Integrating SARS-CoV-2 Surveillance Testing Among Patients Receiving Dialysis Feasible, Requires Improvements

A randomized trial comparing 2 SARS-CoV-2 testing strategies among patients receiving dialysis found that although test integration was feasible and reached patients at high-risk of serious COVID-19 disease, test acceptance was low across the population, indicating the need for incentives to increase voluntary uptake.¹

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For patients receiving maintenance dialysis, viral infectious diseases represent a disproportionate threat to their health. The impacts of the COVID-19 pandemic were staggering to this population, with a 17% increase in all-cause mortality during the early part of the pandemic.²

Additionally, among patients receiving dialysis, the rate of COVID-19 hospitalization was approximately 40 times higher compared with the general population. Surveillance screening in facilities administering dialysis can mitigate these adverse effects, but the feasibility of integrating testing and patient willingness to test—even while asymptomatic—are major questions.^1,2

The study authors conducted this randomized trial (NCT05225298) to evaluate the acceptance of 2 different testing strategies for routine screening among asymptomatic patients in dialysis facilities. One strategy offered patients dynamic SARS-CoV-2 testing, with test frequency based on local SARS-CoV-2 activity, while the other offered static testing at a predetermined interval.^1,3

Offering a hypothesis that dynamic testing would have higher patient-level test acceptance, the investigators reasoned that patients may be more willing to agree to SARS-CoV-2 testing when community-based viral activity is higher, thereby putting them at higher risk.¹

County-level wastewater data or clinical indicators of county-level case or hospitalization data was utilized to determine SARS-CoV-2 activity and how frequent tests should be administered. For the dynamic strategy, a facility was shifted to the weekly test offer frequency when there was a high community presence of COVID-19; when there was low community prevalence, they would be offered a test monthly. The static strategy offered patients tests every 2 weeks.¹

In total, 12,553 tests were offered, with a median of 6 tests offered in static testing facilities versus 4 tests offered in dynamic testing facilities. There were no observed differences in numerous factors, including the total number of tests accepted, mortality between static and dynamic testing facilities, and the proportion of patients accepting at least 1 test, according to the investigators.¹

There was a higher median percentage of offered tests, among patients who accepted at least 1 test (n = 503), for facilities using the dynamic testing strategy (50%; IQR, 33%-75%) compared with facilities using the static strategy (16%; IQR, 17%-42%). Despite this significant difference, the dynamic strategy did not demonstrate a greater likelihood of test acceptance if there was high COVID-19 prevalence, and once-a-week testing was offered.¹

In an important measurement, among patients who accepted at least 1 test and were in a county with high levels of COVID-19 during the trial (n = 93), the median percentage of tests accepted using the dynamic testing strategy was 25% (IQR, 13%-100%) and 33% for the static testing strategy (IQR, 17%-67%). These inconsistent acceptance rates highlight the overall low and piecemeal uptake of SARS-CoV-2 testing, even if there were high levels of community transmission.¹

Testing was successfully integrated into routine care, showcasing the potential for public health surveillance integration within dialysis treatment. “The low overall testing rate, however, indicates that more extensive or sustained training of health care professionals and other incentives for patients and health professionals may be needed for tests to be consistently performed,” the investigators discussed.¹

One hypothesis for the low testing acceptance is the overall de-prioritization of COVID-19 in the minds of the public. A poll from Pew Research Center found that the proportion of Americans expressing action on COVID-19 as a top priority was 26% in January 2023, a major decline from 78% in 2021. This, combined with the low period of COVID-19 prevalence that overlapped with the study period, could have led to patients perceiving a lower risk of infection.^1,4

“This nationwide trial demonstrated that integrating infectious disease screening capacity into routine dialysis care is feasible and reaches high-risk persons, but its effectiveness, if still relevant from a public health perspective, will require additional approaches to improve patient participation,” the investigators concluded.¹

REFERENCES

1. Montez-Rath M, Varkila M, Yu X, et al. Acceptance of SARS-CoV-2 surveillance testing among patients receiving dialysis: a cluster randomized trial. JAMA Netw Open. 2024;7(9):e2434159. doi:10.1001/jamanetworkopen.2024.34159

2. Weinhandl ED, Gilbertson DT, Wetmore JB, et al. COVID-19-associated decline in the size of the end-stage kidney disease population in the United States. KI Reports. 2021;6(10):2698-2701. doi:10.1016/j.ekir.2021.07.019

3. ClinicalTrials.gov. SARS-COV-2 screening in dialysis facilities. National Library of Medicine. Last updated February 28, 2024. Accessed September 24, 2024. https://clinicaltrials.gov/study/NCT05225298?id=NCT05225298&rank=1

4. Pew Research Center. Economy remains the public’s top priority; COVID-19 concerns decline again. Published February 6, 2023. Accessed September 24, 2024. https://www.pewresearch.org/politics/2023/02/06/economy-remains-the-publics-top-policy-priority-covid-19-concerns-decline-again/