Melanie D. Swift, M.D., M.P.H., a preventive medicine specialist at Mayo Clinic, reviews the Centers for Disease Control's current guidelines for employees returning to work after COVID-19 infection and what Mayo has experienced with its test-based strategy.
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Welcome to Mayo Clinic Cove in 19 expert insights and strategies. The following activity is supported in part by an independent medical education grant from Pfizer Inc and is in accordance with a C CMI guidelines. Welcome to Cove in 19 expert Insights and Strategies. I'm Dr Melanie Swift of the Mayo Clinic in Rochester, Minnesota. I have no relevant disclosures pertinent to this presentation, which is about how we return healthcare workers back to the workplace after they have had Covad. 19 are learning objectives are to. First of all, we want to describe the current CDC recommendations from making this return toe work decision as well as their underlying rationale, and then be able to provide some anticipatory guidance when counseling a covert positive worker about their return to work. So let me start with setting the point of view of the Occupational Health Service. When we look at this picture, most of us would identify the person on the right as the patient they are lying down, wearing it down, looking in distress and the calm, reassuring in control. Presence on the left is not usually considered the patient right. Well, welcome to our world, an occupational health. The person on the left is our patient, and that's who were dedicated to protecting. These are the heroes on the front line, but heroes air all too human. And unfortunately, our healthcare personnel can and do get infected with covert 19, whether from their work, their household members or community exposures. It's important to remember that the first priority when we diagnose Cove in 19 and a health care worker is to make sure they have their own medical care. It's surprising how many people don't have a primary care provider, and you know who. The worst patients, our doctors, right? They don't tend to have their own primary care physicians nearly as much as the rest of the population. It's important that we connect them to clinical care so that their underlying health conditions could be assessed medications and their risk for having complications of co vid. So I just want to start out with that. We can't forget that really crucial piece of care, the end connection that we provide. Second, we wanna make sure that they're isolated from others in the community and at home, but also obviously at work. We're not at this point considering returning people who have covert infection to the workplace. We interview each Mayo Clinic health care worker who develops co vid this index case investigation. Phone call. Ask several questions, and the first one is to try to identify any prior exposure, and that may have been occupational or non occupational. It's really helpful for us. Toe have, ah, finger on the pulse of what's going on in our worker community. If we know how many of them are getting exposed from their family members, community members, a zwelling from work, the second thing we want to do is find out when they worked and when they were communicable so that we know if there's a potential for exposure in the workplace and that then starts off contact tracing and you have a separate presentation in this Siris on contact tracing as a topic. So I won't delve into that. But it starts with knowing when the person was communicable when they worked. Then we issue a work restriction, um, to keep that person appropriately off work. There are people, though, who feel pretty well, if not at the beginning, at some point during their recovery, and they may want to tell a work, and so we sometimes will let people work remotely, but not on campus when they have Cove in 19. Then we discuss the return to work and start planning for that, which is the focus of this presentation. The first element in that decision is to assure that they're no longer communicable or infectious to other people. And that has been not such an easy question to answer, um, as well go into in a moment. Then there are other factors that may present a barrier to returning to work, most notably fatigue. Let's do just a little review of the timeline of this pandemic and are returned to work guidance. So we first found out about this new disease in the very last day of 2019, Um, and just a week later it was identified as a new coronavirus, and within two months it had about two months. It had been declared a pandemic about the World Health Organization in the US The first documented case that was confirmed at the time was January 21st, and then within three months we had 10,000 deaths in the United States another month and a half later. 100,000. Now we're over 200,000 who have fallen to this disease. Our first employees case, it Mayo Clinic was March 9th so relatively early. But there was no guidance from the CDC at that point about when that individual could return to work safely. The first return to work guidance didn't come out for another 15 days when the first set of guidance was issued. By that time, we actually had another 25 cases to manage and plan to return to work plan. On April 13th, CDCs guidance changed. By then, we were managing 101 cases or had already managed, um and so this is difficult when you're managing a population and a program and you're communicating with employees and their supervisors about thes, we're gonna be the criteria for when this person can come back to work. And then the guidance changes and you have to gear shift. Um, we've been very cautious about that on DSHEA shifting based upon making sure that we have a consensus in our institution. But it is a constant update. In April 30th, the CDC issued updated guidance again, and then the 17th of July, we had a major update. There was a minor update August 10th. And you know what? I don't think we're done with the changes. This slide is a table that I put together that compiles the changes over time. So you can kind of see what changed when, um at the beginning. It was very simple. Just make sure the person wasn't having a fever, was feeling better and had two consecutive negative PCR tests. Um, that kind of became the test based strategy. Um, And when April 13th rolled around, that was actually the preferred strategy of the CDC. They put forth a non test based strategy as well, which was really intended for places that couldn't do testing. Um on April 30th, the guidance evolved. This changed a little bit so that two things happened. One was that the duration of time for the non test based strategy before the person could come back to work increased from seven days to 10 days, and they called that they changed the terminology to symptom based strategy. And, um, at that point, they made the statement. They no longer were preferring one approach over the other facilities could do whatever they want. And this was based upon the CDCs knowledge that there was emerging data that people had really prolonged positive PCR tests and July there was a bit of an about face again informed by more and more information, more more data coming out that people remained symptomatic for not symptomatic. People remained PCR positive for prolonged periods of time, and there was increasing evidence that this no longer represented a communicable stage. So on July 17th, the CDC officially recommended the symptom based strategy, whereas previously they had recommended the test based strategy. Um, there were some changes to it at that time, lengthening the time off work for people who had severe or critical illness, Um, or people who were severely immuno compromised. The test based strategy was unchanged. It really didn't have a time element ever. Um, and the asymptomatic cases continued to be managed based upon the time since their positive test or two negative PCR is following their positive test. There was a minor change August 10th, which added both stem cell and solid organ transplant to the severely immuno compromising conditions and made a change that wasn't really a clarification a little more oven obfuscation off the time to be out a t least 10 days up to 20 days. And so there's this gray zone in between there where you can consult infectious diseases and make an individual decision. But I think most places air choosing either 10 days or for those, um, uh, people with underlying conditions that mean they may shed live virus longer, just going with the 20 days. So the current guidance is this. If you're symptomatic, it's recommended to use a symptom based strategy staying off work for 10 days or 20 since their symptom onset, making sure fever has resolved. And the 500 actually now says resolution for 24 hours of fever, an improvement in symptoms if they're asymptomatic just 10 days or 20 since their positive test, there still is a test based strategy that you could elect thio use. Um, it's really not recommended to use. This is first line, but if you had someone who really was continuing toe have symptoms that we're not improving, you could resort to doing the two consecutive negative piece ers improved that they really wasn't still co vid causing their symptoms. So That's one way that you could use the test based strategy now. Now what prompted all these changes? Why did we do it in about face? And it really is based upon medical literature that supports this is a reasonable and safe approach. The first study that was very relevant was this Taiwan contact tracing study of 100 Koven positive patients and over 2700 of their close contacts. This was the study that showed us that people were most communicable during the two days before their symptoms and the first five days after their symptoms. In this study, there were 852 people who on Lee had contact in that day, six through 14 period of the index cases illness. So they were not exposed during the pre symptomatic or early symptomatic period. But they were exposed after that, and none of them were found to have transmission, so that is very reassuring. One caveat to that study is that people were only tested if they reported symptoms, so it's possible there were some asymptomatic transmission. Um, that wasn't identified, but certainly much lower risk that the people who were exposed earlier on then the second study that was very important that came out in early summer was this Korean, uh, study that was released by the Korean C. D. C. In this study, they had 285 cases of people who had been hospitalized for cove it. And then they cleared their isolation, um, status with two negative P. C. R. S and got better and were discharged and then later got tested again and were found to be positive. And some of these people were tested because they had a symptom. Some of them were tested because they had an exposure. The average time was a month and a half, 45 days after their initial illness. But they had this re positive PCR So what They did waas meticulous contact tracing. They found the there were 790 identified close contacts. They were all followed and tested. And of that cohort, there were three newly confirmed cases. But on interview each of those three people had sustained an additional confirmed covert exposure in addition to this index case. So it was very difficult to attribute it to the index case and more likely came from this new exposure to someone who was newly infectious. So that was very reassuring. And even mawr reassuring was that they selected a subset of these and for culture. We don't do a lot of viral culture testing because of the safety precautions that are necessary to do this. And it requires biosafety level three, which is kind of a big deal. So they this was a really valuable contribution that they did the culture on 108 of these 285 people when they had their repeat positive PCR, and none of them had viable virus. So it wasn't live virus that they were that was being picked up by the PCR. In any of the cases, half of these folks were symptomatic. The other half were asymptomatic. So this helps us to feel very comfortable that even though people test positive for a prolonged period of time, which is really common, it can you contest positive up to 12 weeks after your initial reported positive that the replication, competent or live virus, does not persist this long. Well, we tried the test based strategy here in Mayo Clinic initially when this was the recommended approach and the conservative approach prior to codified guidance from the CDC. Our 1st 101 consecutive cases were done this way, and we analyzed the outcome so I'll share what we found thes were all male clinic employees or contractors that we had diagnosed with PCR, and we were managing their return toe work. We monitored them twice a day for symptoms and on day 11 are nurse would reach out and make sure they were clinically better. No fever symptoms improving and set them up for a test on day 12. Um, if they had persistent worsening or new symptoms or fever, we would delay three days and if we tested them and they were positive. Still, we would wait three days from, So this shows over time. What our experience. Waas. This is our 1st 101 employees each employee's one row and across the X axis. We have time from their initial positive test from day one at the left. Today, 45 at the right, each colored box indicates a test. The red boxes were positive. Test green were negative tests and the orange were indeterminate tests. And then the black box is the first day that they were returned to work. So what you can see is a lot of repeat reds. So lot of testing, waiting, three days testing again, still positive, waiting three days testing again, sometimes one negative, and then we repeat it and to be positive. So this was the pattern that we saw such that by 15 days. So after their two weeks on Lee, 12% had met criteria to return to work, and by 22 days waiting a full three weeks on Lee, 58% were able to return to work. So multiply this by the size of the organization and the number of people who ultimately would be covert positive. And you can see this is a huge amount of time to lose valuable healthcare workers from being able to take care of patients. In addition, there are a lot of logistic challenges. We had to figure out what to do with indeterminant P. C. R s, the logistics of getting people transportation to and from the test site when often they were also trying to take care of family members who had cove it. And also we're trying to get testing and coordinating everybody's test at the same time, which was a preference, but it was logistically difficult. There were also a lot of communication delays because we would be calling Thio ascertain if they were eligible based on symptoms and leaving a message waiting to hear back. And by the time you play phone tag for a little while, you can delay getting testing set up. So our current criteria have evolved to a symptom based strategy, which we actually shifted to before the C. D. C. Announced an official preference for the symptom based strategy. We wait 10 days or 20 since the positive test. Now, this is a difference from the C. D. C. And the reason is that we find that symptom onset date can sometimes be really difficulty thio to nail down. And it can change as the person's recollection changes over time. So for consistency of managing a program were more comfortable using the positive test than the symptom onset date. Also, it's a little more conservative because generally people develop symptoms and that prompts them to get testing. So the test date is almost always after the symptom onset date we make sure that there have been a federal. We make sure that they have been a federal for three days. And that is another, more conservative deviation from CDC guidance, which calls for them to be a federal for 24 hours. Um, and we make sure that they're feeling well enough to come back to work now. This is becoming a bigger and bigger issue as we have more and more people who are recovering from co vid recovery is not instantaneous. It does take time. This study that was published in the MMWR in July involved 270 adults, and they waited at least two weeks after the person was co vid positive and interviewed them over a third of them were not yet feeling back to their normal state of health. That includes one out of five young adults who were under 35 years old. Furthermore, the symptoms that people experience may not be respiratory symptoms in this study by car fee at all. In JAMA, 143 patients were interviewed after their covert hospitalization, so a little bit sicker group of people they were in the hospital, but they did wait two months after discharged to conduct this survey. What they found was a staggering 87% of them still had symptoms, and and the most common symptom was fatigue. So when you think about that in returning someone to work, if you have someone whose job is physically demanding or requires long shifts or requires that they be mentally alert and nimble and attentive, then it could be a challenge to try to come back to that type of a job if you're suffering from significant fatigue. So we have actually found that, um, there's a significant number of people who can't go 0 to 60 back to their normal job the first minute that they're cleared from an infectious consideration. But they may need some time of gradual react claymation to work. So, in conclusion, use the symptom based strategy. This is because the test based strategy is not only labor intensive, it requires multiple repeat tests, and it results in really prolonged absences for most people. You could still use this selectively, but it is not recommended in most cases, nor is it necessary for safety. Also remember that determining that someone's no longer infectious is only part of the equation and getting them ready to work requires considering all those other factors of their strength and their stamina and energy. Also, we still have a lot to learn about this disease it keeps on teaching us, and so I don't expect that this is the end of the story. I expect that over time we will get better and better at determining when people can return to work at the earliest safest opportunity when they're able to again safely take care of their patients or do their other important job duties. Thank you so much for your time, and I hope that this presentation was helpful to you.