means current or recent infection (Figure 2 ). This is a low percentage compared to what we would have expected from them based on their clinical work and level of clinical training. • A larger number of respondents than expected did not know that a positive COVID-IgG indicated prior infection (Figure 4 ). This included both health-care workers and nonhealthcare workers. • With respect to the question asking if COVID-19 IgM or IgG provides protection, a clarification question to those who answered in the affirmative would be to query how long the protection is expected to last (Figures 3,5 ). • When asked if an asymptomatic person can spread COVID-19 infection, we did not expect to have so many respondents answer either Do Not Know or No ( Figure 6 ). This highlights an important area which may be impacting the uptake of mask wearing as a universal precaution. While at work masks are mandated, however it would be interesting to ask how many of the respondents do not feel it necessary to wear masks outside of work if they are without any symptoms. • It was expected that people would not know how long immunity would last if an antibody result was positive, and in fact only a few answered yes to this question ( Figure 7 ) . The correct answer was defined as no or don't know. Non patient care location staff all answered correctly except one person (Category A2 superior to A1). We found it interesting that anyone answered yes, with affirmative responses higher in environmental services and nurse assistant groups. • A large number of nurses and nurse assistants did not know their Hepatitis B antibody status despite their patient care responsibilities and associated risk of exposure ( Figure 8 ). In the nursing group (25%) and (50%) of nursing assistants did not know if they were immune -notable because of close patient contact. Overall 30% of frontline workers did not know their immune status. Hepatitis B immune status is typically something asked or tested for at the time of employment. • It is possible that participants felt that obtaining a serum antibody test would result in some consequence at work such as limiting their work options. This was not stated to be true but may have been assumed and affected the response. • For participants who have previously tested SARS-CoV-2 positive, they may have also felt some concern in stating that they would want an antibody test. While this questionnaire was anonymous there could have been an inference that results from this could result in some policy development with respect to testing. Review of this data shows that overall more non-patient care than patient care personnel would be tested. It was a small difference and not statistically different. Within the patient care group, there was overall high interest except with transportation who were least likely to say yes to testing (21%) followed by Physician extenders (B4) at 42% It is notable that only slightly more than half of physician/nurse categories would opt in for antibody testing, but the ancillary patient care groups (B3) most likely. People who were identified as being more literate in the subject matter were more likely (60%) to plan to get the antibody test when offered. Those with less literacy were not as likely (20%). Therefore individuals are not incentivised to be aware of their immunity status. The same may hold true in the future for COVID-19 infection. If healthcare workers are not completely aware of asymptomatic transmission of COVID-19, we understand that the general population would not be fully aware either and this would be an area where significant public health education may be directed. for such organizations to spend increased time explaining the pathophysiology of the disease. The school system is another area where this information should be taught. It is unclear when this pandemic will end and an all hands on deck approach is needed, starting from the youngest in our society to the oldest. 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