Pandemic Presenteeism: CA Says HCWs with COVID-19 Can Skip Isolation
A California public health policy allowing asymptomatic healthcare workers with COVID-19 to remain on duty sparked outrage among some nurses, who say it threatens their prime mission to protect and care for patients.
“We have enough COVID in our hospitals. Having COVID-positive workers come to work is very dangerous,” says Sandy Reding, RN, president of the California Nurses Association (CAN). “It can spread between co-workers and patients. The transmission rates are high, our numbers are climbing, our hospitals are full. This seems absurd.”
“[Due to] the critical staffing shortages currently being experienced across the healthcare continuum because of the rise in the omicron variant, there is a change in return-to-work policy through Feb. 1, 2022. Healthcare personnel (HCP) who test positive for SARS-CoV-2 and are asymptomatic may return to work immediately without isolation and without testing, and HCP who have been exposed and are asymptomatic may return to work immediately without quarantine and without testing,” the California Department of Public Health (CDPH) stated in an All Facilities Letter. “These HCPs must wear an N95 respirator for source control.”1
Although the health department set a sundown date and issued a policy — not a regulation — opponents were wary of the move setting a precedent and increasing the level of presenteeism among workers. The CNA called for state health officials to rescind the policy, starting an online petition to rally support against the measure. Addressed to Gov. Gavin Newsom, the petition states “eliminating the isolation time and sending asymptomatic or exposed healthcare workers to work will guarantee more preventable transmission, infections, hospitalizations, and death.”2
“We will stand very strong against this, and we certainly don’t want it to be precedent-setting,” Reding said.
In a contrasting view, the policy will work as long as the healthcare workers abide by the outlined conditions, says Monica Gandhi, MD, MPH, director of the University of California, San Francisco (UCSF) Center for AIDS Research and professor of medicine and associate chief of the division of HIV, infectious diseases, and global medicine at UCSF.
“All healthcare workers in the state of California are required to be vaccinated,” Gandhi says. “Moreover, wearing an N95 mask at work will further minimize any chance of transmission, however miniscule.”
The CDPH letter was sent to acute care hospitals, acute psychiatric hospitals, and skilled nursing facilities throughout the state.
“These HCPs should preferably be assigned to work with COVID-19-positive patients,” the CDPH stated. “However, this may not always be possible in settings such as the emergency department, in which you may not know which patients are COVID-19-positive, or in areas where you may be experiencing extreme staffing shortages.”
The measure calls for facilities implementing this change to first make every attempt to bring in additional registry or contract staff, and must consider changes to non-essential procedures.
“At this time, all healthcare facilities should be planning for staffing shortages by adjusting staff schedules, hiring additional HCP, rotating HCP to positions that support patient care activities, identifying roles that can be cross-covered by those not specifically assigned to a role, and developing regional plans to identify designated healthcare facilities or alternate care sites with adequate staffing to care for patients with SARS-CoV-2 infection,” the CDPH stated.
Nurses, Occ Health Stepping Up
Staff shortages due to COVID-19 infection and isolation are widely reported, creating a vacuum at the bedside that can lead to adverse outcomes for patients. Nurses are stepping up to fill it.
“Everybody has felt this across the country, not just in California,” says Linda Dickey, RN, MPH, CIC, senior director for quality, patient safety, and infection prevention at UC Irvine Health. “I think it is a miracle what has happened. Nurses in particular — the ones who can work are working other shifts, weekends, holidays. They recognize they need to cover for their colleagues, so the ones who can work are working very hard.”
With this level of effort keeping staffing on track, Dickey said her hospital will continue to use antigen tests to clear workers from isolation and expects that many other state facilities will do the same. She credits her employee health and occupational health professionals for leading the way on return-to-work policies for SARS-CoV-2.
“Their data have shown most of our workers and nurses don’t test negative at day five, and many of them are not ready to come back that quickly,” says Dickey, 2022 president of the Association for Professionals in Infection Control and Epidemiology. “I think the intention was good on the part of the state, but from the provider perspective, we feel it is safer to have the [negative antigen test]. Also, it is tough working in an N95 respirator, especially if you’re not feeling well.”
Omicron is hitting healthcare workers with breakthrough infections even as hospitals face a surge of incoming patients.
“We have patients, unfortunately, in hallways and other spaces that we are creating to be able to safely care for them,” said Timothy Dellit, MD, infectious disease physician and chief medical officer at University of Washington (UW) Medicine. “We have just over 600 employees who are out within our clinical environment, either because of infection — about 450 — and 150 on quarantine because of exposure,” he said at a briefing to UW faculty and students.3 “We never saw that before with the previous waves.”
The UW policy for workers who test positive but remain asymptomatic is to isolate and retest at day five. “If they’re negative, they can come back,” Dellit explained. “If they had symptoms, but they are improving and they’re negative on day seven, then they can come back. If they’re positive, then they wait for the full 10 days.”
Joshua Barocas, MD, an infectious disease physician at the University of Colorado Anschutz Medical Campus, said his facility has planned and implemented multiple layers of staff backup.
“People on every service right now have been infected,” Barocas said at a recent briefing held by the Infectious Diseases Society of America (IDSA).4 “I can tell you that this is not just a matter of [clinical staff] — its environmental service workers, food service workers within the hospital and healthcare system.”
A CDC Hybrid
This California revision incorporated both updated Centers for Disease Control and Prevention (CDC) guidance for return to work polices for infected and exposed healthcare workers5 and recommendations to mitigate the effects of staff shortages caused by COVID-19.6 According to the latter guideline, “If shortages continue despite other mitigation strategies, as a last resort consider allowing HCP to work even if they have suspected or confirmed SARS-CoV-2 infection, if they are well enough and willing to work, even if they have not met all return-to-work criteria.”
The CDPH said it “aligned with CDC’s shortened duration of isolation and testing considerations for SARS-CoV-2-infected HCP and consolidated the CDC’s conventional, contingency, and crisis framework into ‘routine’ and ‘critical staffing shortage’ scenarios to reflect the current status of California healthcare facility staffing levels.”
The California policy is somewhat similar to the CDC recommendation in that infected workers in the general public can return after five days isolation without testing if they wear a mask for an additional five days. The theory is those first five days would cover the period of highest risk of transmissibility, and then masking would protect others. There clearly are people in the public who will not comply with the masking recommendation, and might skip isolation as well.
California healthcare workers would be expected to aspire to comply with the state policy, particularly if they are returning to work without isolating at all. If they breach the mask policy, they could pose a threat, as the results of two studies show people remain infectious with COVID-19 even after five days.
A study from the United Kingdom estimated 31% of people remained infectious after five days.7 Results of a European study revealed infectious particles in 54% of vaccinated people at day five, concluding that “perhaps isolation should not be shortened to five days as recommended by the CDC.”8
N95s for Source Control?
Daniel Lucey, MD, wore an N95 respirator for prolonged periods in a Toronto hospital during the SARS-CoV-1 outbreak in 2003. He concurs with the discomfort issue and the potential for breaches as healthcare workers briefly remove them for relief. Lucey also raises a critical question: Where is the science supporting this policy?
“Where are there any data that show SARS-CoV-2 cannot get outside an N95 respirator?” Lucey asks. “I’ve never seen it. We have never used N95 respirators [for source control], but to protect us from [airborne] pathogens like tuberculosis.”
A pandemic expert and consultant for IDSA, Lucey says allowing workers to stay on the job with COVID-19 threatens the bedrock medical principle of “first, do no harm.” It also raises the potential of “moral injury” to healthcare workers if they suspect or confirm a patient is infected.
“These healthcare workers are probably also wondering, ‘If I have to work with omicron with all the physical and emotional stresses, will that make it more likely that I will become symptomatic?’” Lucey says. “It is possible they will compromise their own health by doing this, and we will see more symptomatic cases. Then, they will be out for even longer.”
Overall, policies like the one in California could lead to a general increase in risk acceptance, as they depend heavily on validation of safety measures like proper fit testing and use of N95 respirators, says Cory Worden, PhD, MS, CSHM, a Houston-based expert in occupational health and safety.
“With increased risk acceptance, the probability increases for COVID-19 presenteeism,” Worden explains. “Validation of all safety protocols is necessary. Without it, the risk increases of healthcare workers simply working with COVID-19, unchecked. This outcome would negate the past two years of exposure prevention and could lead to overall risk acceptance culturally. It’s a slippery slope.”
The CNA says the issue is exacerbated by healthcare cost-cutting, with insufficient support staff to allow nurses to conduct their critical job of patient care. Some nurses are unwilling to work under these conditions, so the industry has a retention problem that compounds the pandemic effect.
“If you consistently don’t have enough nurses’ aides, secretaries — all of these duties fall to nurses,” Reding says. “Our concentration should be on healing people and making sure we can get to the bedside as soon we see any subtle decline in the patient’s health. COVID is no joke. We see people who can’t breathe. We are adjusting their oxygenation and monitoring them because it is a downward spiral that can be very rapid. We need to catch those symptoms so we can get them to the ICU.”
- California Department of Public Health. AFL 21-08.7 guidance on quarantine and isolation for health care personnel (HCP) exposed to SARS-CoV-2 and return to work for HCP with COVID-19. Jan. 8, 2022.
- National Nurses United. Tell Gov. Newsom: Rescind dangerous new guidance for nurses and health care workers!
- Infectious Diseases Society of America. IDSA media briefing: COVID-19 & omicron — practical advice. Jan. 11, 2022.
- University of Washington School of Public Health. SPH webinar — Winter quarter and the omicron variant. Jan 6, 2022.
- Centers for Disease Control and Prevention. Interim guidance for managing healthcare personnel with SARS-CoV-2 infection or exposure to SARS-CoV-2. Updated Jan. 21, 2022.
- Centers for Disease Control and Prevention. Strategies to mitigate healthcare personnel staffing shortages. Updated Jan. 21, 2022.
- Bays D, Whiteley T, Pindar M, et al. Mitigating isolation: The use of rapid antigen testing to reduce the impact of self-isolation periods. medRxiv 2021;12.23.21268326. https://doi.org/10.1101/2021.12.23.21268326. [Preprint].
- Puhach O, Adea K, Hulo N, et al. Infectious viral load in unvaccinated and vaccinated patients infected with 2 SARS-CoV-2 WT, delta and omicron. medRxiv 2022;01.10.22269010. https://doi.org/10.1101/2022.01.10.22269010. [Preprint].
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