key: cord-0990386-w2np2s67
authors: Jette, Christine G.; Wang, Tammy; Wang, Ellen; Man, Janice Y.; Mireles, Samuel; Maass, Birgit; Mathew, Roshni; Pinsky, Benjamin A.; Claure, Rebecca E.; D'Souza, Genevieve
title: Novel utilization of strand‐specific reverse transcription polymerase chain reaction in perioperative clinical decision making for SARS‐CoV‐2 polymerase chain reaction positive patients
date: 2022-04-05
journal: Paediatr Anaesth
DOI: 10.1111/pan.14448
sha: fb9c07f0211cc15936ccd8ab35912ac8585574f3
doc_id: 990386
cord_uid: w2np2s67

In order to prevent in‐hospital transmission and potential complications related to SARS‐CoV‐2 in the perioperative patient, most healthcare institutions require preoperative testing for SARS‐CoV‐2 prior to proceeding with elective surgery. The Centers for Disease Control and Prevention (CDC) recommends a time and symptom‐based duration of isolation for the presumed infectious period. The guidance to avoid retesting of asymptomatic patients in the 90 days following a positive reverse transcription polymerase chain reaction (RT‐PCR) test is because of the possibility of detection of non‐infectious viral shedding. When to reschedule asymptomatic patients who test RT‐PCR positive for SARS‐CoV‐2 preoperatively is of considerable debate, both from the perspective of ensuring a patient's full preoperative fitness, as well as reducing the risk of viral transmission within the hospital. We describe the novel perioperative use of a strand‐specific assay to detect minus strand ribonucleic acid (RNA) in a clinical decision‐making algorithm to determine optimal timing of elective surgery after a patient tests RT‐PCR positive for SARS‐CoV‐2. This is the first description in the literature of an attempt to further stratify patients who repeatedly test positive for SARS‐CoV‐2 into infectious versus non‐infectious for perioperative planning.

The COVID-19 pandemic, caused by SARS-CoV-2, has led to mass disruption of healthcare systems and a feeling of uncertainty among healthcare workers, not only in caring for those infected with the virus, but also in learning how to continue the regular work of healthcare and surgeries while not contributing to onward transmission. To that end, many healthcare systems test all patients for SARS-CoV-2 preoperatively and reschedule elective or semi-urgent surgeries if a test results positive. 1 Pediatric patients are more likely to be asymptomatic or mildly symptomatic when infected with SARS-CoV-2 yet may still carry high viral load. 2, 3 Therefore, universal preoperative screening of this patient population is especially important to reduce the risk of in-hospital transmission. 4 Reverse transcription polymerase chain reaction (RT-PCR) is the standard method of detecting SARS-CoV-2. However, patients with a positive RT-PCR test for SARS-CoV-2 can shed ribonucleic acid (RNA) and subsequently continue to test positive by RT-PCR for weeks. 5, 6 RT-PCR cannot distinguish between inactive virus and actively replicating virus; actively replicating virus is critical for a patient to be infectious. It is thought that the majority of viral shedding is non-infectious, which is the basis for CDC recommendations of a time and symptom-based strategy for clearing isolation as opposed to a test-based strategy. 7

Emergency surgeries proceed with appropriate precautions regardless of SARS-CoV-2 status, but the optimal timing of when to reschedule patients for urgent or elective surgeries who have previously tested SARS-CoV-2 positive is of considerable interest, especially in asymptomatic patients. 8, 9 A test-based strategy for determining non-infectious status of patients has broad appeal to healthcare workers trying to protect themselves and their families from COVID-19. Asymptomatic patients who continue to test positive for SARS-CoV-2 after the recommended isolation period present a conundrum for healthcare workers struggling to balance the need for surgery with the risk of viral transmission and further spread in the hospital. In this report, we describe Stanford Children's Health's work to use a novel laboratory-based test to differentiate patients with active viral infection versus the persistence of viral RNA as a tool to guide rescheduling of elective surgery.

While viral culture is the gold standard for determining the presence of replicating virus, this is largely unavailable outside of research settings given the necessary stringent safety precautions.

There is considerable interest in the development of laboratory tests that can differentiate between the presence of remnant viral RNA (i.e., noninfectious) and replication-competent (i.e., infectious) virus. 10 The Clinical Virology Laboratory at Stanford Health Care and Stanford Children's Health developed a strand-specific assay that detects minus-strand viral RNA as a marker for actively replicating SARS-CoV-2, as a tool to help guide clinical decision-making. 11 SARS-CoV-2 is a positive sense single-stranded RNA virus. The viral replication process involves several steps including transcription, translation, protein formation, and eventual exit from the cell. 12, 13 Actively replicating virus produces minus-strand RNA intermediates that can be detected by RT-PCR. The inability to detect minus strand suggests the virus is no longer replicating and the patient is unlikely to be infectious. During test validation, the strand-specific testing demonstrated 100% sensitivity and 72% specificity compared to SARS-CoV-2 viral culture. All culture positive samples had detectable minus strand, as did 28% of non-culturable samples, indicating that strand-specific testing may be more conservative than viral culture as a surrogate for transmissibility.

The anesthesia preoperative clinic (PARC) at Stanford Children's Health began using strand-specific RT-PCR testing on September 17, 2020, as part of a protocol to reschedule and retest patients with upcoming scheduled elective surgery who had previously tested SARS-CoV-2 positive within the last 90 days. A follow-up SARS-CoV-2 RT-PCR test was performed after 30 days of patient isolation and parent quarantine in anticipation of most pediatric patients and their caregiver families being off isolation and quarantine at 34 days. This included 20 days of isolation for the patient (assuming much of our patient population is immunocompromised or frequently hospitalized) in addition to 14 days of quarantine for the parent or caregiver who will accompany the patient for their surgical procedure. If the repeat RT-PCR test was positive, a strand-specific RT-PCR assay was added on to the sample. If the strand-specific RT-PCR assay did not detect the presence of the minus strand, surgery could proceed, and the patient was considered SARS-CoV-2 negative. If the strand-specific RT-PCR assay detected the presence of the minus strand, the patient was considered to be SARS-CoV-2 positive and still infectious, and surgery was either further delayed (if elective) or proceeded with airborne precautions. Any sample collected at a Stanford testing site had the capability of being tested via the strand-specific assay. Due to the labor-intensive nature of the strand-specific assay, samples were run 3 days per week, requiring a full day to result; therefore, considerable planning is needed to occur to ensure the strand-specific assay is re- repeat RT-PCR and therefore did not undergo a strand-specific test.

All patients proceeded to surgery after either their repeat negative RT-PCR or negative strand-specific assay.

Of the seventy-three cases that met inclusion criteria, fifteen were immunocompromised. Nine of those were symptomatic at the time of their initial positive RT-PCR for SARS-CoV-2. The age range was nine months to twenty years. The male to female ratio was 2:1.

Fifty-six patients identified as Hispanic, ten as White/Caucasian, four as Asian, and three as Other. Days between the first and repeat test for SARS-CoV-2 were between 20 and 84 days. It is unknown if any of the patients received treatment for SARS-CoV-2 infection (Table 1) .

For comparison, we also reviewed strand-specific testing of nonsurgical patients in the Stanford Children's Health system during the same time period. We identified eleven patients for whom the minus strand was detected. In some cases, the strand-specific assay was performed and the minus strand detected on a first RT-PCR sample, because teams throughout the healthcare system were utilizing the strand-specific assay in varying clinical contexts. Of these eleven patients, four had detected minus strand at 20 days or beyond their initial positive RT-PCR for SARS-CoV-2 ( Table 2) . Three of these patients were immunocompromised. Two were symptomatic at the time of their strand-specific assay, one patient's symptoms were unknown. One of the four was an otherwise healthy outpatient who had symptoms of nasal congestion at the time of her initial positive SARS-CoV-2 test, but was asymptomatic at the time of minus-strand detection. Other 3

Note: Characteristics of pediatric preoperative patients who tested repeat positive for SARS-CoV-2 20 days or more after their initial positive test.

JETTE ET al.

planning purposes.

In this report, we identified one immunocompetent outpatient and three immunocompromised patients with detected minus strand 20 days or more after their initial positive RT-PCR test. ( Table 2 )

Although it is known that immunocompromised patients may have during the pandemic and assistance in implementing this workflow.

None. 

The datasets used and/or analyzed during this study are available from the corresponding author upon reasonable request. 

Samuel Mireles

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