The lack of widespread testing for COVID-19 in the United States during February and most of March has been widely discussed. The response of the federal government to develop more testing through public-private partnerships is expected to increase the number of tests exponentially in a short time period.
While the use of the COVID-19 test has been restricted by its limited availability, when more tests kits become available, the demand for testing will also increase. This will be especially true in healthcare organizations. Healthcare workers and their unions will likely demand that every healthcare worker be tested – as will patients, their family members, vendors and visitors.
However, even if testing of all healthcare workers were feasible and affordable, it may not be completely useful. The Occupational Safety and Health Administration (OSHA) classifies healthcare workers as having “high exposure risk” or “very high exposure risk” depending on whether the worker performed aerosol-generating procedures on known or suspected COVID-19 patients.[1] Therefore, the fact that a healthcare worker on a single day tests negative does not guarantee that the healthcare worker (1) is not then infected with COVID-19 at an undetectable level, (2) is not capable of transmitting COVID-19 to a patient and (3) will not contract the virus in the future. Accordingly, repeat testing may be the only way to ensure that healthcare workers are uninfected.
The widespread availability of testing for COVID-19 will provide us with helpful information in the effort to control this virus but will also give rise to new issues and challenges in the healthcare context. The risks and responsibilities for healthcare organizations of deciding whether or not to test all healthcare workers – regardless of symptoms and potential exposure – will have profound implications for healthcare delivery systems. To better understand these issues, we need to first look at what a positive test result reveals.
Understanding Testing for COVID-19
The virus that causes COVID-19 is titled severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The primary method of testing for SARS-CoV-2 RNA is by reverse-transcription polymerase chain reaction (RT-PCR). In the United States, the Centers for Disease Control (CDC) recommends collection of a nasopharyngeal swab specimen to test for SARS-CoV-2.[2] While a positive test for SARS-CoV-2 confirms that an individual has COVID-19, the CDC states that the role of pre-symptomatic transmission (infection detection during the incubation period prior to illness onset) is still unknown.[3]
The incubation period for COVID-19 is thought to be up to 14 days following exposure, with most symptoms occurring approximately four to five days after exposure.[4] While our understanding of the virus is rapidly evolving, SARS-CoV-2 has been identified in respiratory tract specimens one to two days before the onset of symptoms and can persist for up to weeks in severe cases.[5]
Testing Considerations: Asymptomatic Individuals
While the testing capacity is still limited in the United States, asymptomatic infections with SARS-CoV-2 have been reported. For example, on a rapidly evolving cruise ship outbreak, where most of the passengers and staff were tested irrespective of whether they had symptoms, 51% of the laboratory-confirmed cases were asymptomatic at the time when the respiratory specimens were collected.[6] Similar statistics have been reported from South Korea and Italy.
According to a recent study published in the New England Journal of Medicine (NEJM), viral RNA levels appear to be higher soon after symptom onset, which raises the possibility that transmission might be more likely in the earlier stage of infection.[7] Additionally, this study revealed that the viral load detected in the asymptomatic patients was similar to that in the symptomatic patients, which suggests asymptomatic or minimally symptomatic patients are contagious and can transmit the virus. Id.
Testing Considerations: Contact Tracing
Given this understanding, the World Health Organization (WHO) is recommending contact tracing of all those who have had social, familial, work or healthcare contact with an individual who has tested positive for COVID-19 from two days before the development of symptoms to up to 14 days after the onset of symptoms.[8] Additionally, the WHO recommends resampling and retesting if initial testing is negative but the suspicion of COVID-19 remains. While person-to-person contact is the most common means of contracting COVID-19, a recent study published in the NEJM examining the aerosol and surface stability of the virus revealed that SARS-CoV-2 can remain alive, and contagious, on surfaces for many hours and in some cases days.[9] As increased incidents of community-spread COVID-19 are likely, contact tracing’s utility and feasibility will decline.
The CDC has acknowledged that contact tracing and risk assessment of all potentially exposed healthcare workers may be impractical to implement in most large facilities. And while the strategy of testing all healthcare workers for COVID-19 may not be feasible at this point given the shortage of testing kits, devoting resources to contact tracing and retrospective risk assessment could divert resources from other important infection prevention and control activities.[10]
Strategies for the Healthcare Workplace: Testing of Healthcare Workers
Healthcare organizations will undoubtedly face major challenges around the demand to test for COVID-19. Once testing is widely available, healthcare organizations will need to determine whether they will test all of their healthcare workers – regardless of reported symptoms or exposure. The frequency of this testing will need to be carefully considered as healthcare workers clearly are at a higher risk of exposure to the virus given their often extensive and close contact with individuals in healthcare settings. While widespread testing may provide assurance that certain healthcare workers are negative for COVID-19, thus allowing them to remain working or return to work, it may also reveal asymptotic healthcare workers who have been providing care to patients.
Broadly, these challenges may include healthcare workers’ refusal to be tested,[11] the confidentiality of healthcare workers’ test results and the potential disclosure obligations related to a positive test result. Healthcare organizations will need to determine what steps are reasonable for reaching out to patients or visitors who have encountered such healthcare workers who test positive and what universal precautions for patients, family and visitors can be required by healthcare organizations to protect them in the healthcare setting. As accessibility to testing increases, healthcare organizations will have to weigh the risks and benefits that accompany access to this information.
The CDC issued interim guidance for risk assessment and public health management of healthcare personnel with potential exposure to COVID-19.[12] While this interim guidance should be referenced by healthcare organizations, it clearly is not definitive. Once testing for healthcare workers is widely available, while different situations may warrant different approaches, we foresee the following scenarios as emerging best practices for healthcare organizations faced with these issues:
- Healthcare workers who test negative: Because of the continuous risk of exposure, healthcare organizations may decide to routinely and repeatedly test healthcare workers. Organizations should emphasize appropriate infection control practices, such as wearing the appropriate personal protective equipment (PPE) and asking healthcare workers to report any known exposures as well as regularly monitoring themselves for fever and any symptoms of respiratory infection.
- Healthcare workers who test negative but have known exposure: Due to the incubation period of this virus and the continuous risk of exposure, these healthcare workers should be monitored daily for symptoms and perhaps be placed on a testing regimen, if permitted by the available resources. Depending on the risk exposure and with the proper PPE, asymptomatic healthcare workers may still be able to provide patient care during the testing regimen.
- Healthcare workers who test positive: Pursuant to the CDC’s recommendations, symptomatic healthcare workers who have tested positive for COVID-19 should cease patient care activities. However, this may prove difficult as the number of people infected with COVID-19 increases and the number of healthcare workers available to work decreases, due to infection, illness and attrition. Organizations may consider having healthcare workers who have tested positive but are asymptomatic provide indirect patient care in these situations. If demand significantly spikes and healthcare staffing resources are exhausted, facilities may be forced to consider more creative and unprecedented solutions, such as separating healthcare workers into cohorts – those who have tested positive for the virus and those who have not. If provided with the proper PPE, healthcare workers who have tested positive but are well enough to work could be permitted to care for patients who have also tested positive, allowing the healthcare workers who test negative to continue to care for otherwise healthy patients.
Conclusion
The increased availability of COVID-19 testing will be a mixed blessing for healthcare organizations. The anticipated demand to test healthcare workers frequently will need to be tempered by understanding better exactly who to test, how frequently to test them, and what to do regarding sharing information with those patients, families, visitors, vendors and other healthcare workers who have encountered those who have tested positive. Organizations should consult with competent legal counsel as they consider how to handle these situations as they arise.
[1] Occupational Safety and Health Administration, Guidance on Preparing Workplaces for COVID-19, https://www.osha.gov/Publications/OSHA3990.pdf.
[2] Centers for Disease Control and Prevention, Interim Guidelines for Collecting, Handling, and Testing Clinical Specimens from Persons for Coronavirus Disease 2019 (COVID-19), Mar. 17, https://www.cdc.gov/coronavirus/2019-nCoV/lab/guidelines-clinical-specimens.html.
[3] Centers for Disease Control and Prevention, Healthcare Professionals: Frequently Asked Questions and Answers, Updated Mar. 17, https://www.cdc.gov/coronavirus/2019-ncov/hcp/faq.html.
[4] Guan, W.J., et al., Clinical Characteristics of Coronavirus Disease 2019 in China. New England Journal of Medicine, February 28, 2020, doi: 10.1056/nejmoa2002032, https://www.nejm.org/doi/full/10.1056/NEJMoa2002032?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%3dpubmed.
[5] European Centre for Disease Prevention and Control, Rapid risk assessment: Novel coronavirus disease 2019 (COVID-19) pandemic: increased transmission in the EU/EEA and the UK, 6th Update, March 12, 2020 (citing Woelfel, R., Corman, V.M., Guggemos, W., Seilmaier, M., Zange, S., Mueller, M.A., et al. Clinical presentation and virological assessment of hospitalized cases of coronavirus disease 2019 in a travel-associated transmission cluster. medRxiv. 2020:2020.03.05.20030502). https://www.ecdc.europa.eu/en/publications-data/rapid-risk-assessment-novel-coronavirus-disease-2019-covid-19-pandemic-increased.
[6] Japanese National Institute of Infectious Diseases. Field Briefing: Diamond Princess COVID-19 Cases, February 20 Update, https://www.niid.go.jp/niid/en/2019-ncov-e/9417-covid-dp-fe-02.html
[7] Zou, L., Ruan, et al., SARS-CoV-2 Viral Load in Upper Respiratory Specimens of Infected Patients. New England Journal of Medicine, 382(12), 1177-1179. doi: 10.1056/nejmc2001737, https://www.nejm.org/doi/full/10.1056/NEJMc2001737?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%3dpubmed.
[8] World Health Organization, Considerations in the investigation of cases and clusters of COVID-19: Interim Guidance, March 13, 2020, available at: https://www.who.int/emergencies/diseases/novel-coronavirus-2019/technical-guidance/surveillance-and-case-definitions.
[9] National Institutes of Health, New coronavirus stable for hours on surfaces, Mar. 17, https://www.nih.gov/news-events/news-releases/new-coronavirus-stable-hours-surfaces.
[10] Centers for Disease Control and Prevention, Interim U.S. Guidance for Risk Assessment and Public Health Management of Healthcare Personnel with Potential Exposure in a Healthcare Setting to Patients with Coronavirus Disease (COVID-19), Mar. 7, https://www.cdc.gov/coronavirus/2019-ncov/hcp/guidance-risk-assesment-hcp.html.
[11] The U.S. Equal Employment Opportunity Commission (EEOC) has issued guidelines for testing employees during a pandemic, available at https://www.eeoc.gov/facts/pandemic_flu.html. However, if non-employed members of Medical Staffs refuse to be tested, consultation with competent legal counsel is recommended.
[12] Centers for Disease Control and Prevention, Interim U.S. Guidance for Risk Assessment and Public Health Management of Healthcare Personnel with Potential Exposure in a Healthcare Setting to Patients with Coronavirus Disease (COVID-19), Mar. 7, https://www.cdc.gov/coronavirus/2019-ncov/hcp/guidance-risk-assesment-hcp.html.
