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Shrestha NK, Burke PC, Nowacki AS, Terpeluk P, Gordon SM. Necessity of Coronavirus Disease 2019 (COVID-19) Vaccination in Persons Who Have Already Had COVID-19. Clin Infect Dis 2022; 75:e662-e671. [PMID: 35028662 PMCID: PMC8807217 DOI: 10.1093/cid/ciac022] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND The aim was to evaluate the necessity of coronavirus disease 2019 (COVID-19) vaccination in persons with prior COVID-19. METHODS Employees of the Cleveland Clinic working in Ohio on 16 December 2020, the day COVID-19 vaccination was started, were included. Anyone who tested positive for COVID-19 at least once before the study start date was considered previously infected. One was considered vaccinated 14 days after receiving the second dose of COVID-19 mRNA vaccine. Cumulative incidences of COVID-19, symptomatic COVID-19, and hospitalizations for COVID-19 were examined over the next year. RESULTS Among 52 238 employees, 4718 (9%) were previously infected and 36 922 (71%) were vaccinated by the study's end. Cumulative incidence of COVID-19 was substantially higher throughout for those previously uninfected who remained unvaccinated than for all other groups, lower for the vaccinated than unvaccinated, and lower for those previously infected than those not. Incidence of COVID-19 increased dramatically in all groups after the Omicron variant emerged. In multivariable Cox proportional hazards regression, both prior COVID-19 and vaccination were independently associated with significantly lower risk of COVID-19. Among previously infected subjects, a lower risk of COVID-19 overall was not demonstrated, but vaccination was associated with a significantly lower risk of symptomatic COVID-19 in both pre-Omicron (HR, .60; 95% CI, .40-.90) and Omicron (HR, .36; 95% CI, .23-.57) phases. CONCLUSIONS Both previous infection and vaccination provide substantial protection against COVID-19. Vaccination of previously infected individuals does not provide additional protection against COVID-19 for several months, but after that provides significant protection at least against symptomatic COVID-19.
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Affiliation(s)
- Nabin K Shrestha
- Department of Infectious Diseases, Cleveland Clinic, Cleveland, Ohio
| | - Patrick C Burke
- Department of Infection Prevention, Cleveland Clinic, Cleveland, Ohio
| | - Amy S Nowacki
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio
| | - Paul Terpeluk
- Department of Occupational Health, Cleveland Clinic, Cleveland, Ohio
| | - Steven M Gordon
- Department of Infectious Diseases, Cleveland Clinic, Cleveland, Ohio
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Shrestha NK, Shrestha P, Burke PC, Nowacki AS, Terpeluk P, Gordon SM. Coronavirus Disease 2019 Vaccine Boosting in Previously Infected or Vaccinated Individuals. Clin Infect Dis 2022; 75:2169-2177. [PMID: 35476018 PMCID: PMC9129118 DOI: 10.1093/cid/ciac327] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Revised: 04/14/2022] [Accepted: 04/21/2022] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND The purpose of this study was to determine whether boosting previously infected or vaccinated individuals with a vaccine developed for an earlier variant of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) protects against the Omicron variant. METHODS Employees of Cleveland Clinic, previously infected with or vaccinated against coronavirus disease 2019 (COVID-19) and working the day the Omicron variant was declared a variant of concern, were included. The cumulative incidence of COVID-19 was examined over 2 months during an Omicron variant surge. Protection provided by boosting was evaluated using Cox proportional hazards regression. Analyses were adjusted for time since proximate SARS-CoV-2 exposure. RESULTS Among 39 766 employees, 8037 (20%) previously infected and the remaining previously vaccinated, COVID-19 occurred in 6230 (16%) during the study. Risk of COVID-19 increased with time since proximate SARS-CoV-2 exposure, and boosting protected those >6 months since prior infection or vaccination. In multivariable analysis, boosting was independently associated with lower risk of COVID-19 among those vaccinated but not previously infected (hazard ratio [HR], .43; 95% confidence interval [CI], .41-.46) as well as those previously infected (HR, .66; 95% CI, .58-.76). Among those previously infected, receipt of 2 compared with 1 dose of vaccine was associated with higher risk of COVID-19 (HR, 1.54; 95% CI, 1.21-1.97). CONCLUSIONS Administering a COVID-19 vaccine not designed for the Omicron variant >6 months after prior infection or vaccination protects against Omicron variant infection. There is no advantage to administering more than 1 dose of vaccine to previously infected persons.
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Affiliation(s)
- Nabin K. Shrestha
- Department of Infectious Diseases, Cleveland Clinic, Cleveland, Ohio, USA,Correspondence: N. K. Shrestha, 9500 Euclid Avenue/G-21, Cleveland, OH 44195, USA ()
| | - Priyanka Shrestha
- Department of Computer Science, Stanford University, Palo Alto, California, USA
| | - Patrick C. Burke
- Department of Infection Prevention, Cleveland Clinic, Cleveland, Ohio, USA
| | - Amy S. Nowacki
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio, USA
| | - Paul Terpeluk
- Department of Occupational Health, Cleveland Clinic, Cleveland, Ohio, USA
| | - Steven M. Gordon
- Department of Infectious Diseases, Cleveland Clinic, Cleveland, Ohio, USA
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Shrestha NK, Marco Canosa F, Nowacki AS, Procop GW, Vogel S, Fraser TG, Erzurum SC, Terpeluk P, Gordon SM. Distribution of Transmission Potential During Nonsevere COVID-19 Illness. Clin Infect Dis 2021; 71:2927-2932. [PMID: 32594116 PMCID: PMC7337652 DOI: 10.1093/cid/ciaa886] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 06/23/2020] [Indexed: 12/20/2022] Open
Abstract
Background Patients recovering from coronavirus disease 2019 (COVID-19) often continue to test positive for the causative virus by polymerase chain reaction (PCR) even after clinical recovery, thereby complicating return-to-work plans. The purpose of this study was to evaluate transmission potential of COVID-19 by examining viral load with respect to time. Methods Health care personnel (HCP) at Cleveland Clinic diagnosed with COVID-19, who recovered without needing hospitalization, were identified. Threshold cycles (Ct) for positive PCR tests were obtained and viral loads calculated. The association of viral load with days since symptom onset was examined in a multivariable regression model, which was reduced by stepwise backward selection to only keep variables significant at a level of .05. Viral loads by day since symptom onset were predicted using the model and transmission potential evaluated by examination of a viral load-time curve. Results Over 6 weeks, 230 HCP had 528 tests performed. Viral loads declined by orders of magnitude within a few days of symptom onset. The only variable significantly associated with viral load was time since onset of symptoms. Of the area under the curve (AUC) spanning symptom onset to 30 days, 96.9% lay within the first 7 days, and 99.7% within 10 days. Findings were very similar when validated using split-sample and 10-fold cross-validation. Conclusions Among patients with nonsevere COVID-19, viral loads in upper respiratory specimens peak by 2 or 3 days from symptom onset and decrease rapidly thereafter. The vast majority of the viral load-time AUC lies within 10 days of symptom onset.
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Affiliation(s)
- Nabin K Shrestha
- Department of Infectious Diseases, Cleveland Clinic, Cleveland, Ohio, USA
| | | | - Amy S Nowacki
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio, USA
| | - Gary W Procop
- Department of Pathology and Laboratory Medicine, Cleveland Clinic, Cleveland, Ohio, USA
| | - Sherilynn Vogel
- Department of Pathology and Laboratory Medicine, Cleveland Clinic, Cleveland, Ohio, USA
| | - Thomas G Fraser
- Department of Infectious Diseases, Cleveland Clinic, Cleveland, Ohio, USA
| | - Serpil C Erzurum
- Department of Pulmonary Medicine, Cleveland Clinic, Cleveland, Ohio, USA
| | - Paul Terpeluk
- Department of Occupational Health, Cleveland Clinic, Cleveland, Ohio, USA
| | - Steven M Gordon
- Department of Infectious Diseases, Cleveland Clinic, Cleveland, Ohio, USA
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Misra-Hebert AD, Jehi L, Ji X, Nowacki AS, Gordon S, Terpeluk P, Chung MK, Mehra R, Dell KM, Pennell N, Hamilton A, Milinovich A, Kattan MW, Young JB. Impact of the COVID-19 Pandemic on Healthcare Workers' Risk of Infection and Outcomes in a Large, Integrated Health System. J Gen Intern Med 2020; 35:3293-3301. [PMID: 32875500 PMCID: PMC7462108 DOI: 10.1007/s11606-020-06171-9] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2020] [Accepted: 08/17/2020] [Indexed: 01/10/2023]
Abstract
BACKGROUND Understanding the impact of the COVID-19 pandemic on healthcare workers (HCW) is crucial. OBJECTIVE Utilizing a health system COVID-19 research registry, we assessed HCW risk for COVID-19 infection, hospitalization, and intensive care unit (ICU) admission. DESIGN Retrospective cohort study with overlap propensity score weighting. PARTICIPANTS Individuals tested for SARS-CoV-2 infection in a large academic healthcare system (N = 72,909) from March 8-June 9, 2020, stratified by HCW and patient-facing status. MAIN MEASURES SARS-CoV-2 test result, hospitalization, and ICU admission for COVID-19 infection. KEY RESULTS Of 72,909 individuals tested, 9.0% (551) of 6145 HCW tested positive for SARS-CoV-2 compared to 6.5% (4353) of 66,764 non-HCW. The HCW were younger than the non-HCW (median age 39.7 vs. 57.5, p < 0.001) with more females (proportion of males 21.5 vs. 44.9%, p < 0.001), higher reporting of COVID-19 exposure (72 vs. 17%, p < 0.001), and fewer comorbidities. However, the overlap propensity score weighted proportions were 8.9 vs. 7.7 for HCW vs. non-HCW having a positive test with weighted odds ratio (OR) 1.17, 95% confidence interval (CI) 0.99-1.38. Among those testing positive, weighted proportions for hospitalization were 7.4 vs. 15.9 for HCW vs. non-HCW with OR of 0.42 (CI 0.26-0.66) and for ICU admission: 2.2 vs. 4.5 for HCW vs. non-HCW with OR of 0.48 (CI 0.20-1.04). Those HCW identified as patient facing compared to not had increased odds of a positive SARS-CoV-2 test (OR 1.60, CI 1.08-2.39, proportions 8.6 vs. 5.5), but no statistically significant increase in hospitalization (OR 0.88, CI 0.20-3.66, proportions 10.2 vs. 11.4) and ICU admission (OR 0.34, CI 0.01-3.97, proportions 1.8 vs. 5.2). CONCLUSIONS In a large healthcare system, HCW had similar odds for testing SARS-CoV-2 positive, but lower odds of hospitalization compared to non-HCW. Patient-facing HCW had higher odds of a positive test. These results are key to understanding HCW risk mitigation during the COVID-19 pandemic.
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Affiliation(s)
- Anita D Misra-Hebert
- Department of Internal Medicine, Cleveland Clinic, Cleveland, OH, USA.
- Healthcare Delivery and Implementation Science Center, Cleveland Clinic, Cleveland, OH, USA.
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, USA.
| | - Lara Jehi
- Department of Neurology, Cleveland Clinic, Cleveland, OH, USA
- Information Technology Division Administration, Cleveland Clinic, Cleveland, OH, USA
| | - Xinge Ji
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, USA
| | - Amy S Nowacki
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, USA
| | - Steven Gordon
- Department of Infectious Disease, Cleveland Clinic, Cleveland, OH, USA
| | - Paul Terpeluk
- Department of Occupational Health, Cleveland Clinic, Cleveland, OH, USA
| | - Mina K Chung
- Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Reena Mehra
- Sleep Disorders Center, Cleveland Clinic, Cleveland, OH, USA
| | - Katherine M Dell
- Center for Pediatric Nephrology, Cleveland Clinic Children's Hospital, Cleveland, OH, USA
| | - Nathan Pennell
- Department of Hematology and Oncology, Cleveland Clinic, Cleveland, OH, USA
| | - Aaron Hamilton
- Department of Hospital Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Alex Milinovich
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, USA
| | - Michael W Kattan
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, USA
| | - James B Young
- Healthcare Delivery and Implementation Science Center, Cleveland Clinic, Cleveland, OH, USA
- Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, OH, USA
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Misra-Hebert AD, Jehi L, Ji X, Nowacki AS, Gordon S, Terpeluk P, Chung MK, Mehra R, Dell KM, Pennell N, Hamilton A, Milinovich A, Kattan MW, Young JB. Impact of the COVID-19 pandemic on healthcare workers risk of infection and outcomes in a large, integrated health system. Res Sq 2020:rs.3.rs-61235. [PMID: 32839766 PMCID: PMC7444292 DOI: 10.21203/rs.3.rs-61235/v1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Background: Understanding the impact of the COVID-19 pandemic on healthcare workers (HCW) is crucial. Objective: Utilizing a health system COVID-19 research registry, we assessed HCW risk for COVID-19 infection, hospitalization and intensive care unit (ICU) admission. Design: Retrospective cohort study with overlap propensity score weighting. Participants: Individuals tested for SARS-CoV-2 infection in a large academic healthcare system (N=72,909) from March 8-June 9 2020 stratified by HCW and patient-facing status. Main Measures: SARS-CoV-2 test result, hospitalization, and ICU admission for COVID-19 infection. Key Results: Of 72,909 individuals tested, 9.0% (551) of 6,145 HCW tested positive for SARS-CoV-2 compared to 6.5% (4353) of 66,764 non-HCW. The HCW were younger than non-HCW (median age 39.7 vs. 57.5, p<0.001) with more females (proportion of males 21.5 vs. 44.9%, p<0.001), higher reporting of COVID-19 exposure (72 vs. 17 %, p<0.001) and fewer comorbidities. However, the overlap propensity score weighted proportions were 8.9 vs. 7.7 for HCW vs. non-HCW having a positive test with weighted odds ratio (OR) 1.17, 95% confidence interval (CI) 0.99-1.38. Among those testing positive, weighted proportions for hospitalization were 7.4 vs.15.9 for HCW vs. non-HCW with OR of 0.42 (CI 0.26-0.66) and for ICU admission: 2.2 vs.4.5 for HCW vs. non-HCW with OR of 0.48 (CI 0.20 -1.04). Those HCW identified as patient-facing compared to not had increased odds of a positive SARS-CoV-2 test (OR 1.60, CI 1.08-2.39, proportions 8.6 vs. 5.5), but no statistically significant increase in hospitalization (OR 0.88, CI 0.20-3.66, proportions 10.2 vs. 11.4) and ICU admission (OR 0.34, CI 0.01-3.97, proportions 1.8 vs. 5.2). Conclusions: In a large healthcare system, HCW had similar odds for testing SARS-CoV-2 positive, but lower odds of hospitalization compared to non-HCW. Patient-facing HCW had higher odds of a positive test. These results are key to understanding HCW risk mitigation during the COVID-19 pandemic.
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Terpeluk P, Rogen B, Gilliam T. Medical and Pharmacy Costs for New Hire Nurses Following a Physical Strength Evaluation Screening in a Large Health System. Workplace Health Saf 2016; 64:420-5. [PMID: 26787671 DOI: 10.1177/2165079915621317] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Nurses often encounter situations that require lifting patients, often using awkward body positions. Hiring nurses with strength suitable for these jobs decreases nurses' risk for illness and injury and would be expected to result in more appropriate and lower health care, pharmacy, and disability costs. The physical strength of new hire nurse applicants was assessed using a defensible isokinetic evaluation in the years 2011 and 2012. Health care and pharmacy costs were monitored for the first 12 months following date of hire and compared with costs for nurses hired without screening during the prior 2 years (2009 and 2010). The strength assessment group had significantly (p < .05) lower health care and pharmacy costs per member per month (PMPM) compared with the comparison group. The study suggests that use of physical capability strength assessment is effective in hiring nurses with appropriate strength capability, resulting in significant health care and pharmacy cost avoidance.
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Miranda C, Yen-Lieberman B, Terpeluk P, Tomford JW, Gordon S. Reducing the Rates of Indeterminate Results of the QuantiFERON-TB Gold In-Tube Test During Routine Preemployment Screening for Latent Tuberculosis Infection Among Healthcare Personnel. Infect Control Hosp Epidemiol 2015; 30:296-8. [PMID: 19199532 DOI: 10.1086/595732] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
We implemented the QuantiFERON-TB Gold (QFT-G) In-Tube test to identify latent tuberculosis infection among potential employees prior to employment. The rates of indeterminate QFT-G In-Tube test results were higher than expected and prompted an investigation that led to successful interventions (eg, manual vortexing before incubation and the use of a modified in-tube method). The tracking of indeterminate results is suggested as an important quality control measure.
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Affiliation(s)
- Cyndee Miranda
- Department of Infectious Disease, Cleveland Clinic, Cleveland, Ohio, USA.
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Daley CL, Reves RR, Beard MA, Boyle J, Clark RB, Beebe JL, Catanzaro A, Chen L, Desmond E, Dorman SE, Hudson TW, Lardizabal AA, Kapoor H, Marder DC, Miranda C, Narita M, Reichman L, Schwab D, Seaworth BJ, Terpeluk P, Thanassi W, Kawamura LM. A Summary of Meeting Proceedings on Addressing Variability around the Cut Point in Serial Interferon-γ Release Assay Testing. Infect Control Hosp Epidemiol 2015; 34:625-30. [DOI: 10.1086/670635] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
On June 13, 2012, a group of key stakeholders, leaders, and national experts on tuberculosis (TB), occupational health, and laboratory science met in Atlanta, Georgia, to focus national discussion on the higher than expected positive results occurring among low-risk, unexposed healthcare workers undergoing serial testing with interferon-γ release assays (IGRAs). The objectives of the meeting were to present the latest clinical and operational research findings on the topic, to discuss evaluation and treatment algorithms that are emerging in the absence of national guidance, and to develop a consensus on the action steps needed to assist programs and physicians in the interpretation of serial testing IGRA results. This report summarizes its proceedings.
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Sahni R, Miranda C, Yen-Lieberman B, Tomford JW, Terpeluk P, Quartey P, Johnson LT, Gordon SM. Does the Implementation of an Interferon-γ Release Assay in Lieu of a Tuberculin Skin Test Increase Acceptance of Preventive Therapy for Latent Tuberculosis Among Healthcare Workers? Infect Control Hosp Epidemiol 2015; 30:197-9. [DOI: 10.1086/593965] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Fraser TG, Kowalczyk J, Schmitt S, Bernstein J, Terpeluk P, Tomford JW, Gordon SM. Active Tuberculosis in a Healthcare Worker: Are You Ready? Infect Control Hosp Epidemiol 2015; 30:80-2. [DOI: 10.1086/592706] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
We describe a healthcare worker with a previously positive tuberculin skin test result who developed active tuberculosis. An investigation revealed 280 potential contacts, 3 of whom had positive tuberculin skin test results. Our experience demonstrates the potential benefits of therapy for latent tuberculosis infection as a component of a tuberculosis-control program.
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