COVID IgG confusion...

[Monte]

Hello,

I'm an urgent care PA in Massachusetts. My workplace just got IgG availability and I'm honestly lost on its worth for the average patient.

My medical director set the protocol as anyone without symptoms in the last 2 weeks are eligible.

I'm looking for thoughts on this mass testing to rack up the bills versus testing certain situations? 

Thank you!

 

 

*edited with current protocol.

Edited May 8, 2020 by Monte

[Mayamom]

This test is going to be a huge $$ maker.  No doubt.  Everybody wants to know if they are immune so they can relax on the restrictions I suppose.  My question how long does the natural immunity last?   Not sure we know that answer currently.  When the vaccine comes out in 12-18 months do you need a booster?  

[Cideous]

2 hours ago, Mayamom said:

This test is going to be a huge $$ maker.  No doubt.  Everybody wants to know if they are immune so they can relax on the restrictions I suppose.  My question how long does the natural immunity last?   Not sure we know that answer currently.  When the vaccine comes out in 12-18 months do you need a booster?  

We still have no definitive evidence that we as a species will actually develop immunity even after infected. Just because you have antibodies doesn't mean you can't or won't get it again.

Edited May 2, 2020 by Cideous

[GetMeOuttaThisMess]

The value of the IgG is relevant only to show evidence of past exposure within an as of yet undetermined time window.  Everyone wants to push the envelope and have all their answers yesterday, which is understandable.  The problem is we need TIME to separate this all out.  Let's ask another question.  Let's assume that a decision is made determining that prior IgG antibody response implies lifetime immunity but someone down the line screens you again and you don't have IgG measured antibodies.  Now what?  Well, we don't have to look far for our answer.  Therapeutic range HbsAb (quantitative, not qualitative) titer is measured six months after completing your Hep B series (not recommended though many healthcare entities require it).  Five years down the road you have an exposure and an employee health nurse who has no clue what the guidelines are for the need for revaccination repeats your HbsAb screen and behold you have no measurable antibodies and recommends another series of three.  Noooooooo.  Current guidelines say there is no need to do anything (hard to do nothing).

Bottom line, we don't have an answer.  I refer back to my simple mind and a simple question I always used to ask myself, "Will the test result alter treatment of the patient?"  If no, it typically doesn't matter.  In this case, it would be relevant from a universal monitoring perspective IF someone is doing a protocol established study.  If not, and some yahoo just wants to know, it's a waste of time and money with what we know today.

[Monte]

Thank you three for responding! I completely agree that because of its limitations,  it's main use (for UC) seems like creating a $300-400 billed urgent care visit for no real answers...? I just wanted to see how others felt.

2 hours ago, GetMeOuttaThisMess said:

 

Bottom line, we don't have an answer.  I refer back to my simple mind and a simple question I always used to ask myself, "Will the test result alter treatment of the patient?"  If no, it typically doesn't matter.  In this case, it would be relevant from a universal monitoring perspective IF someone is doing a protocol established study.  If not, and some yahoo just wants to know, it's a waste of time and money with what we know today.

 This seems to sum it up pretty well. Still open to any other thoughts. The worst part about this personally is that when asymptomatic patients come in to be tested with IgG, I still have to do a full visit on them 

[ventana]

Hold on. 
 

please look at this he quality of he tests.    They stink. 
not only are you collection money for no reason, you are likely dealing with a test “maybe” with sensitivity and specificity in the low 80% or possibly worse

 

these tests should not be used clinically till we get a handle on them.  20% false positive and false negative is horrible.  
 

as for the data.  Look at the PI. Google the test.  
 

it is the wild Wild West out there for AB testing for covid and we owe our patients better

 

[EMEDPA]

On 5/2/2020 at 7:20 AM, Cideous said:

We still have no definitive evidence that we as a species will actually develop immunity even after infected. Just because you have antibodies doesn't mean you can't or won't get it again.

but if you got it before and didn't know, you will probably survive your next exposure. that isn't to say you won't be a carrier...

[JTATC]

I have a handful of friends, including some PA students that are going out and paying cash to get one of these antibody tests, just to find out if they probably had it at some point. But without knowing if antibodies actually confer lasting immunity, how long it lasts for, or what a positive titre is the test is useless. Not to mention the test quality seems to be poor as ventana stated. If I have a chance to get drawn as part of a study, sure, that could satisfy my curiosity and help us learn more about this thing. But paying big bucks to a private lab to get results that don't really mean anything... I don't get it.

[Mayamom]

9 hours ago, ventana said:

please look at this he quality of he tests.    They stink. 
not only are you collection money for no reason, you are likely dealing with a test “maybe” with sensitivity and specificity in the low 80% or possibly worse

Urgent care don't seem to care.  Its all about the $$$$

[Boatswain2PA]

The business of medicine is to make money.  It ain't right, but it's the way it is (especially in UC).

Is there an IgG test that is specific to COVID-19?  The ones I have looked up all say a positive test doesn't necessarily mean you had SARS-Cov-2, but could have instead infected with several other coronavirus strains (that are common).

[WeBuyAndSellJunk]

There are more reasonable tests on the market. Tests with sensitivities and specificities in the high 90s. That still results in a lot of false positives with such low seroprevalence, but you simply need to just repeat the test twice (not unlike HIV testing). We also effectively have no specific treatment and thus some immune response is obviously occurring to allow people to have disease resolution. The most likely situation is that immunity last 2-4 years, like other corona viruses. Sure, that isn’t to say that these specific antibodies are the ones that indicate immunity, but a test where antibody generation is corresponding temporally with prior PCR positive testing is likely to be accurate. The real issue is the roll out to the public. This should go to front line workers first, with the knowledge that they may be a false positive or still have some amount of risk. Even that amount of possible risk mitigation (I.e., I am potentially immune) could go a long way for me feeling safe taking care of regular old non-COVID people. 

Edited May 5, 2020 by printer2100

[rev ronin]

On 5/3/2020 at 10:12 PM, JTATC said:

But paying big bucks to a private lab to get results that don't really mean anything... I don't get it.

https://en.wikipedia.org/wiki/Kübler-Ross_model

I think it's under "Bargaining" somewhere.

[Monte]

Just to follow up on this.. Still testing approximately 20-30 people per day at my urgent care with IgG. The medical director set protocol as anyone without symptoms in the last 2 weeks can be tested. If I hadn't just started this job I'd be more inclined to not order it but... so yeah this is a waste of time and money.

Edited May 8, 2020 by Monte

[Lucy199]

@Monte I just finished a shift in the ed, in mass, and one of the docs works primarily at an UC that does serum antibody testing...... Something absolutely mind-blowing, is that if you test positive for IgG, you are "required" to quarantine for 14 days by the state of Massachusetts (DPH)..... I asked, "but if you're not testing anyone for 14 days since day 1 of being asymptomatic, why would you need to quarantine?".... and he had no answer... so, with that in mind, make sure you have nothing going on for 14 days if you get tested as the DPH is following up with people and are getting involved...... ( and please, this came straight from my attending's mouth, but if anyone has a more updated, factual response to that feel free to let us know)

I understand that IgM transfers to IgG around day 7-14 and so on, but what about the person who was sick in early march and just wants to know? a positve IgG means you have to stay out of work for 2 weeks...makes no sense

[Mayamom]

9 hours ago, Lucy199 said:

Something absolutely mind-blowing, is that if you test positive for IgG, you are "required" to quarantine for 14 days by the state of Massachusetts (DPH)..

What???  I live in Mass had not heard this.  

[Monte]

@Lucy199 Can't say I've heard this.. wish I could find something on it. 

Edited May 9, 2020 by Monte

[kargiver]

On 5/8/2020 at 10:36 PM, Lucy199 said:

@Monte I just finished a shift in the ed, in mass, and one of the docs works primarily at an UC that does serum antibody testing...... Something absolutely mind-blowing, is that if you test positive for IgG, you are "required" to quarantine for 14 days by the state of Massachusetts (DPH)..... I asked, "but if you're not testing anyone for 14 days since day 1 of being asymptomatic, why would you need to quarantine?".... and he had no answer... so, with that in mind, make sure you have nothing going on for 14 days if you get tested as the DPH is following up with people and are getting involved...... ( and please, this came straight from my attending's mouth, but if anyone has a more updated, factual response to that feel free to let us know)

I understand that IgM transfers to IgG around day 7-14 and so on, but what about the person who was sick in early march and just wants to know? a positve IgG means you have to stay out of work for 2 weeks...makes no sense

I'd like to see the DPH policy on this... as it makes absolutely no sense, epidemiologically, immunologically, or clinically.

G