ABSTRACT
Background. Combining rapid antigen and RT-PCR tests optimizes detection of COVID-19 compared with either test alone. Therefore, coincident with the Omicron surge, in November 2021, the Atlanta VA Health Care System (AVAHCS) initiated combination testing for all patients admitted from the emergency department (ED) to the inpatient wards. We retrospectively compared test performance for all patients with combination testing performed at AVAHCS, assessed impact of combination testing on ED disposition, and reviewed clinical characteristics of those admitted from the ED with discordant results. Methods. We assessed concordance of antigen (Abbott Binax NOW) and RT-PCR (either Cepheid GeneXpert or Roche cobas 6800) tests performed within 24 hours of each other (i.e., combination test-pairs) for any patient during November 25, 2021- January 27, 2022, and calculated test characteristics of the antigen test using RT-PCR as the gold standard. For those patients evaluated in the ED who had discordant results, we determined ED disposition then performed standardized medical record reviews for those admitted to ascertain clinical history and hospital course and disposition. Combination Antigen and RT-PCR Testing Algorithm for Patients in the Emergency Department, Atlanta VA Healthcare System Results. Of 836 combination test-pairs, 112 (13%) were discordant, of which 111 were antigen-negative/RT-PCR positive. Sensitivity of the antigentest was 50%, specificity was 100%, positive predictive value 99%, and negative predictive value was 85%. Of 68 patients evaluated in the ED who had antigen-negative/RT-PCR positive results, 21 (31%) were admitted, of whom 17 (81%) had COVID-19-related symptoms at time of ED evaluation. Of the 21 admitted patients, all were admitted to a COVI Disolationunit, 20 (95%) had >=1 chronic comorbidity, 12 (57%) had not completed vaccination, 14 (67%) received COVID-19-specific treatment while inpatient, 6 (29%) received care in an intensive care unit, 17 (81%) discharged home, and 1 (5%) died during hospitalization. Conclusion. The sensitivity of antigen testing was 50% compared to RT-PCR among patients tested across AVAHCS, consistent with published literature. Combination testing facilitated earlier diagnosis, isolation, and treatment of some patients hospitalized from the ED, likely preventing nosocomial transmission.
ABSTRACT
Background. Monoclonal antibody (Mab) infusions have reduced hospitalization and mortality among higher risk patients with mild to moderate COVID-19 symptoms. Using an interdisciplinary team approach, we created a clinical team to proactively screen and outreach patients with COVID-19 to equitably offer Mab. Methods. From December 28, 2020 - May 3, 2021, a clinical team consisting of an Infectious disease pharmacist and physician, reviewed each outpatient with a positive SARS-CoV-2 PCR test at the Atlanta VA Healthcare System (AVAHCS) daily. The clinical team used the published Emergency Use Authorization criteria to determine eligibility. Eligible patients were prioritized using the Veterans Health Administration (VACO) Index for COVID-19 Mortality, which estimates the risk of 30-day mortality after COVID-19 infection using pre-COVID-19 health status (Figure 1). Eligible patients were contacted via telephone to confirm eligibility and obtain verbal consent. We performed SARS-CoV-2 IgG antibody tests when possible prior to Mab infusion, but results did not preclude Mab receipt. Telehealth follow-up occurred at 1- and 7-days post infusion. Overview of the elements of the VACO index, part 2 of 2. Results. In total, 1,346 COVID-19 patients were identified;86 (6%) patients were eligible, and 48/86 (55%) received Mab infusions (Figure 2). The median time from symptom-onset to positive COVID-19 PCR test result was 6 days (0-9) and the median time from positive COVID-19 PCR test result to Mab infusion was 2 days (0-8). SARS-CoV-2 IgG antibodies were detected in 4 of 24 (17%) patients tested. The most common comorbidities were hypertension (73%) and diabetes, (42%) (Table). Five (10%) patients required hospitalization for worsening COVID-19 symptoms post infusion. No deaths occurred. Conclusion. This approach of combining laboratory surveillance and active screening minimized delay in symptoms onset to Mab infusion, thereby optimizing outpatient treatment of COVID-19 disease. Our approach successfully treated a more diverse patient population compared to clinical trials. Mab infusions overall was well tolerated with few hospitalizations and no deaths in this cohort.
ABSTRACT
Purpose of Study The Atlanta VA Healthcare System (AVAHCS) Infectious Diseases Clinic (IDC) implemented measures to promote and improve COVID-19 vaccination rate in people living with HIV (PWH). Our goal was to determine the impact of these efforts on COVID-19 vaccination rates and compare with other populations. Methods Used Beginning in March 2021, the AVAHCS IDC implemented targeted outreach strategies to educate PWH regarding COVID-19 vaccinations including emails, phone calls, and informational appointments. We assessed vaccination rates among PWH who had at least one clinical encounter in the IDC from December 15th, 2020 through August 5th, 2021. We stratified vaccination status by age and HIV viral load and compared PWH vaccination rates with all patients at the AVAHCS and the population of Georgia. Summary of Results As of August 5, 2021, the overall rate of full vaccination was among 1248 PWH was 69% (864 patients out of 1248). Seventy six percent of PWH received at least one dose (953 patients out of 1248). In comparison, the vaccination rate of all patients at the AVAHCS (50%) and the population of Georgia (39%) was lower (figure 1 and figure 2). PWH with a HIV viral load of <200 copies/ml had a higher vaccination rate compared to PWH with a higher viral load (77% vs. 66% respectively). In each age cohort, the PWH vaccination rate was higher compared to the state of Georgia;the greatest difference was observed among 45-64- year-olds (26%). Conclusions PWH at IDC had higher rates of COVID-19 vaccination compared to all patients at the AVAHCS and the population of Georgia. This is likely due to proactive patient outreach, education and follow up.
ABSTRACT
Background: The contributions of non-AIDS comorbidities and HIV-related factors to coronavirus disease 2019 (COVID-19) outcomes among persons with HIV (PWH) remain unclear. We aimed to identify risk factors for COVID-19 hospitalization among PWH. Methods: We evaluated all adult (≥18 years) PWH with a positive SARS-CoV-2 PCR evaluated in a public safety-net hospital system, a Ryan White-funded HIV clinic and a Veterans Affairs medical center in Atlanta, GA between March 1, 2020 and November 15, 2020. Demographic and clinical characteristics and COVID-19 disease outcomes were ascertained by medical record abstraction. We performed multivariable logistic regression to determine associations with COVID-19 hospitalization. Results: 180 patients (mean age 49 years, 78% male, 78% Black, 14% Latinx) were included. 97% were on antiretroviral therapy (ART), 91% had HIV-1 RNA <200 copies/ml, and mean CD4 count was 527 cells/mm3. 60 patients (33%) were hospitalized, 28 (47%) required supplemental oxygen. Overall mortality rate among PWH was 1.63%;mortality among hospitalized PWH was 5%. 130 patients (72%) had at least 1 non-AIDS comorbidity;22% had >4 comorbidities (hypertension, dyslipidemia, obesity and diabetes were most prevalent). In univariable models, age, hypertension, dyslipidemia, diabetes, heart disease, and chronic kidney disease were associated with hospitalization. HIV characteristics including CD4 count, viral load, and ART use were not associated with hospitalization. After adjusting for those baseline characteristicsassociated with hospitalization, only age [aOR(95%CI) 1.073 (1.036-1.110), p<0.0001] and diabetes mellitus [aOR(95%CI) 2.653 (1.027-6.853), p=0.0439] were associated with hospitalization. In a multivariable model adjusting only for age, comorbidity count was associated with a 25% increased risk for hospitalization [aOR(95% CI) 1.245 (1.013-1.531), p=0.0375];and having ≥4 comorbidities was associated with a 2.8-fold increased risk of hospitalization compared with 0-1 comorbidities [aOR(95% CI) 2.848 (1.174-6.910), p=0.0240] (Figure). In age-adjusted analyses restricted to CD4 <200 cells/mm3 or HIV-1 RNA >200 copies/mL, HIV-related factors were not associated with hospitalization. Conclusion: In a cohort of PWH with well-controlled HIV and COVID-19, age and non-AIDS comorbidities, but not HIV-related factors, were associated with hospitalization for COVID-19. Further research into causes of severe COVID-19 among PWH is warranted. (Figure Presented).