
Using water to treat prostates; back-to-school COVID outlook; rapid home tests: Upstate Medical University's HealthLink on Air for Sunday, Sept. 4, 2022
Urologist Hanan Goldberg, MD, explains aquablation treatment for enlarged prostates. Pediatric infectious disease specialist Joe Domachowske, MD, provides COVID guidelines for kids returning to school. And public health professor Chris Morley, PhD, discusses the reliability of home (rapid antigen) tests for COVID.
Transcript
Host Amber Smith: Coming up next on Upstate's "HealthLink on Air," a urologist explains how he uses water to treat enlarged prostates.
Hanan Goldberg, MD: ... the water actually completely ablates, completely resects, the tissue. It is all removed completely because the water jet is so strong. ...
Host Amber Smith: A pediatric infectious disease doctor gives advice about protecting kids from COVID at school.
Joe Domachowske, MD: ... keeping our vaccination status up to date, staying home when we're sick, good hand hygiene, keeping our respiratory etiquette as careful as we can, given the age groups that we're talking about ...
Host Amber Smith: And a public health professor discusses the reliability of rapid antigen tests.
Chris Morley, PhD: ... basically, what you need is, you need enough virus to be detectable. So the antigen tests work when you have a fairly, relatively high viral load. ...
Host Amber Smith: All that, and a visit from "The Healing Muse," coming up after the news.
This is Upstate Medical University's "HealthLink on Air," your chance to explore health, science and medicine with the experts from Central New York's only academic medical center. I'm your host, Amber Smith. On this week's show, we learn how best to protect students from COVID as they head back to school. Then we hear about new guidelines for using rapid antigen tests. But first, a urologist offers a new way of treating enlarged prostates -- using water.
From Upstate Medical University in Syracuse, New York, I'm Amber Smith. This is "HealthLink on Air."
Men with enlarged prostates have a variety of treatment options, including medication and surgery. And now a urologist at Upstate is offering one more option. It's called aquablation. And here with me to explain how it works is Dr. Hanan Goldberg. Dr. Goldberg is an assistant professor of urology at Upstate. Welcome back to "HealthLink on Air," Dr. Goldberg.
Hanan Goldberg, MD: Thank you. Thanks so much for having me.
Host Amber Smith: So what is aquablation?
Hanan Goldberg, MD: Aquablation is a relatively new procedure and part of the many procedures that are today available for the treatment of what we call BPH or benign prostatic hyperplasia, benign prostatic enlargement, which basically means enlargement of the prostate that happens to all men with age.
As a result of that, men suffer from lower urinary tract symptoms, frequency, urgency, weak stream, trouble emptying their bladder. And that is all mostly because of the prostate being enlarged and obstructing their urethra, obstructing their bladder from emptying completely. And that's one of the procedures that is now available to treat BPH.
BPH procedures are usually divided into resective procedures and nonresective procedures, which means either we cut the tissue, or we do something that pushes the tissue aside. So that is the nonresective tissue. Aquablation is part of the resective tissue because tissue is actually being cut.
What we do in this specific procedure, it's a minimally invasive procedure. There's no incisions. We don't open the abdomen. There's no surgical incisions or anything like that. We go in through the urethra, through the natural orifices, and basically it uses a free water jet controlled by robotic technology to remove prostate tissue and create a channel that men can empty their bladder.
Host Amber Smith: So this is for someone whose prostate has enlarged to the point where they're having symptoms that are making their life difficult.
Hanan Goldberg, MD: Correct.
Host Amber Smith: Is the procedure painful?
Hanan Goldberg, MD: So the procedure is done in the hospital, under general anesthesia. The patient is completely asleep. He doesn't feel anything. He doesn't remember anything. It takes approximately one hour, give or take, and the patient wakes up, once the procedure is done, with a catheter, which is a tube going inside through the urethra, into the bladder and draining his urine. And the reason we put in a catheter is because it allows the urethra and the prostate bed, where the surgery was performed, to heal faster.
Catheter is usually in anywhere between one to three days. And patients usually stay one night in the hospital. And the next morning they go home with, or without, a catheter, depending on the surgeon, depending on the procedure. But the catheter, as I said, usually is removed within one to three days after the procedure.
Host Amber Smith: Now, you were describing how water is used. Does the water push the tissue out of the way, or does it do something to remove the tissue?
Hanan Goldberg, MD: So this is a high water jet that is emanating from a robotic probe that goes inside through the prostate, and the water actually completely ablates, completely resects, the tissue, and it actually completely makes it disappear. It is all removed completely because the water jet is so strong.
It is actually used in the metal industry to cut metal. So, we of course do this in a very accurate manner. And part of the advantages of this procedure is that we use both a camera that goes in through the urethra that is called a cystoscope, but we also use an ultrasound probe that goes through the rectum during the procedure. So we have two methods to actually view the prostate.
And the way the procedure is done is that we plan, before the actual surgery takes place, during the procedure, there is a planning phase where we actually can pinpoint exactly where we want the robotic arm that has the water jet coming from it, where we want that water jet to hit and what kind of tissue we want to destroy. And that's using the ultrasound that is in place during the procedure.
Host Amber Smith: How new is this procedure? How long has it been FDA (Food and Drug Administration) approved and in use?
Hanan Goldberg, MD: I think FDA approved it approximately two to three years ago, if I remember correctly.
And there's been some studies done on this, actually many studies, already. When I looked a few days ago, I think more than 140 studies have already been done on aquablation procedure. There's been a randomized, controlled study that has actually compared aquablation to the gold-standard procedure, which is called the TURP, the transurethral resection of prostate, which, that procedure's been around for, I don't know, 50, 60 years, something like that.
That is the gold-standard procedure that we compare it to. That is also a minimally invasive procedure, but it uses electricity to cut tissue. And the randomized study that was done that was comparing aquablation to the TURP procedure was done in men with prostates ranging between 30 to 80 grams, which is the majority of men.
And it was shown that this procedure is as effective as a TURP, if not even more, with less side effects, so that is the great advantage of this procedure.
Host Amber Smith: After the procedure, have you created a new, second channel for urine, or is it the same channel, that you've just replaced the original channel?
Hanan Goldberg, MD: Good question. It's the same channel. It's not a new channel, but basically what happened to the old channel is that prostate tissue has grown, and pretty much obstructed, that channel. And then it's very difficult for the bladder to empty urine. And what we do is, basically, we remove that obstruction in the same channel, allowing the bladder to have the old open channel that it was used to when the man was younger.
Host Amber Smith: This is Upstate's "HealthLink on Air," with your host, Amber Smith. I'm talking with urologist Dr. Hanan Goldberg about a new procedure called aquablation for men who have enlarged prostates.
What type of patient is the best candidate for this procedure?
Hanan Goldberg, MD: The good thing about this procedure is that, as people might know, we are all different, and we all come in different shapes and sizes, and we all have a different prostate size.
Some of us have small prostates, some of us have very big prostates, and also the shape of the prostate is very different, and that really does affect what kind of surgical intervention and what kind of treatment we can offer men. But one of the many advantages of aquablation is that this is pretty much appropriate and suitable for any kind of prostate, any size, any shape. There's reports of this being done on prostates as small as 30 grams and prostates as big as 300 grams, so that's why any man with any kind of prostate is basically an appropriate candidate for this procedure.
Host Amber Smith: Does it matter if the man had tried medications before the procedure, or if he'd had another procedure before?
Hanan Goldberg, MD: So a lot of the men that we actually see are men that have previously been treated with some sort of modality, whether it's medications, which is probably the most common one, or some kind of previous intervention, and again, aquablation is a suitable treatment for these men. This could be the first treatment that you're receiving. This could be a treatment that you're receiving after you have failed another treatment, such as medications, such as UroLift, such as HoLEP (those are other surgical procedures), or any other surgery that is available today for men with BPH.
Host Amber Smith: Are there any conditions that would prevent someone from having this procedure done?
Hanan Goldberg, MD: Men who take anticoagulation medications and have some kind of contraindication and cannot stop it, that is a clear contraindication for this procedure.
Of course, if someone is too sick, and we cannot put him to sleep because we need to use anesthesia for this, of course this is also not something that I would offer that patient, but the percentage of these men is usually very, very small.
Host Amber Smith: You talked about planning that gets done before the procedure. What involves the patient, or is there any testing that the patient would go through?
Hanan Goldberg, MD: No. The planning phase is done while the patient is already asleep. That is actually the part of the procedure that takes the longest, because this is done while the patient is already asleep.
He's lying down, the ultrasound probe is already inside him, in the rectum, and the camera port, the cystoscope, is already inside the urethra. And basically we use the ultrasound to map the prostate exactly where we want the water jet to cut. And that is why it is so accurate, because we can actually control where we cut more, where we cut less, to preserve different organs, different areas that we know are important for later function, whether it's sexual function or whether it's urinary function.
For instance, the bladder neck, which we know that is the area where the prostate connects to the bladder itself, we try to preserve the bladder neck as much as we can, because we know that has a function in incontinence and in controlling your urine and not leaking.
And that is also important for ejaculation, for sexual function. So with the aquablation, we can actually pinpoint, and completely decide, how deep the water jet goes, how strong the water jet is. And that way we can basically do a whole plan of the prostate, and we know exactly what is being cut, how deep and how strong the water jet will be.
Host Amber Smith: What are the potential complications?
Hanan Goldberg, MD: Like any other procedure that is a resective procedure for BPH, we always talk about incontinence, and we always talk about erectile dysfunction, and we always talk about what we call retrograde ejaculation, which basically means that the ejaculate ... it's not that it doesn't exist anymore, but instead of going forward, it actually goes backward -- that's why it's called a retrograde -- goes inside the bladder. And it's diluted in the urine, and then the man just voids (urinates) it out.
So I would say, according to the data that we have, including the randomized studies that were done on aquablation, the erectile dysfunction and incontinence rate are zero, basically. It just doesn't exist. The retrograde ejaculation, I would say anywhere between 15% to 30%, that can happen, which is lower than the TURP procedure, which is, again, the gold standard, which we compare this procedure to, and that is something that we always consult our patients and let them know.
It's important to know that although ejaculation is very important to most men, it has medical significance only if you are trying to bring children. If you are not trying to bring children, this really does not have any kind of effect on the man. And most men that we do this on, as you can imagine, bringing children is not part of their agenda at this point.
But it is important for a lot of men, and we do counsel them that it can happen, and anywhere between 15% to 30%, which is, again, better than most other procedures.
Host Amber Smith: Now, you already said that it usually comes with an overnight hospital stay, and the man wakes up from the procedure with a catheter that may stay in for one to three days. Beyond that, are there any other guidelines that you want to make men aware of for during the recovery?
Hanan Goldberg, MD: Yes. So, it's important to note that the reason we keep them overnight is not because we are doing anything, but what happens is that, as I said, they wake up with a catheter, and they have irrigation to the bladder, which means that there's water flowing in through the catheter and actually coming out through the catheter, and the goal of that water, that irrigation, is basically to clear all pieces that might have been left, to clear any blood, any clots that might have been left. And that allows us to monitor the color of the urine for at least 24 hours after the procedure and make sure that before the patient goes home, his urine is in a satisfactory color, and he's not bleeding.
And that way we know that at least he's been observed for 24 hours, and his urine is getting back to normal color. What happens after we remove the Foley catheter (the urine drainage tube), in terms of recovery, again, like any other resective procedure of the prostate, HoLEP, TURP or other procedures that are done today, the most common symptoms, at least for the first two to three weeks, are a little bit of frequency, urgency, burning. That is all part of the healing process, and that is to be expected in aquablation as well.
Host Amber Smith: How soon after the procedure would a man notice that symptoms of BPH are clearing up?
Hanan Goldberg, MD: Most men notice that the stream is automatically, significantly, improved right after the catheter is removed. They feel that immediately because the channel is so much bigger right now. But again, because of these symptoms that I mentioned before, I think they truly feel the real improvement within two to three weeks, when these symptoms go away and they're not bothered by them anymore, and then they really, really feel how improved their stream is.
What we actually do before the procedure and after the procedure, we have them void, we have them urinate, in a special machine that can actually measure their flow. And then they can see visually, aside from of course feeling it, how improved their stream is. And we have many patients that their flow is actually tripled or even quadrupled, and it's flow. It's much faster now. It's much stronger now. It's a very clear improvement.
Host Amber Smith: For some men, is this a permanent solution?
Hanan Goldberg, MD: So the prostate tissue, unfortunately, grows back, but it does take a very long time.
And with the aquablation, I think, at least, from all the procedures that I know and do, that is the procedure that takes a very significant amount of tissue out. More than the TURP, I would say. And with the amount of tissue that is being removed, the time that it will take the tissue to grow back is many, many years.
So for the majority of men, this will be the first and final procedure, and they will not need any additional procedures after this.
Host Amber Smith: We want to let listeners know they can call the main 315-464-1500 number for the urology department at Upstate to learn more about this procedure or get connected to you.
Hanan Goldberg, MD: Yes, absolutely. Right now the aquablation device is available in our Utica office. I'm hoping it will be available in other offices as well. And it's important to know that in the Upstate area, this is the only place that aquablation can be done right now. The closest place after us is probably New York City. So in the whole entire area of Upstate New York, this is the only place that this can be done.
Host Amber Smith: Well, Dr. Goldberg, thanks for taking time to tell us about it.
Hanan Goldberg, MD: Thank you so much for having me.
Host Amber Smith: My guest has been Dr. Hanan Goldberg. He's an assistant professor of urology at Upstate. I'm Amber Smith for Upstate's "HealthLink on Air."
The best way to protect students from COVID -- next, on Upstate's "HealthLink on Air."
From Upstate Medical University in Syracuse, New York, I'm Amber Smith. This is "HealthLink on Air." As the school year gets underway, the Central New York community and the rest of the U.S. still has a highly transmissible variant of the virus that causes COVID-19 circulating. How can you keep your kids and yourself safe? I'm talking about this with Dr. Joe Domachowske, a professor of pediatrics at Upstate specializing in infectious disease. Welcome back to "HealthLink on Air" Dr. Domachowske.
Joe Domachowske, MD: It's a pleasure to be here. Thanks.
Host Amber Smith: As we go into the third fall/winter of the pandemic, how is this school year for kids likely to be different than the last two?
Joe Domachowske, MD: I think the major difference we're going to see are the recommendations. They're going to be different, depending on the level of threat in a particular region or a particular city or state. The CDC guidance is going to seem like it's discordant, but really it's based specifically now on what is the level of threat in our community at the time and how can we keep our kids as safe as possible?
Host Amber Smith: So, very region-specific.
Joe Domachowske, MD: Very much so.
Host Amber Smith: Will we see students in masks, maybe?
Joe Domachowske, MD: I think we will see students in masks at their choice. At the present time, we are pretty much on the low end of risk, as far as things go, but that could change after school starts. If we become at medium risk -- based on the community rates of hospitalization, the number of cases, and metrics like that If we become medium risk then you'll see the kids that are at higher risk for severe illness wearing masks again.
Host Amber Smith: Do you think we'll hear about quarantines if a close contact tests positive?
Joe Domachowske, MD: The CDC the U.S Centers for Disease Control and Prevention (has basically removed that completely from the algorithm. And I think it makes a lot of sense, along with removing the "test to stay" paragraphs that were included in the recommendations for schools for a while, because tests to stay were because of quarantine in people who did not have symptoms, right? So I think that all of it makes sense that we don't need to quarantine because of the community immunity at large. We no longer need to do that. And we don't have to do any tests to stay, for the same reason. But quarantine no longer makes sense. It's more of isolation and protection if you become ill.
Host Amber Smith: So someone who tests positive, a teacher or a student, they would still need to isolate?
Joe Domachowske, MD: Well, they should stay home if they're sick, right? That's true, whether it's COVID or not. So, we always start there, and then, as long as they remain symptomatic, with signs or symptoms of a respiratory illness, we ask them to stay out of school, and when they feel better, they no longer have to doa test to prove that they can come back. They just have to mask on return for a total of 10 days from the time their symptoms started. These are the brand new recommendations, and they make a whole lot more sense than what we were dealing with before.
Host Amber Smith: You used the phrase "community immunity," but we still do have some unvaccinated people, kids and adults. Are they still at greatest risk for getting COVID?
Joe Domachowske, MD: Certainly anyone that's not been immunized for whatever reason remains at the greatest risk for serious illness. But the models from the CDC and from Hopkins Johns Hopkins ( University tell us that close to 95% of Americans have either been vaccinated or have had at least one illness consistent with a COVID infection that would induce some level of immunity So as we increase our immune repertoire if you will and that can take repeated infections or repeated vaccinations or a combination of both, we will start to see the overall illness burden dampen down even further.
Host Amber Smith: If children come from a family where a family member has a compromised immunity, is there still a concern that that child could potentially pick up COVID germs and bring them home to that person?
Joe Domachowske, MD: Absolutely. That's a possibility, always, with COVID with influenza and with other types of infections, that we try to cocoon, protect, if you will, our most vulnerable. And those are going to be somewhat individualized decisions based on the level of immune compromise of the particular individual and the comfort level of the family and the caretakers that are involved in keeping that child healthy.
Host Amber Smith: Well, let me ask you a little bit more about vaccination. If children have not been vaccinated yet, is that something that they need to do before they go back to school?
Joe Domachowske, MD: Absolutely. You know, it's one of the very important tools in the toolbox that we have that just makes perfect sense.
Keeping our vaccination status up to date, staying home when we're sick, good hand hygiene, keeping our respiratory etiquette as careful as we can, given the age groups that we're talking about. And then for schools and buildings, making sure that they're cleaned regularly in a systematic way, and that ventilation is optimized.
Those things are very straightforward, easy things to do, and, going beyond that really requires much more effort, much more interaction, much more involvement about public health and the levels of disease that we're dealing with at the present time.
Host Amber Smith: Are the vaccines and boosters that are available right now, are they equipped to protect us against this latest variant? Or should we postpone getting a booster or a vaccine so that we get the latest version?
Joe Domachowske, MD: I'm not a fan of postponing. Once you reach the interval duration from your most recent vaccine, please go ahead and get the next dose, the next booster. But it may also mean that you'll get an additional dose once those variant or hybrid vaccines become available for each of the individual age groups. We don't even yet have them for adults. To think that we would have hybrid vaccines for the most recent variants available for children before school starts is fantasy.
I'm thinking that it'll be early into the next calendar year, before we even start to see it become available for middle school students and high schoolers.
Host Amber Smith: This is Upstate's "HealthLink on Air" with your host, Amber Smith. I'm talking with Upstate pediatric infectious disease specialist Dr. Joe Domachowske about what the school year may look like, COVID-wise for kids this year.
Can the COVID vaccine be given at the same time other childhood vaccines are given at the pediatrician's office?
Joe Domachowske, MD: Yes, the advisory committee on immunization practices made a decision quite some time ago as the COVID vaccines first became authorized for use in children that co-administration with other vaccines at the same visit was appropriate, in most instances. And they've stuck with that. And now of course, there's real-life data for having been doing so now for not quite a year. And so we know that it's safe, and we know they remain as effective as they can be, given the variant that we're dealing with.
Host Amber Smith: There's a list of required childhood vaccinations. Is the COVID vaccine on that list yet?
Joe Domachowske, MD: Let's explore what "required" refers to. So, we have public health laws that require certain vaccines for school attendance. We have ACIP, Advisory Committee on Immunization Practices, routine guidance for vaccination of certain age groups.
And then we have all the vaccines that are possible and available for individuals at large. So, when I hear folks refer to vaccines that are required, I'm thinking that they're most likely referring to vaccinations that are required for school entry in New York state, because state by state, the number and types of vaccines you need is different across the board.
That is not true for any state, for any COVID vaccine currently for children, simply because we don't have full FDA (Food and Drug Administration) approval for the age group at the start of public school. We have emergency use authorization, EUA and unless, or until, we have full FDA approval, I don't think any state legislature is interested in trying To lobby or require COVID vaccine as one of the added vaccines. Now with that said, it is routinely recommended, starting at 6 months of age. Depending on the child's age, of course, they can get one or another of the formulations of the vaccine. The ACIP routine schedule for routine immunization I think is what we should be looking at Not the required vaccinations The ACIP recommended schedule is much broader and comprehensive than the requirements for school entry. And we should not be restricting ourselves to what's required.
Host Amber Smith: Are booster shots for kids recommended?
Joe Domachowske, MD: Absolutely. When they're ready and they meet the EUA criteria, emergency use authorization criteria, for a booster, they should receive it.
I'm even telling some of my clinical trial participants who will be removed from the trial if they get a booster because they aged in, they turned 5 And now the EUA goes down to 5 years of age I'm telling them The clinical trial doesn't accommodate you to have a booster in the trial. Technically, you're still in the trial for another year, but I'm recommending that you get the booster through your primary care office or through a community. vaccinator so that you can maintain that high level of immunization," even though it means compromising their position in the clinical trial.
I do think it's more important than that role in the trial at this point.
Host Amber Smith: At this point, the vaccines are only available as a shot, is that right?
Joe Domachowske, MD: That's correct.
Host Amber Smith: Kids of all ages have been receiving this vaccine for months now. Are there any adverse reactions that are concerning to you?
Joe Domachowske, MD: The typical adverse reactions following the vaccine are the ones that we see very typically from other childhood vaccines and not quite as severe as we might see with a pertussis-containing vaccine for whooping coughthey tend to be a little bit more reactogenic (likely to produce an adverse reaction) but somewhere in the middle, there are children that develop fever for a couple days, local injection site concerns or complaints. These are self-limiting reactions. I have not personally seen any, long-term effects from vaccine, but I know that, some long-term effects have been reported, very rarely, in the safety databases.
Host Amber Smith: Given that COVID is still fairly prevalent in our community, what is your advice for parents if their children complain of a sore throat and theyw develop the sniffles? How should a parent deal with that?
Joe Domachowske, MD: Well, they should have medical attention, and COVID testing should be performed as part of that medical attention, if appropriate. Those symptoms that you mentioned certainly could be consistent with COVID. And then we want to make sure that individual is isolated, not quarantined, but isolated and masked for that 10-day period or less if their symptoms resolve before that
Host Amber Smith: So COVID tests are still recommended. And if they're. Positive, does the parent need to alert the pediatrician, or is there anything the pediatrician would do?
Joe Domachowske, MD: If their child is not at high risk for severe illness, and has a mild illness that the parents are comfortable dealing with at home with symptomatic care -- hydration, fever-reducers pain relievers, stuff like that -- if they're comfortable with it, then I don't think they necessarily need to notify the primary health care provider but it's always a good idea to let them know so they can just document it in the health care record so that they're aware that they had an over-the-counter test or point-of-care test at some point outside of the medical home that was positive for COVID with symptoms X Y and Z So it's very clear This is what their immunization status was like, this is when their last dose of vaccine was given, this is when they became symptomatic and tested positive outside of the medical home. So that if there's anything unusual that happens subsequently, for instance,repeat testing shows repeat positive results, which almost never makes sense and is caused by different reasons, that they can work through it and give the family a good explanation for why that might be happening.
Host Amber Smith: Are there symptoms that should prompt a parent to be a little more concerned? I mean, I hear you explaining, basically, how to take care of them as you would, maybe for a cold or a flu, keep them comfortable and hydrated and that sort of thing. But is there any symptom that a parent should be on the lookout for?
Because early in the pandemic, there were some concerns about a disease or something that was related to COVID that was affecting kids severely.
Joe Domachowske, MD: The disease that you're referring to is abbreviated MIS-C, for multisystem inflammatory syndrome of childhood. And that's a condition that usually occurs several weeks after the acute COVID infection.
And many of those children don't have much in the way of signs or symptoms of the COVID infection. We're not even aware that they had the infection until their MIS-C presentation shows us otherwise. Those kids present with high persistent fevers, often very uncomfortable, with rash, a lot of gastrointestinal symptoms and can have serious cardiac consequences.
So they're almost always hospitalized, and we treat them very aggressively. The inflammation can be quite stubborn, but we usually, Are able to get it under control within the first couple of days and give that child some relief. They are followed for months afterwards to watch for different types of long-term side effects And one of the under-spoken benefits of vaccination is that we know vaccination prevents MIS-C
Host Amber Smith: So if your child is isolated and you're hydrating them and keeping them comfortable, how do you tell when they're no longer infectious and they can come out of isolation?
Joe Domachowske, MD: Well, the CDC says 10 days from the time symptoms start, and, on average, that's a reasonable number to go with. Determining infectivity based on a test result is not useful. So I would discourage people from repeat testing until negative in order to make a decision about whether or not that child can go maskless or be out and about, no longer isolated, but, once the primary respiratory symptoms are gone. it's perfectly acceptable to mask and begin interacting with the community, including going back to school. But as long as the mask stays on up until the end of day 10 from the time the symptoms started, that is what the current guidance is.
Host Amber Smith: So, what is your general outlook for parents, or what do you think parents should think going into this school year in terms of COVID?
Joe Domachowske, MD: It'll be a different year. Expect the unexpected. I think it'll be better, but it's going to feel discordant, I think, for many folks who like to have rules be rules. Because of the way the decision-tree algorithm is written out and the way the guidance is being provided, the level of virus activity in the community is going to play a major role in how schools deal with things such as testing isolation maybe even quarantine At some point even though it's taken out of the official guidance completely right now or high-risk activities like going to band, team sports, where they get really close, and they're right there in each other's faces.
So, in low-risk areas, those are all things that are permitted to be happening, and we should expect them to happen. When there are outbreaks, there's going to be community based decision making that is going to rely on the way the CDC decision-tree algorithm is written out for how to handle them. And so it's going to feel, I think, for many folks that like very specific, black-and-white rules to be followed, they're going to feel like some of this is discordant. It really is taking multiple factors into consideration to make a final decision about what's best for the population, the community and the children at that school.
Host Amber Smith: Well, Dr. Domachowske, I appreciate you making time for this interview.
Joe Domachowske, MD: My pleasure. Happy to do it.
Host Amber Smith: My guest has been Dr. Joe Domachowske, a professor of pediatrics specializing in infectious disease at Upstate. I'm Amber Smith, for Upstate's "HealthLink on Air."
Next on Upstate's "HealthLink on Air:" new advice for COVID testing using rapid antigen tests.
From Upstate Medical University in Syracuse, New York, I'm Amber Smith. This is "HealthLink on Air." To determine if they're infected with the virus that causes COVID 19, during the pandemic, people have typically sought either PCR testing through a laboratory or rapid antigen tests done at home. Those rapid tests are popular because they're so convenient. But a group of researchers at Upstate has analyzed the use of these tests to screen people who are asymptomatic -- and the results have not been good. And now the government has issued some new guidelines about how to use those tests. Here with me to explain is Dr. Christopher Morley. He leads the department of public health and preventive medicine at Upstate. Welcome back to "HealthLink on Air," Dr. Morley.
Chris Morley, PhD: Thanks for having me back, Amber, it's always a pleasure to be with you.
Host Amber Smith: Now, before we get into the study, can you explain why this is important now? Because I feel like a lot of people think the pandemic's over.
Chris Morley, PhD: Sure. And thank you for giving me the opportunity to say so. Unfortunately we in public health have been saying all along that as long as there's still viral transmission, we're going to see new variants and those variants will produce new spikes. And we have some precedent for that. For example, the 1918-1919 flu actually took about 10 years or so to fully abate as an epidemic. They were still seeing peaks and valleys for some time after the full wave. And that's kind of where we are now. We are still seeing surges, and we saw one here in Central New York that was caused by a novel variant that seems to have emerged here, or at least been first detected here in Central New York.
That was the BA 2.1 variant. And that caused a spring spike. When other places were seeing a lull, we still had a lot of cases. And eventually it turned out to be a new variant. And that's largely happening right now, as we speak with the BA 5 variant. And what happens is every time there's a new transmission of the virus, the virus replicates. It makes millions and billions and trillions of copies of itself, and every one of those copies can carry mutations. All you need is one or two of those mutations to matter, being more infectious or more dangerous, to get around our immunity. That produces a new spike. And so we are still seeing new cases. We've got about 130 to 135 cases a day that we are identifying, even with less testing here in Onondaga County, for example, as we speak.
Host Amber Smith: Well, let's talk more about this testing. Rapid antigen tests: How are they designed to work, and how do they compare with the PCR tests?
Chris Morley, PhD: The antigen test essentially, everything that's marketed now uses a nasal swab, and they look for, essentially, proteins that are on the viral shell. When the test finds those proteins, it basically lights up on a little cassette, or card. So basically what you need is, you need enough virus to be detectable. So the antigen tests work when you have a fairly, relatively high viral load, and there's implications for that. And I'll explain that in a minute. But first I want to compare that with PCR, or polymerase chain reaction, if anybody's wondering what PCR stands for. But the polymerase chain reaction, or PCR tests, essentially take either nasal swabs or saliva in this case. A number of good saliva tests are also available. And what they do is they look for the RNA that is encapsulated within the viral shell. And the PCR procedure replicates that RNA and makes millions and millions of copies of the RNA. So that basically you need much less of that RNA floating around in order to detect it. So the PCR procedures tend to be much more sensitive.
And what this works out to in practice is that the antigen tests do a pretty good job if a person is symptomatic. if you have enough of a viral load to be symptomatic, you have a better chance of testing positive. They also, once you've shed that actual viral particle mass, they tend to fade off and not test positive once you've basically cleared the infection. But there's a much narrower window when those tests actually can detect whether you have a virus in your system or not.
Compare that with PCR, which amplifies the nucleic acid. PCR can detect an infection much earlier, in presymptomatic phases, as well as detect -- this is where a problem comes from and people get confused -- often we have viral debris, like pieces of RNA that still float around in your system, and a PCR test can amplify that long after you've cleared infection. So people early on in the pandemic before we understood all of the dynamics, were talking about people still testing positive. And so PCR, we've refined the protocol, so that's not much of a problem anymore. But the bottom line is when people get confused, the antigen tests typically have a very narrow window when people have the highest viral load. And PCR can detect much earlier and a little bit later, actually. And what that ultimately works out to is that we consider PCR to be the gold standard. It's much more sensitive, which means it can pick up the infection much more easily. Whereas antigen tests are less sensitive. But both are very specific. If you're positive on either you are probably infected.
Host Amber Smith: Now in recent days, the FDA (Food and Drug Administration) and the CDC (Centers for Disease Control and Prevention) issued guidelines about the rapid antigen tests, telling people to repeat testing if they get a negative result, regardless of whether they have symptoms. Do you think someone in the government read your study?
Chris Morley, PhD: I think we're all reading the same studies, and our paper was actually a rapid review of 11 different published studies on four different brands of rapid antigen tests or RATS, we call them. But the bottom line is that the evidence converges that essentially, there are still a lot of uses for antigen tests, but what the FDA clarified in its recent communication is that for you to really avoid that false negative and the false sense of security that comes with finding a negative, when in fact you may be carrying the virus, is that you should find that window I just described when you are actually carrying enough virus for an antigen test to detect by serially testing. We call serial testing the use of several tests in a row. And now the FDA clarified. They typically want people to test at least twice with a 48-hour window. And in some cases, where you really think you've been exposed, to test as many as three times with 48 hours in between. Hopefully, if you are carrying the virus, by doing so serially, you will eventually find that window where you're most able to detect the infection with a rapid antigen test.
Host Amber Smith: This is Upstate's "HealthLink on Air" with your host, Amber Smith. I'm talking with Dr. Chris Morley. He's the chair of the department of public health and preventive medicine at Upstate, and we're discussing a study he was involved in that looked at the reliability of rapid COVID tests.
So what made your team want to look into this issue? And what was your overall conclusion in your paper?
Chris Morley, PhD: The core issue is that rapid antigen tests are good for some things, and we can talk about when it's appropriate to use them. But your question begs, why we would look and what really predicated our study. And that's the fact that PCR involves a laboratory. You need a laboratory. There are some home tests, but they themselves are very expensive. So for all intents and purposes, most PCR happens in a laboratory. You need a laboratory staff, and you need to run a PCR procedure, which can takehours to days, depending on the backlog in the lab. It takes lots of reagents. It's expensive. So there's a lot to a PCR, which is the gold standard.
And when we were looking at large institutions, particularly educational institutions like colleges that were doing screening of asymptomatic people, basically everybody was required to submit some testing, and some places were doing it twice a week. Here at Upstate, we were doing it every week. Everybody on campus had to submit a PCR swab every week. There were campuses that found that both infrastructurally, logistically and financially compromising and were asking, "Hey, can we just use these much more affordable and quicker, more rapid antigen tests to achieve the same result?"
Now, the problem is that if you are using a once-a-week protocol with an antigen test, you are not serially testing, and furthermore, you are increasing the chance that people will be having false negatives. Not only will that identify fewer cases -- somewhat defeating the purpose of systematic screening -- but you'll actually create another adverse consequence where people who test negative believe that they've gotten a negative test, and they're free, which with a PCR, because it has that much wider window, the earlier detection capacity, they might have had some ability to believe that they're infection free with a PCR for at least a few days between tests. Whereas a negative antigen test would convey essentially. A false sense of security and let them behave in ways as though they were virus free, when in fact they may not have been. So it was not only not a very effective alternative the way we were doing asymptomatic screening, but it also had potential problems as a result.
Host Amber Smith: So what is the best strategy for institutions, or for individuals, to make use of rapid antigen tests?
Chris Morley, PhD: Rapid tests are really good in a couple of circumstances. And I'll tell you, I'm not just describing what the FDA recommends. I am describing how I, as a scientist and public health expert, have been using this with my own family and in my own gatherings and even within my own department. So one of the notable features of a rapid antigen test is that it probably is better at detecting a high viral load when you're most infectious. So if you were to use an antigen test, for example, if you're going to go into an environment where you're going to gather with other people, using an antigen test the same day, or even right before that gathering, it's not a 100% guarantee that nobody in the room is infectious, but if everybody antigen tests, some people might be infected, but you probably don't have anybody with a high viral load and massive amounts of shedding. So if you have a room where everybody, or at least most people are vaccinated and people are generally cautious, and everybody does an antigen test, you're probably not going to have a super spreader event. You might not have any spread, if people use an antigen test in that environment.
They're also good if you have to make a rapid assessment, if you have had an exposure and you don't want to go out and find a PCR test right away, or you can't, or you really need to know what's happening right this second. Initiating a series of rapid antigen tests can give you a lot more information that isn't available to you if you have to make an appointment and go find a PCR and then wait for the results to return.
What I generally have used them in an institutional setting is, if we're gonna have an in-person meeting, I do ask that people antigen test the same day. I'm actually about toattend a small meeting with a couple of colleagues, and I actually did my own antigen test today. And I paired that with a PCR earlier this week. When people have had exposures, we've aggressively used antigen tests for several days in sequence, often paired with a PCR, and that gives you a fair amount of assurance that somebody who's been exposed hasn't picked up the virus. So there's still a lot of uses, both in an institutional setting and for individuals. We keep a stock at home for that very purpose.
Host Amber Smith: I think a lot of families maybe have a stash of these at home. When they became available, people ran out and got them. But as we go into the third school year of this pandemic, what do you advise families about the use of these rapid tests in their home?
Chris Morley, PhD: Well, I do want to recognize the practicality of keeping a large stash. The federal government was handing out, I believe it was eight per household. They're also available widely in pharmacies now. They're fairly easy to come by. What I would recommend is that if families want to be as careful as possible, I would do two things. First of all, we're coming not only upon school season, but we're coming up on allergy season, and that brings two different things. That brings sinus conditions like congestion, runny noses, coughing, due to allergies as we enter the fall. It also puts children in proximity to other kids in closed settings where other things like RSV, (respiratory syncytial virus) other cold-producing viruses can occur, and we will enter flu season at some point as well. So basically, having tests on hand to make sure that what you're dealing with isn't the SARS COV 2 virus, COVID-19, is important.
And, well, if a lot of people are immunized and we're seeing more people have better health outcomes, why do we care if it's not the flu and it's COVID-19, or it's not the common cold and it's COVID-19? Well, the bottom line is, it still actually is hospitalizing more people than the flu and a lot more people than the cold. So while many people experience this as a bad cold, or a flu-like condition, it is still actually leading to more hospitalizations and more long term adverse outcomes than either of those. It's not everybody, but it's still higher. And so those people can still infect others who are at higher risk for those adverse outcomes.
So if you're trying to rule out symptoms, I would still behave differently. If you think you have allergies or a non-COVID produced sinus infection, I would behave differently. I still don't want to spread those other things, the infectious components of those to other people, but I would behave much differently and actually isolate and follow isolation guidelines if it was COVID. I might not be as stringent if I knew it wasn't due to COVID.
The other thing to do is if you've been exposed, you might want to know more quickly, because if you have a child who comes home from school and says, "Hey, Jenny or Johnny was out today, and it sounds like they had a really bad cold and they're out for a while," you might want to test your child or test the whole household because you might not want to then bring your child around their grandparents, for example. So there's still extra caution we should exercise, and having a stash of tests either to rule out symptoms or to test post exposure or for that situation where I just described, if you're going to be gathering with people, having everyone able to test before you gather, would all be safer ways to operate even now, in this post vaccination phase of the pandemic.
Host Amber Smith: Well, thank you so much for making time for this interview, Dr. Morley.
Chris Morley, PhD: Oh, it's been my pleasure. It's always nice to speak with you.
Host Amber Smith: My guest has been Dr. Chris Morley, who leads the department of public health and preventive medicine at Upstate. I'm, Amber Smith for Upstate's "HealthLink on Air".
And now, Deirdre Neilen, editor of Upstate Medical University's literary and visual arts journal, The Healing Muse, with this week's selection.
Deirdre Neilen, PhD: What's it like waiting for test results? Rich H. Kenny Jr. is an associate professor of social work in Chadron, Nebraska. His poem "Closer Looks" describes the passage of time for one patient.
Monday, the fifth
A stray dog ransacks a trashcan.
Dark skies linger like a taste of bad wine.
Wind-blown headlines tumbleweed across a yard.
The interstate becomes a parking lot.
Raucous birds fly overhead.
An obituary is clipped from a newspaper.
The guard tells a visitor not to touch the exhibit.
A man is tested for cancer.
Thursday, the eighth
Pals pose trailside in a decades-old photo.
A Horse with No Name plays in bumper-to-bumper traffic.
A man in his sixties feeds ducks at the lake.
Sidebars and box scores flutter against a neighbor's fence.
The abandoned puppy breakfasts from a shiny blue bowl.
Puckering rain clouds spritz wine cellar skies.
At shift change, the young girl discovers art with her fingers.
The man studies skin left too long in the sun.
Monday, the twelfth
Canadian geese, in perfect V-formation, splash down at the lake.
The tail-wagging beagle drops a tennis ball at my feet.
I tape and frame the tattered picture.
A student, blind since birth, tells me she wants to become a sculptor.
I crank up Mud Slide Slim in the rush-hour commute.
There's a hint of promise in robust, blackberry skies.
I unhook yellowed bylines and hang wind chimes from the breezeway.
Biopsy results will be ready tomorrow.
Host Amber Smith: This has been Upstate's "HealthLink on Air," brought to you each week by Upstate Medical University in Syracuse, New York. Next week on "HealthLink on Air": what to expect if you or someone you love is hospitalized. If you missed any of today's show, or for more information on a variety of health, science and medical topics, visit our website at healthlinkonair.org. Upstate's "HealthLink on Air" is produced by Jim Howe, with sound engineering by Stephen Shaw. This is your host Amber Smith, thanking you for listening.