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Ahmed F, Nowalk MP, Zimmerman RK, Bear T, Grijalva CG, Talbot HK, Florea A, Tartof SY, Gaglani M, Smith M, McLean HQ, King JP, Martin ET, Monto AS, Phillips CH, Wernli KJ, Flannery B, Chung JR, Uzicanin A. Work Attendance with Acute Respiratory Illness Before and During COVID-19 Pandemic, United States, 2018-2022. Emerg Infect Dis 2023; 29:2442-2450. [PMID: 37917142 PMCID: PMC10683820 DOI: 10.3201/eid2912.231070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2023] Open
Abstract
Both SARS-CoV-2 and influenza virus can be transmitted by asymptomatic, presymptomatic, or symptomatic infected persons. We assessed effects on work attendance while ill before and during the COVID-19 pandemic in the United States by analyzing data collected prospectively from persons with acute respiratory illnesses enrolled in a multistate study during 2018-2022. Persons with previous hybrid work experience were significantly less likely to work onsite on the day before through the first 3 days of illness than those without that experience, an effect more pronounced during the COVID-19 pandemic than during prepandemic influenza seasons. Persons with influenza or COVID-19 were significantly less likely to work onsite than persons with other acute respiratory illnesses. Among persons with positive COVID-19 test results available by the second or third day of illness, few worked onsite. Hybrid and remote work policies might reduce workplace exposures and help reduce spread of respiratory viruses.
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Tartof SY, Xie F, Yadav R, Wernli KJ, Martin ET, Belongia EA, Gaglani M, Zimmerman RK, Talbot HK, Thornburg N, Flannery B. Prior SARS-CoV-2 infection and COVID-19 vaccine effectiveness against outpatient illness during widespread circulation of SARS-CoV-2 Omicron variant, US Flu VE network. Influenza Other Respir Viruses 2023; 17:e13143. [PMID: 37246146 PMCID: PMC10209645 DOI: 10.1111/irv.13143] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Revised: 04/28/2023] [Accepted: 05/03/2023] [Indexed: 05/30/2023] Open
Abstract
BACKGROUND We estimated combined protection conferred by prior SARS-CoV-2 infection and COVID-19 vaccination against COVID-19-associated acute respiratory illness (ARI). METHODS During SARS-CoV-2 Delta (B.1.617.2) and Omicron (B.1.1.529) variant circulation between October 2021 and April 2022, prospectively enrolled adult patients with outpatient ARI had respiratory and filter paper blood specimens collected for SARS-CoV-2 molecular testing and serology. Dried blood spots were tested for immunoglobulin-G antibodies against SARS-CoV-2 nucleocapsid (NP) and spike protein receptor binding domain antigen using a validated multiplex bead assay. Evidence of prior SARS-CoV-2 infection also included documented or self-reported laboratory-confirmed COVID-19. We used documented COVID-19 vaccination status to estimate vaccine effectiveness (VE) by multivariable logistic regression by prior infection status. RESULTS Four hundred fifty-five (29%) of 1577 participants tested positive for SARS-CoV-2 infection at enrollment; 209 (46%) case-patients and 637 (57%) test-negative patients were NP seropositive, had documented previous laboratory-confirmed COVID-19, or self-reported prior infection. Among previously uninfected patients, three-dose VE was 97% (95% confidence interval [CI], 60%-99%) against Delta, but not statistically significant against Omicron. Among previously infected patients, three-dose VE was 57% (CI, 20%-76%) against Omicron; VE against Delta could not be estimated. CONCLUSIONS Three mRNA COVID-19 vaccine doses provided additional protection against SARS-CoV-2 Omicron variant-associated illness among previously infected participants.
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Affiliation(s)
- Sara Y. Tartof
- Department of Research and EvaluationKaiser Permanente Southern CaliforniaPasadenaCaliforniaUSA
- Department of Health Systems ScienceKaiser Permanente Bernard J. Tyson School of MedicinePasadenaCaliforniaUSA
| | - Fagen Xie
- Department of Research and EvaluationKaiser Permanente Southern CaliforniaPasadenaCaliforniaUSA
| | - Ruchi Yadav
- Centers for Disease Control and PreventionAtlantaGeorgiaUSA
| | - Karen J. Wernli
- Kaiser Permanente Washington Health Research InstituteSeattleWashingtonUSA
| | - Emily T. Martin
- University of Michigan School of Public HealthAnn ArborMichiganUSA
| | | | - Manjusha Gaglani
- Baylor Scott & White HealthTempleTexasUSA
- Texas A&M University College of MedicineTempleTexasUSA
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Price AM, Flannery B, Talbot HK, Grijalva CG, Wernli KJ, Phillips CH, Monto AS, Martin ET, Belongia EA, McLean HQ, Gaglani M, Mutnal M, Geffel KM, Nowalk MP, Tartof SY, Florea A, McLean C, Kim SS, Patel MM, Chung JR. Influenza Vaccine Effectiveness Against Influenza A(H3N2)-Related Illness in the United States During the 2021-2022 Influenza Season. Clin Infect Dis 2023; 76:1358-1363. [PMID: 36504336 PMCID: PMC10893961 DOI: 10.1093/cid/ciac941] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Revised: 11/28/2022] [Accepted: 12/08/2022] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND In the United States, influenza activity during the 2021-2022 season was modest and sufficient enough to estimate influenza vaccine effectiveness (VE) for the first time since the beginning of the coronavirus disease 2019 pandemic. We estimated influenza VE against laboratory-confirmed outpatient acute illness caused by predominant A(H3N2) viruses. METHODS Between October 2021 and April 2022, research staff across 7 sites enrolled patients aged ≥6 months seeking outpatient care for acute respiratory illness with cough. Using a test-negative design, we assessed VE against influenza A(H3N2). Due to strong correlation between influenza and severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccination, participants who tested positive for SARS-CoV-2 were excluded from VE estimations. Estimates were adjusted for site, age, month of illness, race/ethnicity, and general health status. RESULTS Among 6260 participants, 468 (7%) tested positive for influenza only, including 440 (94%) for A(H3N2). All 206 sequenced A(H3N2) viruses were characterized as belonging to genetic group 3C.2a1b subclade 2a.2, which has antigenic differences from the 2021-2022 season A(H3N2) vaccine component that belongs to clade 3C.2a1b subclade 2a.1. After excluding 1948 SARS-CoV-2-positive patients, 4312 patients were included in analyses of influenza VE; 2463 (57%) were vaccinated against influenza. Effectiveness against A(H3N2) for all ages was 36% (95% confidence interval, 20%-49%) overall. CONCLUSIONS Influenza vaccination in 2021-2022 provided protection against influenza A(H3N2)-related outpatient visits among young persons.
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Affiliation(s)
- Ashley M Price
- Influenza Division, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Brendan Flannery
- Influenza Division, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - H Keipp Talbot
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Carlos G Grijalva
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Karen J Wernli
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington, USA
| | - C Hallie Phillips
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington, USA
| | - Arnold S Monto
- Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor, Michigan, USA
| | - Emily T Martin
- Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor, Michigan, USA
| | | | | | - Manjusha Gaglani
- Department of Pediatrics, Baylor Scott & White Health, USA
- Department of Medical Education, Texas A&M University College of Medicine, Temple, Texas, USA
| | - Manohar Mutnal
- Department of Pediatrics, Baylor Scott & White Health, USA
- Department of Medical Education, Texas A&M University College of Medicine, Temple, Texas, USA
| | - Krissy Moehling Geffel
- Department of Family Medicine, University of Pittsburgh Schools of the Health Sciences and University of Pittsburgh Medical Center, Pittsburgh, Pannsylvania, USA
| | - Mary Patricia Nowalk
- Department of Family Medicine, University of Pittsburgh Schools of the Health Sciences and University of Pittsburgh Medical Center, Pittsburgh, Pannsylvania, USA
| | - Sara Y Tartof
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
| | - Ana Florea
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
| | - Callie McLean
- Influenza Division, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Sara S Kim
- Influenza Division, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Manish M Patel
- Influenza Division, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Jessie R Chung
- Influenza Division, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
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Shafer L, Ahmed F, Kim S, Wernli KJ, Jackson ML, Nowalk MP, Bear T, Zimmerman RK, Martin ET, Monto AS, Gaglani M, Reis M, Chung JR, Flannery B, Uzicanin A. Relationship between Telework Experience and Presenteeism during COVID-19 Pandemic, United States, March-November 2020. Emerg Infect Dis 2023; 29:278-285. [PMID: 36599411 PMCID: PMC9881775 DOI: 10.3201/eid2902.221014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
Persons with COVID-19-like illnesses are advised to stay home to reduce the spread of SARS-CoV-2. We assessed relationships between telework experience and COVID-19 illness with work attendance when ill. Adults experiencing fever, cough, or loss of taste or smell who sought healthcare or COVID-19 testing in the United States during March-November 2020 were enrolled. Adults with telework experience before illness were more likely to work at all (onsite or remotely) during illness (87.8%) than those with no telework experience (49.9%) (adjusted odds ratio 5.48, 95% CI 3.40-8.83). COVID-19 case-patients were less likely to work onsite (22.1%) than were persons with other acute respiratory illnesses (37.3%) (adjusted odds ratio 0.36, 95% CI 0.24-0.53). Among COVID-19 case-patients with telework experience, only 6.5% worked onsite during illness. Telework experience before illness gave mildly ill workers the option to work and improved compliance with public health recommendations to stay home during illness.
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Tartof SY, Xie F, Yadav R, Wernli KJ, Martin ET, Belongia EA, Gaglani M, Zimmerman RK, Talbot HK, Thornburg N, Flannery B. Prior SARS-CoV-2 Infection and COVID-19 Vaccine Effectiveness against Outpatient Illness during Widespread Circulation of SARS-CoV-2 Omicron Variant, US Flu VE Network. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.01.10.23284397. [PMID: 36711929 PMCID: PMC9882409 DOI: 10.1101/2023.01.10.23284397] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Background We estimated combined protection conferred by prior SARS-CoV-2 infection and COVID-19 vaccination against COVID-19-associated acute respiratory illness (ARI). Methods During SARS-CoV-2 Delta (B.1.617.2) and Omicron (B.1.1.529) variant circulation between October 2021 and April 2022, prospectively enrolled adult patients with outpatient ARI had respiratory and filter paper blood specimens collected for SARS-CoV-2 molecular testing and serology. Dried blood spots were tested for immunoglobulin-G antibodies against SARS-CoV-2 nucleocapsid (NP) and spike protein receptor binding domain antigen using a validated multiplex bead assay. Evidence of prior SARS-CoV-2 infection also included documented or self-reported laboratory-confirmed COVID-19. We used documented COVID-19 vaccination status to estimate vaccine effectiveness (VE) by multivariable logistic regression by prior infection status. Results 455 (29%) of 1577 participants tested positive for SARS-CoV-2 infection at enrollment; 209 (46%) case-patients and 637 (57%) test-negative patients were NP seropositive, had documented previous laboratory-confirmed COVID-19, or self-reported prior infection. Among previously uninfected patients, three-dose VE was 97% (95% confidence interval [CI], 60%- 99%) against Delta, but not statistically significant against Omicron. Among previously infected patients, three-dose VE was 57% (CI, 20%-76%) against Omicron; VE against Delta could not be estimated. Conclusions Three mRNA COVID-19 vaccine doses provided additional protection against SARS-CoV-2 Omicron variant-associated illness among previously infected participants.
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Affiliation(s)
- Sara Y. Tartof
- Kaiser Permanente Southern California, Department of Research & Evaluation,Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA USA
| | - Fagen Xie
- Kaiser Permanente Southern California, Department of Research & Evaluation
| | - Ruchi Yadav
- Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Karen J. Wernli
- Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA USA,Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA
| | - Emily T. Martin
- University of Michigan School of Public Health, Ann Arbor, MI, USA
| | | | - Manjusha Gaglani
- Baylor Scott & White Health, Temple, TX, USA,Texas A&M University College of Medicine, Temple, TX, USA
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Kim SS, Chung JR, Talbot HK, Grijalva CG, Wernli KJ, Kiniry E, Martin ET, Monto AS, Belongia EA, McLean HQ, Gaglani M, Mamawala M, Nowalk MP, Moehling Geffel K, Tartof SY, Florea A, Lee JS, Tenforde MW, Patel MM, Flannery B. Effectiveness of two and three mRNA COVID-19 vaccine doses against Omicron- and Delta-Related outpatient illness among adults, October 2021-February 2022. Influenza Other Respir Viruses 2022; 16:975-985. [PMID: 36825251 PMCID: PMC9353375 DOI: 10.1111/irv.13029] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Revised: 07/19/2022] [Accepted: 07/21/2022] [Indexed: 01/11/2023] Open
Abstract
Background We estimated SARS-CoV-2 Delta- and Omicron-specific effectiveness of two and three mRNA COVID-19 vaccine doses in adults against symptomatic illness in US outpatient settings. Methods Between October 1, 2021, and February 12, 2022, research staff consented and enrolled eligible participants who had fever, cough, or loss of taste or smell and sought outpatient medical care or clinical SARS-CoV-2 testing within 10 days of illness onset. Using the test-negative design, we compared the odds of receiving two or three mRNA COVID-19 vaccine doses among SARS-CoV-2 cases versus controls using logistic regression. Regression models were adjusted for study site, age, onset week, and prior SARS-CoV-2 infection. Vaccine effectiveness (VE) was calculated as (1 - adjusted odds ratio) × 100%. Results Among 3847 participants included for analysis, 574 (32%) of 1775 tested positive for SARS-CoV-2 during the Delta predominant period and 1006 (56%) of 1794 participants tested positive during the Omicron predominant period. When Delta predominated, VE against symptomatic illness in outpatient settings was 63% (95% CI: 51% to 72%) among mRNA two-dose recipients and 96% (95% CI: 93% to 98%) for three-dose recipients. When Omicron predominated, VE was 21% (95% CI: -6% to 41%) among two-dose recipients and 62% (95% CI: 48% to 72%) among three-dose recipients. Conclusions In this adult population, three mRNA COVID-19 vaccine doses provided substantial protection against symptomatic illness in outpatient settings when the Omicron variant became the predominant cause of COVID-19 in the United States. These findings support the recommendation for a third mRNA COVID-19 vaccine dose.
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Affiliation(s)
- Sara S. Kim
- Centers for Disease Control and PreventionAtlantaGeorgiaUSA
| | | | | | | | - Karen J. Wernli
- Kaiser Permanente Washington Health Research InstituteSeattleWashingtonUSA
| | - Erika Kiniry
- Kaiser Permanente Washington Health Research InstituteSeattleWashingtonUSA
| | - Emily T. Martin
- University of Michigan School of Public HealthAnn ArborMichiganUSA
| | - Arnold S. Monto
- University of Michigan School of Public HealthAnn ArborMichiganUSA
| | | | | | - Manjusha Gaglani
- Baylor Scott and White HealthTempleTexasUSA
- Texas A&M University College of MedicineTempleTexasUSA
| | | | | | | | - Sara Y. Tartof
- Kaiser Permanente Southern CaliforniaPasadenaCaliforniaUSA
| | - Ana Florea
- Kaiser Permanente Southern CaliforniaPasadenaCaliforniaUSA
| | - Justin S. Lee
- Centers for Disease Control and PreventionAtlantaGeorgiaUSA
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Chung JR, Kim SS, Belongia EA, McLean HQ, King JP, Nowalk MP, Zimmerman RK, Moehling Geffel K, Martin ET, Monto AS, Lamerato LE, Gaglani M, Hoffman E, Volz M, Jackson ML, Jackson LA, Patel MM, Flannery B. Vaccine effectiveness against COVID-19 among symptomatic persons aged ≥12 years with reported contact with COVID-19 cases, February-September 2021. Influenza Other Respir Viruses 2022; 16:673-679. [PMID: 35170231 PMCID: PMC9111783 DOI: 10.1111/irv.12973] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 01/30/2022] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND Individuals in contact with persons with COVID-19 are at high risk of developing COVID-19; protection offered by COVID-19 vaccines in the context of known exposure is poorly understood. METHODS Symptomatic outpatients aged ≥12 years reporting acute onset of COVID-19-like illness and tested for SARS-CoV-2 between February 1 and September 30, 2021 were enrolled. Participants were stratified by self-report of having known contact with a COVID-19 case in the 14 days prior to illness onset. Vaccine effectiveness was evaluated using the test-negative study design and multivariable logistic regression. RESULTS Among 2229 participants, 283/451 (63%) of those reporting contact and 331/1778 (19%) without known contact tested SARS-CoV-2-positive. Adjusted vaccine effectiveness was 71% (95% confidence interval [CI], 49%-83%) among fully vaccinated participants reporting a known contact versus 80% (95% CI, 72%-86%) among those with no known contact (p-value for interaction = 0.2). CONCLUSIONS This study contributes to growing evidence of the benefits of vaccinations in preventing COVID-19 and support vaccination recommendations and the importance of efforts to increase vaccination coverage.
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Affiliation(s)
| | - Sara S. Kim
- Centers for Disease Control and PreventionAtlantaGeorgiaUSA
| | | | | | | | - Mary Patricia Nowalk
- University of Pittsburgh Schools of the Health Sciences and University of Pittsburgh Medical CenterPittsburghPennsylvaniaUSA
| | - Richard K. Zimmerman
- University of Pittsburgh Schools of the Health Sciences and University of Pittsburgh Medical CenterPittsburghPennsylvaniaUSA
| | - Krissy Moehling Geffel
- University of Pittsburgh Schools of the Health Sciences and University of Pittsburgh Medical CenterPittsburghPennsylvaniaUSA
| | - Emily T. Martin
- School of Public HealthUniversity of MichiganAnn ArborMichiganUSA
| | - Arnold S. Monto
- School of Public HealthUniversity of MichiganAnn ArborMichiganUSA
| | | | - Manjusha Gaglani
- Baylor Scott and White HealthDallasTXUSA
- Texas A&M University College of MedicineTempleTexasUSA
| | | | | | - Michael L. Jackson
- Kaiser Permanente Washington Health Research InstituteSeattleWashingtonUSA
| | - Lisa A. Jackson
- Kaiser Permanente Washington Health Research InstituteSeattleWashingtonUSA
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8
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Struyf T, Deeks JJ, Dinnes J, Takwoingi Y, Davenport C, Leeflang MM, Spijker R, Hooft L, Emperador D, Domen J, Tans A, Janssens S, Wickramasinghe D, Lannoy V, Horn SRA, Van den Bruel A. Signs and symptoms to determine if a patient presenting in primary care or hospital outpatient settings has COVID-19. Cochrane Database Syst Rev 2022; 5:CD013665. [PMID: 35593186 PMCID: PMC9121352 DOI: 10.1002/14651858.cd013665.pub3] [Citation(s) in RCA: 36] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND COVID-19 illness is highly variable, ranging from infection with no symptoms through to pneumonia and life-threatening consequences. Symptoms such as fever, cough, or loss of sense of smell (anosmia) or taste (ageusia), can help flag early on if the disease is present. Such information could be used either to rule out COVID-19 disease, or to identify people who need to go for COVID-19 diagnostic tests. This is the second update of this review, which was first published in 2020. OBJECTIVES To assess the diagnostic accuracy of signs and symptoms to determine if a person presenting in primary care or to hospital outpatient settings, such as the emergency department or dedicated COVID-19 clinics, has COVID-19. SEARCH METHODS We undertook electronic searches up to 10 June 2021 in the University of Bern living search database. In addition, we checked repositories of COVID-19 publications. We used artificial intelligence text analysis to conduct an initial classification of documents. We did not apply any language restrictions. SELECTION CRITERIA Studies were eligible if they included people with clinically suspected COVID-19, or recruited known cases with COVID-19 and also controls without COVID-19 from a single-gate cohort. Studies were eligible when they recruited people presenting to primary care or hospital outpatient settings. Studies that included people who contracted SARS-CoV-2 infection while admitted to hospital were not eligible. The minimum eligible sample size of studies was 10 participants. All signs and symptoms were eligible for this review, including individual signs and symptoms or combinations. We accepted a range of reference standards. DATA COLLECTION AND ANALYSIS Pairs of review authors independently selected all studies, at both title and abstract, and full-text stage. They resolved any disagreements by discussion with a third review author. Two review authors independently extracted data and assessed risk of bias using the QUADAS-2 checklist, and resolved disagreements by discussion with a third review author. Analyses were restricted to prospective studies only. We presented sensitivity and specificity in paired forest plots, in receiver operating characteristic (ROC) space and in dumbbell plots. We estimated summary parameters using a bivariate random-effects meta-analysis whenever five or more primary prospective studies were available, and whenever heterogeneity across studies was deemed acceptable. MAIN RESULTS We identified 90 studies; for this update we focused on the results of 42 prospective studies with 52,608 participants. Prevalence of COVID-19 disease varied from 3.7% to 60.6% with a median of 27.4%. Thirty-five studies were set in emergency departments or outpatient test centres (46,878 participants), three in primary care settings (1230 participants), two in a mixed population of in- and outpatients in a paediatric hospital setting (493 participants), and two overlapping studies in nursing homes (4007 participants). The studies did not clearly distinguish mild COVID-19 disease from COVID-19 pneumonia, so we present the results for both conditions together. Twelve studies had a high risk of bias for selection of participants because they used a high level of preselection to decide whether reverse transcription polymerase chain reaction (RT-PCR) testing was needed, or because they enrolled a non-consecutive sample, or because they excluded individuals while they were part of the study base. We rated 36 of the 42 studies as high risk of bias for the index tests because there was little or no detail on how, by whom and when, the symptoms were measured. For most studies, eligibility for testing was dependent on the local case definition and testing criteria that were in effect at the time of the study, meaning most people who were included in studies had already been referred to health services based on the symptoms that we are evaluating in this review. The applicability of the results of this review iteration improved in comparison with the previous reviews. This version has more studies of people presenting to ambulatory settings, which is where the majority of assessments for COVID-19 take place. Only three studies presented any data on children separately, and only one focused specifically on older adults. We found data on 96 symptoms or combinations of signs and symptoms. Evidence on individual signs as diagnostic tests was rarely reported, so this review reports mainly on the diagnostic value of symptoms. Results were highly variable across studies. Most had very low sensitivity and high specificity. RT-PCR was the most often used reference standard (40/42 studies). Only cough (11 studies) had a summary sensitivity above 50% (62.4%, 95% CI 50.6% to 72.9%)); its specificity was low (45.4%, 95% CI 33.5% to 57.9%)). Presence of fever had a sensitivity of 37.6% (95% CI 23.4% to 54.3%) and a specificity of 75.2% (95% CI 56.3% to 87.8%). The summary positive likelihood ratio of cough was 1.14 (95% CI 1.04 to 1.25) and that of fever 1.52 (95% CI 1.10 to 2.10). Sore throat had a summary positive likelihood ratio of 0.814 (95% CI 0.714 to 0.929), which means that its presence increases the probability of having an infectious disease other than COVID-19. Dyspnoea (12 studies) and fatigue (8 studies) had a sensitivity of 23.3% (95% CI 16.4% to 31.9%) and 40.2% (95% CI 19.4% to 65.1%) respectively. Their specificity was 75.7% (95% CI 65.2% to 83.9%) and 73.6% (95% CI 48.4% to 89.3%). The summary positive likelihood ratio of dyspnoea was 0.96 (95% CI 0.83 to 1.11) and that of fatigue 1.52 (95% CI 1.21 to 1.91), which means that the presence of fatigue slightly increases the probability of having COVID-19. Anosmia alone (7 studies), ageusia alone (5 studies), and anosmia or ageusia (6 studies) had summary sensitivities below 50% but summary specificities over 90%. Anosmia had a summary sensitivity of 26.4% (95% CI 13.8% to 44.6%) and a specificity of 94.2% (95% CI 90.6% to 96.5%). Ageusia had a summary sensitivity of 23.2% (95% CI 10.6% to 43.3%) and a specificity of 92.6% (95% CI 83.1% to 97.0%). Anosmia or ageusia had a summary sensitivity of 39.2% (95% CI 26.5% to 53.6%) and a specificity of 92.1% (95% CI 84.5% to 96.2%). The summary positive likelihood ratios of anosmia alone and anosmia or ageusia were 4.55 (95% CI 3.46 to 5.97) and 4.99 (95% CI 3.22 to 7.75) respectively, which is just below our arbitrary definition of a 'red flag', that is, a positive likelihood ratio of at least 5. The summary positive likelihood ratio of ageusia alone was 3.14 (95% CI 1.79 to 5.51). Twenty-four studies assessed combinations of different signs and symptoms, mostly combining olfactory symptoms. By combining symptoms with other information such as contact or travel history, age, gender, and a local recent case detection rate, some multivariable prediction scores reached a sensitivity as high as 90%. AUTHORS' CONCLUSIONS Most individual symptoms included in this review have poor diagnostic accuracy. Neither absence nor presence of symptoms are accurate enough to rule in or rule out the disease. The presence of anosmia or ageusia may be useful as a red flag for the presence of COVID-19. The presence of cough also supports further testing. There is currently no evidence to support further testing with PCR in any individuals presenting only with upper respiratory symptoms such as sore throat, coryza or rhinorrhoea. Combinations of symptoms with other readily available information such as contact or travel history, or the local recent case detection rate may prove more useful and should be further investigated in an unselected population presenting to primary care or hospital outpatient settings. The diagnostic accuracy of symptoms for COVID-19 is moderate to low and any testing strategy using symptoms as selection mechanism will result in both large numbers of missed cases and large numbers of people requiring testing. Which one of these is minimised, is determined by the goal of COVID-19 testing strategies, that is, controlling the epidemic by isolating every possible case versus identifying those with clinically important disease so that they can be monitored or treated to optimise their prognosis. The former will require a testing strategy that uses very few symptoms as entry criterion for testing, the latter could focus on more specific symptoms such as fever and anosmia.
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Affiliation(s)
- Thomas Struyf
- Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium
| | - Jonathan J Deeks
- Test Evaluation Research Group, Institute of Applied Health Research, University of Birmingham, Birmingham, UK
- NIHR Birmingham Biomedical Research Centre, University Hospitals Birmingham NHS Foundation Trust and University of Birmingham, Birmingham, UK
| | - Jacqueline Dinnes
- Test Evaluation Research Group, Institute of Applied Health Research, University of Birmingham, Birmingham, UK
- NIHR Birmingham Biomedical Research Centre, University Hospitals Birmingham NHS Foundation Trust and University of Birmingham, Birmingham, UK
| | - Yemisi Takwoingi
- Test Evaluation Research Group, Institute of Applied Health Research, University of Birmingham, Birmingham, UK
- NIHR Birmingham Biomedical Research Centre, University Hospitals Birmingham NHS Foundation Trust and University of Birmingham, Birmingham, UK
| | - Clare Davenport
- Test Evaluation Research Group, Institute of Applied Health Research, University of Birmingham, Birmingham, UK
- NIHR Birmingham Biomedical Research Centre, University Hospitals Birmingham NHS Foundation Trust and University of Birmingham, Birmingham, UK
| | - Mariska Mg Leeflang
- Department of Clinical Epidemiology, Biostatistics and Bioinformatics, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, Netherlands
| | - René Spijker
- Medical Library, Amsterdam UMC, University of Amsterdam, Amsterdam Public Health, Amsterdam, Netherlands
- Cochrane Netherlands, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
| | - Lotty Hooft
- Cochrane Netherlands, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
| | | | - Julie Domen
- Department of Primary Care, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
| | - Anouk Tans
- Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium
| | | | | | | | - Sebastiaan R A Horn
- Department of Primary Care, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
| | - Ann Van den Bruel
- Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium
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9
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Kim SS, Chung JR, Belongia EA, McLean HQ, King JP, Nowalk MP, Zimmerman RK, Balasubramani GK, Martin ET, Monto AS, Lamerato LE, Gaglani M, Smith ME, Dunnigan KM, Jackson ML, Jackson LA, Tenforde MW, Verani JR, Kobayashi M, Schrag SJ, Patel MM, Flannery B. Messenger RNA Vaccine Effectiveness Against Coronavirus Disease 2019 Among Symptomatic Outpatients Aged ≥16 Years in the United States, February-May 2021. J Infect Dis 2021; 224:1694-1698. [PMID: 34498052 PMCID: PMC8522410 DOI: 10.1093/infdis/jiab451] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Accepted: 09/07/2021] [Indexed: 01/10/2023] Open
Abstract
Evaluations of vaccine effectiveness (VE) are important to monitor as coronavirus disease 2019 (COVID-19) vaccines are introduced in the general population. Research staff enrolled symptomatic participants seeking outpatient medical care for COVID-19-like illness or severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) testing from a multisite network. VE was evaluated using the test-negative design. Among 236 SARS-CoV-2 nucleic acid amplification test-positive and 576 test-negative participants aged ≥16 years, the VE of messenger RNA vaccines against COVID-19 was 91% (95% confidence interval, 83%-95%) for full vaccination and 75% (55%-87%) for partial vaccination. Vaccination was associated with prevention of most COVID-19 cases among people seeking outpatient medical care.
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Affiliation(s)
- Sara S Kim
- Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Jessie R Chung
- Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | | | - Huong Q McLean
- Marshfield Clinic Research Institute, Marshfield, Wisconsin, USA
| | - Jennifer P King
- Marshfield Clinic Research Institute, Marshfield, Wisconsin, USA
| | - Mary Patricia Nowalk
- University of Pittsburgh Schools of the Health Sciences, Pittsburgh, Pennsylvania, USA
| | - Richard K Zimmerman
- University of Pittsburgh Schools of the Health Sciences, Pittsburgh, Pennsylvania, USA
| | | | | | | | | | - Manjusha Gaglani
- Baylor Scott and White Health
- Texas A&M University College of Medicine, Temple, Texas, USA
| | | | | | - Michael L Jackson
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington, USA
| | - Lisa A Jackson
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington, USA
| | - Mark W Tenforde
- Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | | | - Miwako Kobayashi
- Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | | | - Manish M Patel
- Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Brendan Flannery
- Centers for Disease Control and Prevention, Atlanta, Georgia, USA
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