Prevalence of SARS-CoV-2 infection and immunity in a New York county in 2022 reveals frequent asymptomatic or undiagnosed infections

Accurate and timely surveillance of SARS-CoV-2 prevalence and immunity is critical to local and national COVID-19 pandemic responses. Representative surveillance surveys reveal more accurate estimates of COVID-19 infection than other measures based on reported test results. Our main research objectives were (i) to provide local health department officials with prevalence estimates calculated from a representative sample to better inform their decision-making efforts in response to the COVID-19 pandemic and (ii) to identify characteristics associated with COVID-19 infections among high-risk groups. Three municipalities were sampled at one timepoint (February, April, or October 2022) using a 2-stage cluster sampling design. Participants provided anterior nares swabs, which were tested for SARS-CoV-2 with a RT-PCR and for nucleocapsid protein and receptor binding domain antibodies by multiplex Luminex assay. Participants completed a survey on socio-demographics, SARS-CoV-2 prevention behaviors and attitudes, and vaccination and infection history. A total of 233 individuals from 221 households provided anterior nares swabs, and 215 samples were linked to survey data. After adjusting for study design, the household prevalence of PCR-positive tests was less than 5%, but approximately half of the population had antibodies from a prior infection and most (81% to 92%) had antibodies from either infection or vaccination. Discrepancies between self-reported positive test and vaccination status and antibody results suggested a high prevalence of asymptomatic infection and waning antibody titers. County-level infection prevalences, estimated from the county test reporting system, were 16.6% in February, 19.1% in April, and 23.8% in October, substantially lower than the prevalence of individuals with antibodies from infection in the surveys, also supporting a high prevalence of asymptomatic or unconfirmed infections. The overall small sample size precluded an analysis of characteristics associated with active or past infection. In conclusion, surveillance surveys can provide timely data on infection status and immunity to support public health responses.