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 Table of Contents  
LETTER TO EDITOR
Year : 2021  |  Volume : 10  |  Issue : 3  |  Page : 249-251

COVID-19-positive health-care workers in an oncology setup: Considerations for return to work


1 Department of Microbiology, ACTREC-TMC, HBNI, Navi Mumbai, Maharashtra, India
2 Department of Composite Laboratory, Composite Laboratory, ACTREC-TMC, HBNI, Navi Mumbai, Maharashtra, India
3 Department of Medical Administration, ACTREC-TMC, HBNI, Navi Mumbai, Maharashtra, India
4 Department of Medical Oncology, ACTREC-TMC, HBNI, Navi Mumbai, Maharashtra, India

Date of Submission28-Sep-2020
Date of Decision01-Apr-2021
Date of Acceptance09-Apr-2021
Date of Web Publication04-Aug-2021

Correspondence Address:
Dr. Preeti D Chavan
Composite Laboratory, ACTREC-TMC, HBNI. Plot No. 1 and 2, Sector 22, Kharghar, Navi Mumbai - 410 210, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijhas.IJHAS_240_20

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How to cite this article:
Bhat VG, Chavan PD, Bhat PC, Khattry NS. COVID-19-positive health-care workers in an oncology setup: Considerations for return to work. Int J Health Allied Sci 2021;10:249-51

How to cite this URL:
Bhat VG, Chavan PD, Bhat PC, Khattry NS. COVID-19-positive health-care workers in an oncology setup: Considerations for return to work. Int J Health Allied Sci [serial online] 2021 [cited 2024 Mar 29];10:249-51. Available from: https://www.ijhas.in/text.asp?2021/10/3/249/322991



Sir,

Health-care facilities and public health authorities all over the world are grappling with the problem of their staff being infected with COVID-19, and the issue of when to allow them to return to work and resume care of patients is a decision that has to be taken on a daily basis. This is a particularly sensitive issue in a cancer or a transplant setting, where most patients are immunocompromised, and there is a fear that a health-care worker (HCW) who is shedding virus may infect these patients and other staff. While the United States Centres for Disease Control (CDC) and the Ministry of Health and Family Welfare (MOHFW) Government of India have addressed this issue to some extent with their interim guidance, health-care authorities would like greater clarity regarding the same. The CDC favors symptom-based strategy in general for their return to work criteria. The guidelines say that, for mild and moderate cases, at least 10 days must have passed since onset of symptoms with at least 24 h without COVID-19-related symptoms such as fever, cough, and shortness of breath; and for severely ill and immunocompromised HCWs, it must be from 10 up to 20 days since onset of symptoms, but with complete resolution of COVID-like symptoms for ≥24 h for allowing them to return to work.[1] A test-based strategy may also be used for severely ill and immunocompromised HCWs, in which in addition to improvement of symptoms and no fever, two consecutive reverse transcription polymerase chain reaction (RT-PCR) assays for SARS-CoV-2 collected ≥24 h must be negative. The Indian MOHFW guidelines require one RT-PCR test to be negative for severely ill and immunocompromised patients to return to work after resolution of symptoms.[2]

There are several issues that health-care facilities face while dealing with the problem of COVID-19-positive individuals and high-risk contact HCWs. One problem is shortage of trained staff, especially in key areas such as intensive care units, transplant units, and the problem of dealing with their absence in terms of substitute staff and leave issues. Another dilemma is whether these staff who have returned to work can be immediately posted to areas with high-risk immunocompromised patients. At the same time, staff shortage may be alleviated by allowing them to return back to work at the earliest. However, this needs to be balanced against the risks.

The detection of virus in RT-PCR from upper respiratory samples of infected individuals has been observed for up to 2–12 weeks, the median being 3–4 weeks, in various studies.[3],[4] However, the duration of shedding of infectious virus in published studies has been observed to be up to 20 days with a median of 8 days.[5] There was a ≤5% chance that live virus can be isolated after ≥15 days since the onset of symptoms. Therefore, although the COVID-19 positive patient may demonstrate the presence of virus RNA in RT-PCR tests in nasal and pharyngeal swabs beyond 2–3 weeks after onset of symptoms, it may not be replication competent, and as such not pose an infection risk to other patients or HCWs. The body also responds to the infection by way of producing antibodies to SARS-CoV-2 virus. Many test methods have been developed to detect the presence of various antibodies against COVID-19 virus protein such as Nucleocapsid, Spike Protein, Envelop, and Membrane. However, neutralizing antibodies against receptor binding domain (RBD) which is on S1 unit of Spike protein remain important. The United States Food and Drug Administration has authorized new tests that are capable of giving an estimate of these neutralizing antibodies in patients who have recovered from the SARS-CoV-2 infection,[6] Although semi-quantitative, these tests give an estimate of the amount of antibodies that are present in these patients. The detection of neutralizing antibodies has been associated with decreased risk of transmission in COVID-19 patients. Kai-Wang et al. showed that the appearance of anti-SARS-CoV-2-RBD IgG antibodies by day 14 after onset of symptoms correlated well with the virus neutralization titer.[7] Wölfel et al. found that seroconversion occurred in all patients in 2 weeks,[4] and live virus could not be isolated from any of these seroconverted patients. The Korea CDC report also found an inverse relation between virus culture and appearance of neutralizing antibodies.[3]

Based on the above studies, we propose an interim guidance algorithm that makes the use of neutralizing antibodies and RT-PCR tests to formulate a strategy for HCWs returning back to work after testing positive for COVID-19 [Figure 1]. As various studies showed the duration of shedding of infectious virus to be up to 20 days, we propose to keep the period of isolation for HCW for 21 days. This would be followed by a repeat RT-PCR test and test for the presence of neutralizing antibodies. The presence of neutralizing antibodies and absence of symptoms for at least 3 days, irrespective of RT-PCR status, would be used as the criteria for the HCW to join the work after a mandatory 21-day period of isolation was over [Figure 1]. This algorithm would apply mainly to centers with severely ill or immunocompromised patients as in a cancer and transplant setting like ours and will be helpful in both protecting patients and staff from spread of COVID infection as well as help to reduce the staff shortage. As COVID-19 is an evolving disease, and as more information becomes available, the strategy may be modified as need be. The addition of neutralizing antibody test to the algorithm can serve as an additional buffer in terms of reducing transmission from recovered COVID-19-positive HCWs returning to work. This may also help in getting the health-care workers back sooner to their duties and can serve as a boost to the already depleted human resources of health-care facilities.
Figure 1: Protocol for return to work for health-care workers (original)

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Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Center for Disease Control and Prevention. Interim U.S. Guidance for Risk Assessment and Work Restrictions for Healthcare Personnel with Potential Exposure to COVID-19. Available from: https://www.cdc.gov/coronavirus/2019-ncov/hcp/guidance-risk-assesment-hcp.html. [Last accessed on 2020 Sep 02].  Back to cited text no. 1
    
2.
Ministry of Health & Family Welfare Directorate General of Health Services (EMR Division) Government of India. Advisory for Managing Health Care Workers Working in COVID and Non-COVID Areas of the Hospital. Available from: https://www.mohfw.gov.in/pdf/ReviseddischargePolicyforCOVID19.pdf. [Last accessed on 2020 Sep 02].  Back to cited text no. 2
    
3.
Korea Centers for Disease Control and Prevention. Findings from Investigation and Analysis of Re-Positive Cases. May 19, 2020. Available from: https://www.cdc.go.kr/board/board.es?mid=a30402000000&bid=0030&act=view&list_no=367267&nPage=1. [Last accessed on 2020 Sep 02].  Back to cited text no. 3
    
4.
Wölfel R, Corman VM, Guggemos W, Seilmaier M, Zange S, Müller MA, et al. Virological assessment of hospitalized patients with COVID-2019. Nature 2020;581:465-9.  Back to cited text no. 4
    
5.
Van Kampen J, van de Vijver D, Fraaij P, Haagmans B, Lamers M, Okba N, et al. Shedding of infectious virus in hospitalized patients with coronavirus disease-2019 (COVID-19): duration and key determinants. (Preprint) Medrxiv. 2020. Available at: https://www.medrxiv.org/content/10.1101/2020.06.08.20125310v1 doi: https://doi.org/10.1101/2020.06.08.20125310.  Back to cited text no. 5
    
6.
U.S. Food & Drug Administration. Coronavirus (COVID-19) Update: FDA Authorizes First Tests that Estimate a Patient's Antibodies from Past SARS-CoV-2 Infection. Available from: https://www.fda.gov/news-events/press-announcements/coronavirus-COVID-19-update-fda-authorizes-first-tests-estimate-patients-antibodies-past-sars-cov-2. [Last accessed on 2020 Sep 02].  Back to cited text no. 6
    
7.
Kai-Wang To K, Tak-Yin Tsang O, Leung W, Tam AR, Wu TC, Lung DC, et al. Temporal profiles of viral load in posterior oropharyngeal saliva samples and serum antibody responses during infection by SARS-CoV-2: An observational cohort study. Lancet Infect Dis 2020;20:565-74.  Back to cited text no. 7
    


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