key: cord-0818287-57liv13z
authors: Wang, Jiancong; Lee, Yew Fong; Zhou, Mouqing
title: What is the best timing for health care workers infected with COVID-19 to return to work?
date: 2020-07-03
journal: Am J Infect Control
DOI: 10.1016/j.ajic.2020.06.217
sha: 862a1ee3f30305e42bd946a76aa414965426e291
doc_id: 818287
cord_uid: 57liv13z

nan

What is the best timing for health care workers infected with COVID-19 to return to work?

The current COVID-19 pandemic has exposed the health care system to its greatest risk, evident with a rapid depletion of medical resources and draining of intensive care units' capacity. 1 Nosocomial transmissions, especially health care workers (HCWs) getting infected with COVID-19 in health care facilities, have been reported by many countries, for example, 20% in Lombardy (Italy) and 26% in Spain, respectively. 2 Wang et al 3 advocated a need to increase the awareness of personal protection (ie, sufficient personal protective equipment and appropriate hand hygiene) in order to minimize the impacts from the loss of the frontline workforces due to infections; however, the question of "what is the best timing for HCWs infected with COVID-19 to return to work" was not still addressed. Globally, monitoring and identification of HCWs with COVID-19 have raised concerns. The main 2 strategies that need urgent attention are: (1) symptom monitoring and screening of HCWs; (2) suitability of HCWs Return-to-Work postinfection. In general, policy-makers and researchers supported and agreed with the strategy of symptom monitoring and screening, which should include: (1) active self-monitoring (ie, self-reporting of signs and symptoms of COVID-19), (2) continuous screening (ie, cross-sectional serological testing), (3) detection of asymptomatic or mildly symptomatic cases among HCWs, and (4) conducting self-quarantine; even though strategy of symptom monitoring and screening poses significant administrative and financial challenges across countries. However, the best Returnto-Work strategy has been debated widely, when balancing between the health status of HCWs and capacities of health care services.

In the United States of America, symptom-based (at least 10 days have passed since symptoms first appeared) and test-based strategies (negative results for SARS-CoV-2 detections from at least 2 consecutive respiratory specimens collected ≥24 hours apart) are proposed by the Centers for Disease Control and Prevention as the Return-to-Work criteria. 4 In Canada, health authorities justified allowing COVID-19 positive HCWs to return to work 10 days from the start of them having symptoms. 5 In Germany, home quarantine periods are recommended 14 days after being tested negative or without respiratory symptoms; in the case of staff shortages, the criteria of minimum 48 hours without symptoms and with 2 consecutive negative testing are applied. 6 Although these recommendations are implemented with the aim to protect health care workforces, these measures remain a great challenge for developing countries (ie, Brazil) especially when the large number of HCWs infected with COVID-19 were on leave from work, resulting in the depletion of workforces. 7 Therefore, criteria of HCWs Return-to-Work in high-income countries may not be implementable and adoptable in the developing countries. As such, issues to consider are: (1) Should Return-to-Work strategy be based on HCWs who have recovered or had an asymptomatic infection but without risk of increased transmission?, (2) Should Returnto-Work strategy be based on confirmatory of negative polymerasechain-reaction (PCR) testing alone and/or in the combination with detection of either all negative antibodies or IgM (À) and IgG (+) for the signal of recovery?, (3) Should Return-to-Work strategy be based on longitudinal clinical observation of HCWs with protective immune response against SARS-CoV-2?, (4) Should Return-to-Work criteria be more or less restrictive?, and (5) How can Return-to-Work policies be adjusted to reduce the loss of health care workforces?

Based on current best available scientific evidence, the median of SARS-CoV-2 incubation period is 5.1 days (95% confidence interval 4.5-5.8 days), and 97.5% of those who develop symptoms will do so within 11.5 days (95% confidence interval 8.2-15.6 days) of infection. 8 Furthermore, current hypothesis has suggested that the population infected with COVID-19 are able to produce protective neutralizing antibodies, and the level of titer of which are related to whether it provides the protection from reinfection and the effects of inhibiting SARS-CoV-2 replication in mechanism. 9 Hence, ideally, the best recommended Return-to-Work strategy for COVID-19 positive HCWs would be 14 days of home quarantine, along with 2 consecutive negative PCR testing at a 48 hours interval, without clinical respiratory symptoms and CT imaging progress. However, in reality, in order to possibly reduce the loss of the frontline workforces, we propose that alternative strategies are also implemented in various regions/countries to address limited medical workforces, that is, allowing asymptomatic and mildly symptomatic HCWs with only 8-9 days of home quarantine, along with both 2 negative PCR testing at a 48 hours interval, and detection of either all negative antibodies or IgM (À) and IgG (+) of SARS-CoV-2, before returning to work. Other infection control measures should be stringently applied, that is, self-active monitoring, temperature surveillance, hand hygiene practices, appropriate personal protective equipment, appropriate face masking, and social distancing.

More research (ie, repeated cross-sectional sero-epidemiological study) is urgently needed for policy-makers to make an informed decision on the best timing for HCWs infected with COVID-19 to Return-to-Work. In-depth analysis and knowledge are required to understand the effectiveness and safety of shortening home quarantine when combined with other infection control measures, which should take into consideration immune response and possibly reinfection. With this, health services would be most efficient where HCWS are protected and more lives can be saved.

Could the COVID-19 pandemic aggravate antimicrobial resistance?

Dear editor:

The coronavirus disease 2019 (COVID-19) pandemic reached Latin America later than other continents. The first case recorded in Brazil was on February 25, 2020, and 4 months later (June 20, 2020) there have been 1,032,913 confirmed cases including 48,954 deaths. These numbers have made Latin America the epicenter of the disease in the world (Fig 1) (Data extracted from COVID-19 Dashboard by the Center for Systems Science and Engineering at Johns Hopkins University, June 20, 2020). Some points regarding COVID-19 in the world should be highlighted: (1) COVID-19 hospitalized patients at Intensive Care Units (ICU) share underlying diseases associated and risk factors to bacterial and fungal infections, such as corticosteroid therapy, chronic respiratory diseases, intubation/mechanical ventilation, and immunoinflammatory response (cytokine storm) 1 ; (2) Secondary infections were found in 50% of COVID-19 mortalities. Therefore, bacterial and/or fungal secondary infections or coinfections are a probable factors that affect mortality of critically ill patients with COVID-19 1 ; (3) In hospital care the rate of antibiotics usage (94%-100%) was much higher than the reported incidence of secondary infection (10%-15%) 2 ; (4) During the COVID-19 pandemic hospitals are overcrowded, with some medical centers reporting 50% more patients than normal. 2 The increase in the number of invasive procedures associated with the use of antibiotics, steroidal anti-inflammatory and other immunomodulatory drugs and the overcrowding in health care settings may lead to an increase in Healthcare-Associated Infections. At the same time, there may be an increment in the severity of Healthcare-Associated Infections, resulting from the exposure of the patient's microbiota to these factors, through the selection, emerge and spread of resistance factors and more virulent microorganisms. In Brazil, these facts are particularly worrying. The overall prevalence of ICU-acquired infections in Brazilian hospitals is higher than reported in most European countries and the USA, with a greater proportion of infections caused by Gram-negative bacteria. 3 Another point which should be considered is the telemedicine modality implemented to help in COVID-19 diagnosis and treatment. Previously the use of telemedicine to monitor antimicrobial stewardship showed better antibiotic selection and reductions in bacterial resistance. However, a study developed in a pediatric population reveals that over prescription of antibiotics is much more common in telemedicine than in face-to-face visits. 4 Thereby, telemedicine antimicrobial prescription during the COVID-19 pandemic should be observed to avoid exacerbating antibiotic prescription. At moment, no antimicrobial stewardship interventions were described for COVID-19 in Brazil. Thus, microbiological data must necessarily be collected, mainly to identify pathogens, previously described or emerging, related to secondary infections in patients with Severe Acute Respiratory Syndrome. 5 Today Brazil is the third country in terms of the absolute number of the deaths by COVID-19, and the Brazilian states with lower health resources have shown the highest mortality rate. Similarly, the number of hospitalizations has also increased. These observations alert us to the worsening of the antimicrobial resistance problem in Brazil, during and after the COVID-19 pandemic. Consequently, it is 0 1,000,000 2,000,000 3,000,000 

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