Mayor wants change in COVID-19 policy

Mayor wants change in COVID-19 policy

Health departments in at least three major Texas cities — Houston, Dallas and Austin — investigate COVID-19 cases in which a person tests positive for the novel coronavirus in an antigen test but has no symptoms.

The San Antonio Metropolitan Health District does not investigate such cases, nor does it consider them even as “probable” cases of COVID-19.

Metro Health instructs its case investigators to “kindly inform” all antigen positive patients without symptoms “that they are not considered a case by the city of San Antonio,” close the case, classify it as “not probable or confirmed” and change the lab test category to “none.”

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The policy has raised alarms for members of a Metro Health contact tracing work group worried that the health department is ignoring people without symptoms who test positive for COVID-19. Metro Health Director Colleen Bridger has dismissed their concerns as “a whole lot of ado about nothing.”

On Friday, Mayor Ron Nirenberg told the San Antonio Express-News that he wants Metro Health’s policy to change.

“I support contact tracing, following up with and reporting all asymptomatic antigen positive residents,” Nirenberg said. “It’s my goal that we always implement the best practices to ensure that we’re protecting public health, and I’m confident that we’re going to begin following through and investigating these asymptomatic cases.”

Positive results from antigen tests are highly accurate. Most of them correctly identify the virus more than 99 percent of the time, according to the Centers for Disease Control and Prevention. And they’re rapid; the tests can identify infections within minutes by detecting proteins from the virus in secretions from the nose and throat.

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Antigen tests are not as sensitive as PCR tests, so a negative result from an antigen test does not rule out an infection. Negative results from an antigen test may need to be confirmed with a PCR test, which looks for pieces of the virus in the nose or throat.

A positive antigen test, however, means the person likely has an active COVID-19 infection — even if they have no symptoms.

Last week, Dr. Joseph Petrosino, chairman of the Department of Molecular Virology and Microbiology at the Baylor College of Medicine in Houston, said that anyone who tested positive in an antigen test should be counted and traced as if they tested positive in a PCR test.

Experts say nearly half of those who get infected have no symptoms but are able to transmit the virus as so-called “silent spreaders.”

Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases, told the Texas Association of Mexican American Chambers of Commerce on Thursday that 40 to 45 percent of people infected by the virus have no symptoms.

“Then it becomes the silent spread,” Fauci said, “which is what we call community spread.”

Concerned about these “silent spreaders,” San Antonio tech entrepreneur Graham Weston has formed a new nonprofit with the mission of screening hundreds and eventually thousands of residents to identify who is infected without symptoms and stop them from unknowingly spreading the virus.

Once residents are infected, investigating positive cases — tracing their close contacts to stop the spread — is critical to controlling an epidemic.

For each new COVID-19 case, a case investigator is assigned to call the patient and collect information on any close contacts. The investigators share that information with contact tracers, who warn the close contacts that they’ve been exposed to the virus and encourage them to get tested and to self-quarantine.

Metro Health does open investigations into antigen positive patients if they have symptoms. The district includes those cases in its total COVID-19 case count, classifying them as “probable.”

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At a COVID-19 briefing on Thursday, city officials defended Metro Health’s practice of not counting or investigating antigen positive patients without symptoms.

“There aren’t any other health departments in Texas that are doing that,” Dr. Junda Woo, Metro Health’s medical director, said.

Nirenberg said at that briefing that since August, Metro Health had received only about 100 positive antigen test results in people without symptoms. He called that “a relatively small amount.”

The city has recorded almost 54,000 confirmed COVID-19 cases since March.

“A little perspective,” Nirenberg said then. “San Antonio is the only public health authority in Texas, except for Tarrant, that is actually counting any antigen tests at all.

“I do want to assure people who are watching this that San Antonio Metro Health, the public health authority, has raised the standard,” Nirenberg continued, “that it seems like very few, if any, public health authorities are meeting at this point in terms of counting and being rigorous with following through with infections in our community.”

On Friday, Nirenberg acknowledged he was wrong when he made those statements.

Officials at the Houston Health Department, Austin Public Health and the Dallas County Judge’s Office said that health authorities in those cities consider all antigen positive patients — even those without symptoms — as “probable” cases and open contact investigations into them.

“By both the state and the national case definition antigen tests would be investigated as a probable case not a confirmed case,” said Porfirio Villarreal, spokesman for the Houston Health Department.

Alina Carnahan, a spokeswoman for Austin Public Health, echoed Villarreal.

She said both the CDC and the Texas Department of State Health Services define antigen positive patients as “probable” cases “regardless of whether there are symptoms.” She said the Austin health department opens investigations into those cases.

Lauren Trimble, chief of staff for Dallas County Judge Clay Jenkins, confirmed that Dallas County Health and Human Services handles positive antigen patients without symptoms the same way.

“Contact tracing/public health investigations are done on those cases just as they are with confirmed cases,” Trimble said.

Nirenberg said the change in policy at Metro Health was under consideration by the contact tracing work group that raised the concerns last week.

“They’re researching,” Nirenberg said, “and will make their recommendations to Metro Health.”

Bridger has dismissed the concerns of the work group, saying last week that “they do not have the full understanding of the situation, which is not surprising given they don’t currently work in a health department.”

She said Metro Health was not counting or investigating antigen positive patients without symptoms because the Food and Drug Administration has authorized the use of antigen tests only in people who have symptoms of COVID-19.

But after the mayor made his statement on Friday, Bridger seemed to accept the possibility of changing the health authority’s policy.

“We are currently following the State Public Health guidance on how to process asymptomatic positive antigen cases,” she said in a statement. “However, responding to any novel virus requires constant adaptation as disease control experts study its characteristics and transmission.

“We have had great success throughout this pandemic of collaborating with our community to thoroughly vet and discuss emerging issues,” Bridger continued. “In fact, we are waiting on the contact tracing work group of the COVID-19 Community Response Coalition to provide a recommendation to our epidemiologist about potential modifications to our case definition and process.”

Metro Health also came under scrutiny this summer, when it failed to ramp up its number of case investigators before a surge of infections overwhelmed the agency. Only 25 investigators were working when cases spiked in June, a fraction of the 175 that a panel of health experts had recommended in April.

Dawn Emerick, the former director of Metro Health, had tried to recruit and train more than 100 case investigators in April. But she halted those plans after receiving push back from Bridger, who was her supervisor at the time.

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