My father was a career educator with over four decades of teaching and coaching experience. One of his most frequent and powerful statements was, “practice does not necessarily make the perfect, only perfect practice makes perfect.“ In other words, the things we execute must be connected to an appropriate level of proper preparation.
As we survey the COVID-19 global pandemic landscape from the perspective of its impact on the workplace, we can find that there are a number of health and safety “practices“ that are far from “perfect“
This does not suggest that there is a perfect mechanism for navigating this landscape, however there is enough vetted and reliable scientific and public health data to fuel sound, evidence-based decision-making, particularly as it relates to managing employees that require quarantine and/or isolation as a result of confirmed COVID-19 positivity, exposure to known COVID-19 positive individuals or contact with individuals who have been tested who do not yet know their test results.
WHAT WE CURRENTLY KNOW
1. The virus thrives in spaces where people congregate; most notably in indoor spaces
2. There are still no widely available treatments for the infected
3. A large percentage of patients of all ages have mild-to-moderate symptoms or no symptoms at all
4. There is still no ‘cure’ and a safe, reliable and widely distributable vaccine is still likely 6 months to a year away
5. As we enter the fall/winter season, best estimates suggest that only 10-15% of the US population has been exposed (and therefore presumed, though not confirmed immune) to COVID-19
LACK OF STANDARDIZATION
Anecdotal evidence from within the Greater Pittsburgh business community suggests that there is considerable variation with respect to some critically important elements in determining the need for and nature of quarantine. These areas include:
Variation In Defining A Fever: A clinical fever is defined as a temperature greater than 100.4°. There is no such thing as a “low grade fever“ from the clinical standpoint. Individuals conducting surveillance ranging from private businesses, government offices and educational institutions have defined fever with temperatures ranging from 99.0 to 101. The current CDC recommendation with respect to fever in the context of COVID is that any temperature greater than 100 should be considered abnormal from a symptom-screening standpoint. Inaccurate information with respect to defining fever is likely to impact who might be included in a quarantine roster. Omitting people who should be included places employees and the workspace at risk, while including individuals who could be excluded may result in potentially unnecessarily high workplace absentee rates.
Variation In Symptom Number. Surprisingly, there is a little variation with respect to what the symptoms are, though periodically new symptoms are being added to the list of potential COVID-19 symptoms. What is distressing however is that many entities have added the caveat that you must have “more than one“ symptom to be considered eligible for quarantine. This is not part of the current CDC guidance. When you consider that upwards of 30% of adults and closer to 50% of teenagers may have no symptoms at all, it is alarming that business and academic environments have taken it upon themselves to add this potentially dangerous stipulation when screening their workers or students. There is presently no readily accessible data to suggest that having more than one COVID-19 symptoms makes infection more likely compared to having only one symptom. The guidance is clear that certain non-specific symptoms (such as cough, congestion, sore throat) may be excluded only if they can be confidently attributed to another identifiable cause such as seasonal allergies. Again, non-scientifically-based modification of the guidance provided by the medical and public health community places workers at considerable risk.
Variations In Community Physician Guidance & Response: Unfortunately, there is as much variation in physician responses to COVID-19 as there appears to be within community response. Some physicians have taken it upon themselves to omit certain symptoms from their own clinical screening. Others have opted to employ non-evidence-based strategies to modify periods of quarantine. I recently had a patient who was told by a community physician that if they quarantined their child “just for the weekend“ and they remain fever free, they could return to school. The variations in physician management and response to symptomatic patients as well as those without symptoms but at-risk, potentially exposed and those simply desiring testing is a symptom to a largely dysfunctional National medical response to this pandemic. The result, however, has the potential to have potentially disastrous local consequences. The impact on the workplace is that in the absence of a standardized and centrally-coordinated workplace response, the potential exists for employees to be ‘cleared’ to return to the work environment without having met any of the recommended surveillance guidance.
Variation In Quarantine Procedure & Duration: There have been very few modifications in the duration of quarantine for individuals who have been infected and those who have been exposed and not yet tested. Despite this consistency, there is considerable variance with respect to quarantine practices.
Variation In Testing Procedures: There are currently two general categories of available COVID-19 screening tests—the antigen test and the RT-PCR test. Both tests have the capacity to be sent to outside labs for analysis and both testing platforms are now available as rapid, on-site tests that can produce results within 15-20 minutes. Within the framework of these two testing platforms, there is a test-based strategy for shortening quarantine periods by documenting two negative test results separated by at least 24-hours. Currently, the CDC only recognizes the RT-PCR testing platform for use for test-based shortening of a quarantine period owning to its documented superior accuracy and reliability. Many business and educational entities that are employing test-based strategies to ‘clear’ employees to return to work are either utilizing the antigen testing platform that is not recommended and/or they are only requiring one negative test as ‘evidence’ of negativity.
WORKPLACE SAFETY THROUGH EVIDENCE-BASED STANDARDS
The current best practice guidelines from the Centers for Disease Control recommend either of two options for self-quarantined individuals: a time and symptom-based approach and a test-based approach. Knowing the ins and outs of these two pathways is the first step in determining which might be the best and safest for your workforce.
The Time And Symptom-Based Approach
The time and symptom based quarantine approach requires a 14-day period of self-quarantine, with close monitoring of symptoms including fever. Individuals would be considered ‘cleared’ to end quarantine after 14, if either an asymptomatic individual has remained asymptomatic or a symptomatic individual can report improvement in symptoms. Additionally, the quarantined individual will have to have remained fever-free for at least 24-hours without the aid of a fever-reducing medication. If an asymptomatic individual develops symptoms or a symptomatic individual experiences new or worsening symptoms, the quarantine period would be extended and COVID-19 testing would be recommended.
The Test-Based Approach
There are a two important elements to the test-based approach that individuals and businesses must consider if opting to consider this pathway—they are the type of test used and the timing of the tests.
Current CDC guidance recommends only the use of the RT PCR test due to its documented accuracy and reliability. The CDC does not currently recognize rapid antigen testing platforms for use in the test-based approach due to documented false-negative rates as high as 30%. Under the test-based approach, an individual under self-quarantine must have two negative RT-PCR tests separated by at least 24-hours. If both tests are negative, the individual would be considered CLEARED to resume work without completing an entire 14-days of self-quarantine.
A PRACTICAL EXAMPLE
An individual placed under quarantine on a Monday for an exposure to a presumed/confirmed COVID-19 positive individual would need to remain in quarantine for 14-days (or potentially longer depending on symptoms) under a time/symptom-based approach, while that same individual using the test-based approach could be tested on Tuesday and Wednesday—and cleared by Wednesday/Thursday assuming both tests were negative.
BENEFIT OF STANDARDIZATION
Whether a business opts to use a time/symptom or a test-based approach, standardization of the process optimizes the likelihood that all employees are being managed in a way that is consistent company-wide and anchored to currently available and vetted best-practices.
As companies re-acquire their footing after the first wave of the COVID pandemic, there are still many questions to be asked as it relates to shaping health and safety policies that balance employee health and wellness against productivity and profitability. Because the presence and footprint of this pandemic will linger for the foreseeable future, companies will be hungry for external partnerships that can assist them in navigating the logistics of the COVID-impacted workplace.
And with the flow of information and best-practice recommendations ever-changing and as we learn more about the novel coronavirus, only time will tell how this necessary synergy between business and healthcare impacts the marketplace. As we continue to navigate the landscape of the COVID-19 global pandemic, it is clear that the ‘new normal’ will require both continued attention to ever-changing information, and best-practice approaches to disease surveillance and contact-tracing that are streamlined and standardized.
Even when a viable, safe and widely distributable vaccine reaches the healthcare marketplace, businesses will need to have access to clear and consistent best-practices with respect to managing their employees as well as access to reliable help-resources.
Presently many businesses have some semblance of a workplace guideline which often directs the employee to have their return-to-work coordinated by a primary care source or urgent care center. This flawed approach, though shifting the burden of surveillance to the employee opens the door to a workforce and a workspace with sub-optimally mitigated risk.
Understanding the landscape of the COVID-workplace interface is the best way to co-manage the workforce and the bottom-line. Knowing and understanding the facts while also working to seamlessly integrate and translate this knowledge into practical and workable workplace practices allows for targeted responses when COVID finds its way into your businesses’ workspace.
Christopher T. Conti, MD is a concierge physician with Connected Health in Wexford, PA, where he provides primary care services while also specializing in emergency medicine, disaster medicine & preparedness, sports & concussion health, travel medicine and occupational health. He is also a pastor, community advocate and author with specific interest in population health and health equity and justice.