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Ep. 147 - LiveWell Talk On...COVID-19 Antibody Testing (Dr. Jonathan Newberry)

episode 147

Ep. 147 - LiveWell Talk On...COVID-19 Antibody Testing

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Host: Dr. Dustin Arnold, chief medical officer, UnityPoint Health - St. Luke's Hospital

Guest: Dr. Jonathan Newberry, medical director, St. Luke's MedLabs

Dr. Arnold:
This is LiveWell Talk On...COVID19 antibody testing. I'm Dr. Dustin Arnold, chief medical officer at UnityPoint Health - St. Luke's Hospital. Today I'm joined by my colleague, Dr. Jonathan Newberry, pathologist with Cedar Valley Pathologists and St. Luke's Med Labs. In this episode, we're going to discuss what is antibody testing, test results and what they mean, and how is this going to influence the future of the pandemic and COVID-19 care as far as document immunity, etc. Dr. Newberry, welcome.

Dr. Newberry:
Thank you for having me.

Dr. Arnold:
First podcast, I think.

Dr. Newberry:
It is my first. I appreciate the opportunity to highlight an area of laboratory related care in the pandemic.

Dr. Arnold:
Well, you know, we don't let you out of the basement very often, but at least we're doing it today virtually. You're getting out of the basement.

Dr. Newberry:
I come out twice a day for food and water.

Dr. Arnold:
Yeah. Well, you know, I get a lot—there is a reoccurring question about antibody testing for COVID-19. Particularly with vaccine mandates, people want to document their natural immunity, etc. So I want to get into that. But first, I really want to cover for people that don't understand, how integral laboratory service has been during the pandemic. Even personally, I never had any real relevancy to how microbiology itself is more of an art than a science, as far as the skills of those people performing those tests. Those are procedures being performed, they're not just technicians. You know, I mean, it's really a skillset. And the lab has had to deal with so many supply issues over the time, ongoing supply issues. And the lab really has been imperative to be part in discussions and moving forward, and they've done a great job. Why don't you tell us a little bit about how the lab has handled the pandemic and what your experience has been?

Dr. Newberry:
Yeah, certainly. I would echo your commendations to the lab. They've done a really great job all along the way. The lab's role in the pandemic, as it usually is in most aspects of medical care, has been a little bit behind the scenes. Our main priority from the beginning really, has just been to facilitate access and availability of the different types of COVID testing for the providers and the patients. And as you mentioned, this has been an incredible challenge at times. Not only due to the shortages of testing kits and supplies, particularly in the beginning, but you know, surges and testing demand at various points, including this recent Delta surge. But yeah, COVID testing as the listeners know, has obviously been an important piece of navigating the pandemic. Whether it be from a medical standpoint and just identifying new positive cases, but also to guide treatment and quarantine, as well as provide opportunities for pre-procedure screening.

Dr. Newberry:
This has really allowed the hospital to be able to resume operations and continue to care for patients in a way that minimizes risk. And certainly testings also play a strong role in the public health standpoint, just tracking the number of cases in our local area. You know, the lab tracks the numbers and types of cases of COVID testing performed, positivity rates. And we're always accounting for the number of available testing resources we have on hand in order to make adjustments along the way to ensure that we can meet expectations and demands. So that's really what the laboratory's role has been and what I see it to continue to be as this pandemic moves forward.

Dr. Arnold:
And I had some experience prior to the pandemic from a pharmacy side. That, you know, I don't think a lot of people understand, that you can only request supplies on what's called allocation. You can't just—it's a good process because it prevents people from hoarding things and stockpiling items, whether it's medicines or supplies. So I completely get it, but I don't think—we were held to the previous allocation that wasn't relevant to the pandemic. And so that slowed things down as well, pharmacy side, supply side as well. And I think we've done a good job of navigating that. Compliments to the lab and lab leadership. You know, particularly Cassie down there. I mean, she is just amazing and is always innovative, trying to figure out what's the best way to do it. Sometimes those ancillary departments of the hospital, I think all of them are good, but I think the lab truly understands that at the end of their work is a patient, and they make decisions that way. You know, they feel integrated into the delivery of healthcare, and I think that really reflects why they've been so successful.

Dr. Newberry:
Certainly. You know, as the medical director of the lab, I am daily indebted to the layers of administrative and managerial support and leadership who really do a lot of the heavy lifting day to day and making sure that these services are seamless for our providers and patients. So certainly yes, they do a wonderful job and continue to work very hard. You know, we're 20+ months into the pandemic, so you know, certainly there are days where burnout is a real thing and I commend their resiliency and their persistence and doing the right thing for the patients and the providers in this regard.

Dr. Arnold:
Well, you haven't been on the podcast before, but on the podcast we referred to it as pandemic fatigue. Because burnout to me, this is my definition, burnout is you're doing the same thing you always did, and it's just not emotionally satisfying anymore. Where this is something that we weren't doing and it just continues and it's really a fatigue. And so even the resiliency is even more amazing quite honestly. Well, next question. What are the different types of antibody testing? Excuse me, different types of COVID-19 testing? Let's just start with determining if someone's positive or negative. And also in that answer, hit on, there is some skillset in collecting the test, correct?

Dr. Newberry:
Right. Yeah, so there's different types of COVID tests. These tests either test for current infection or past infection. In order to test for a current infection, you're going to need a variety of viral tests. So the two main types of viral tests that are used, the best and most reliable is a nucleic acid amplification test. This is also known as a molecular or PCR based test. I think most of the listeners by now have heard about these, and this is really the best and most sensitive form of viral testing to detect a current infection. You can also do things called antigen tests. These are typically more rapid, but a slightly less sensitive form of testing, and just can't pick up a new active test quite as soon as a molecular based test. A lot of people in the pandemic have had the opportunity to actually be collected for one of these tests by now. Certainly the collection piece is such an important aspect of this because we do have to get a swab fairly deep into that nasopharynx in order to get enough of those cells in order to get a satisfactory evaluation.

One of the things that's been difficult and characterizing precisely how well these tests are performing. One of the variables here is the adequacy of test collection. And in fact for a time, and even now, the lab also has been supporting a specimen acquisition clinic where patients are scheduled by appointment to have their pre-procedural test screens collected there. And this has been one of the ways that we can ensure good quality control on how the tests are being collected.

So that's to test for current infection, a viral test. To test for past infection, and this is the primary subject of today's podcast, would be an antibody test. An antibody test does not test for the virus itself, but rather tests for your body's response to the infection. An antibody test could also tell you if a person has been vaccinated and subsequently developed antibodies to that. So that's kind of the main broad overview of the different types of COVID testing. Either to test for current infection with a viral test, or past infection with an antibody test.

Dr. Arnold:
One other thing I want to touch on, just more as informational, because I know the answer. I know you know the answer. That these tests don't come back within minutes. They have to be collected, sent to the lab, run on a instrument, and reported out. And I think patients and physicians get flustered when it's not back instantaneously. And even as, I think the turnaround time today was in the mid twenties. You know, we send tests out. And, you know, the time to collect a report is 20 hours. And that's just something that I'd like people to understand. I don't know if you want to comment on that, Jonathan. But I want to get that out to people that this isn't—you know, if we could get it back in seconds, we would.

Dr. Newberry:
Right. So turnaround time is always a priority for us. The unfortunate reality is we just don't have a high enough throughput instrument that can accommodate all the COVID testing that we're being required to perform in our area. I like to explain it kind of like you have a certain size dishwasher. You're only going to be able to put X-number of dishes through on one load. And try as we may to accommodate all the tests that we get, we only have a throughput of a relatively limited number of COVID tests we can perform. You could even take the analogy a step farther. If you think of those little detergent pods that you need to wash the dishes, and pretend like those are actually test kits. We only have a limited number of test kits that we're allowed to receive for certain vendors.

So what we have to do is kind of triage certain different populations of patients, our outpatients being one of those, our inpatients and emergency room being another. And we have pediatrics and we also have OB, as well as pre-procedural screens for these tests. And really the end result is we have to be reliant on some of our larger affiliate labs in the system to perform some of this testing for us. Currently, our viral COVID testing is going to Peoria. And as you mentioned, turnaround time typically is around 24 hours. The majority of this time is not the actual time it takes to run the test, it's the processing and handling of that specimen to get it on the carrier, to leave our area and actually go to the different reference labs and run on the analyzer.

Most of the time, the actual analytical runtime of these tests is on the order of an hour or two. But it's really the transit time that accounts for the majority of the turnaround time here. The good news is, actually our lab is bringing on a higher throughput analyzer in a matter of a few weeks. And we're fairly confident we will be able to accommodate all of our local testing for COVID within a month or so. And should the demand for COVID testing die down, the great thing about this new analyzer that we're getting, is we'll also be able to perform other types of testing on it. So the equipment is going to be utilized even if the demand for COVID related testing dies down.

Dr. Arnold:
This is a little inside baseball, but you're referencing the Panther.

Dr. Newberry:
That's correct.

Dr. Arnold:
I tell people, I say, look, it's about four hours. By the time they collect it, when it's run in house, it's about four hours. You know, don't be looking for that result within four hours. You know, give it at least four hours. They're working as fast and as busy as they can. I think, here's where people get hung up or at least raise a legitimate question. That if we possess the antibody testing to study the vaccines, to confirm that an immune response had occurred, how come we don't have antibody testing to test natural immunity to the general public? Does that make sense? Do you see where I'm coming from?

Dr. Newberry:
Yeah.

Dr. Arnold:
So, I mean, I understand that on one hand you can say, well, we just don't have—Because there are other illnesses that your antibody testing is kind of flipping a coin, you know. I mean, we see that all time. And you get people that have an IgG to something, CMV. That doesn't mean they have CMV many times remotely. You know, we don't know. So I think people get caught with how come antibody testing is effective for one thing, but not the other? Can you comment on that?

Dr. Newberry:
Yeah. So it sort of ties into just the different types of antibody tests that exists. So, you know, there's two main types of antibody testing in the context of COVID. There's either a qualitative test. This is a type of test that will give you a yes or no answer, whether there's the presence of antibodies at all. Or there's a quantitative test, or at least semi-quantitative test. And these are types that will give us a numerical value that establish how many antibodies that exist in our blood. The unfortunate part about COVID antibody testing is, you know, for quantitative test to really mean something you have to rely on reference ranges of antibodies. And with COVID-19, whatever number you get, it might be accurate, but the reference ranges really aren't that well characterized or understood at that point, since it's a relatively novel virus as compared to say measles or something that's been around for decades. So it's going to take some time until we really know what's what. We really don't know how long immunity is going to last. Perhaps you do have antibodies and perhaps you are immune, but are those antibodies going to last one week, or one month, or years. And all that information just isn't quite yet known. There's also some other aspects of our immune system that may play a role to different degrees, depending on the person besides just antibody. You have different antibodies. You have other aspects of your immune system that can come to bat. So my army of antibodies may be enough for me, but they might not be enough for somebody else to fight off the infection satisfactory really if they're exposed.

Dr. Arnold:
Okay. That certainly makes sense. I guess one of my things that I'm disappointed in, is that at a national health level—I mean, we're the United States of America. We should've had some sort of antibody testing developed and confirmed just from an epidemiology standpoint, just to see how this virus—You know, so I really feel that an opportunity was missed and that's my own personal opinion. You know, we've been very resistant if not, you know, not accepting antibody testing when it's done for pre-procedures. Just because we don't really know what it means.

Dr. Newberry:
Right.

Dr. Arnold:
I mean, and I know sometimes it's frustrating to patients and clinicians. But trust me, if we had an antibody test that we could accept and prevent us from doing another test on you, we would. You know, hands down we would. And I think that's a great explanation for that.

Well, we'll continue discussing antibody testing in just one moment, but first I want to tell listeners about a new segment on the podcast, the mailbag. If you have a question about COVID-19, the latest technologies and procedures, services provided at UnityPoint Health, or other medical topics, you can simply submit your question to me at UnityPoint.org/mailbag. They may be answered on a future podcast. Please note the mailbag is not an alternative to a medical appointment, even though I do consider myself to one of the smartest doctors in the world. But any questions about personal symptoms or conditions need to be directed your primary care clinician or urgent care. In the case of emergency as always, call 911, or go to your nearest emergency department. Once again, you can submit your questions to me at UnityPoint.org/mailbag. I look forward to hearing from you, our amazing listeners.

Dr. Newberry:
Well, in closing Dr. Newberry, I just want to give a shout out to the laboratory leadership during this time. I mean, I've always been in a position where I've had a lot of good relationships and interactions with the lab, whether it's blood laboratory testing, laboratory protocols to put in place from the medical staff. So it wasn't a huge surprise to me what a great group of people are down there. But I think the rest of the medical staff has gotten to see that and understands the pride they take in their work and are really appreciative. So do you have any closing thoughts on the future of antibody testing? Do you think someday we'll have a test that will say, okay, here's your quantitative amount and you are immune? Do you think that's coming?

Dr. Newberry:
Yeah, I hope so. I hope we begin to learn more about truly what antibody testing means for the individual in terms of providing some kind of quantitative tests. That really gives, you know, the individual an opportunity to have a sense of security and a sense that they truly do have a layer of immunity there. At the present time, I just don't think that exists in every situation. The reality is antibody testing may not be that helpful for an individual at this point, because as we mentioned, we simply just don't quite have enough information to know what to do with these tests yet. You know, I think what we'll see moving forward, is that the role of antibody testing will have importance in the broader population, as we begin to learn better how to use them to assess the prevalence of immunity within certain communities. In other words, we'll begin to even better understand not only where the virus is, but where it has been, and try to use this information to respond to outbreaks, but also understand where new outbreaks may be likely to occur.

As we kind of mentioned earlier, I think the biggest role of antibiotic testing presently would be the ongoing support of these vaccination trials. We have to learn how to use them to assess the true efficacy of the vaccination. You know, a lot of the preliminary data from the vaccine trials would in fact suggest that the vaccines are very effective. But because we do have somewhat limited information, we just can't make a firm, we don't have a firm grasp of how long they are effective for. So the antibody testing will continue to be a good resource just to monitor this duration of immunity. Furthermore, I think there were certain specific groups that weren't really ever included in some of these clinical trials for the vaccine. Some of the elderly and immunosuppressed, and some of the other groups that had certain pre-existing conditions or comorbidities. So the use of antibody testing moving forward to monitor some of these subsets of patients is also going to be important.

Dr. Arnold:
Pregnancy. Pregnancy is another group that a lot of these trials didn't have for obvious reasons. Well, this is your first podcast. We hope to have you back. But one last question. Why did you choose pathology? That's a common closing question we ask all the guests.

Dr. Newberry:
Yeah, that's a good question. I discovered that there were quite a few good reasons for me to choose pathology during my training and medical school. I think it's true that most people tend to kind of gravitate towards those professions and work that they feel suit their personality and temperament. And truth be told, a stereotypical pathologist is fairly introverted and doesn't necessarily thrive off of running a clinic and face-to-face interaction with patients, or the types of stress that come with being in the operating room. And if I'm honest, I do suppose I fit that mold. But I did still want a career in medicine and I was very drawn to learning about, you know, basic sciences behind human illness and the study of different diseases. My dad was actually a pathologist. And because of this, I think I was a little more intentionally observant to pathologists during my training and medical school. For the listeners who don't really entirely understand what a pathologist does, I typically describe it as we're the doctors who take a close look at any tissue that comes out of, or off of your body. We generate a report and diagnosis and relay that information to your treating provider to help guide them in taking care of you. And certainly, we do oversee the clinical laboratories where blood work and other types of specimens are tested. You know, all in all, I do find the work fulfilling and I'm glad to be a part of this good UnityPoint team.

Dr. Arnold:
Well, that's great description of the choice you've made. We're glad at least virtually, we got you to come out of the basement. But you know, I know you're busy. Thank you so much for joining me today. Once again, that's Dr. Newberry, he is a pathologist here at St. Luke's Cedar Rapids, part of Cedar Valley Pathologists, as well as St. Luke's Med Labs. For more information on all things COVID-19 visit UnityPoint.org.

Dr. Newberry:
Thank you for having me.

Dr. Arnold:
Thank you for listening to LiveWell Talk On. If you enjoyed this episode, don't forget to subscribe, and if you want to spread the word, please give us a five-star review and tell your family, friends, neighbors, strangers about our podcasts. We're available on Apple Podcast, Spotify, Pandora, or wherever you get your podcasts. Until next time, be well.