key: cord-0956404-f77h58ux
authors: Bundgaard, Johan S.; Raaschou-Pedersen, Daniel T.; Todsen, Tobias; Ringgaard, Anna; Torp-Pedersen, Christian; Von Buchwald, Christian; Iversen, Kasper; Bundgaard, Henning
title: Danish Citizen´s Preferences for at-home Oropharyngeal/nasal SARS-CoV-2 Specimen Collection
date: 2021-07-01
journal: Int J Infect Dis
DOI: 10.1016/j.ijid.2021.06.060
sha: 59437ddb6fb0bb726ccefc052007f928595b8370
doc_id: 956404
cord_uid: f77h58ux

INTRODUCTION: Diagnostic confirmation of SARS-CoV-2 by self-collection of specimens is a reliable method compared to healthcare worker collected samples. Citizen's preferences for collection method are unknown, but at-home collection could have several advantages. METHODS: This study investigated the preference for guided at-home self-collection versus at-hospital specimen collection by healthcare workers. RESULTS: Among the 3,709 participants, an at-home swab collection was the preferred setting for 2,362 (63.7%), as compared with 1,347 (36.3%) reporting a preference for an at-hospital swab procedure. CONCLUSION: A high preference for guided at-home self-collection of oropharyngeal/nasal SARS-CoV-2 Specimen exists and could be a future norm beyond COVID-19.

Summary: 24

Introduction: Diagnostic confirmation of SARS-CoV-2 by self-collection of specimens is a reliable 25 method compared to healthcare worker collected samples. Citizen's preferences for collection 26 method are unknown, but at-home collection could have several advantages. 27

Methods: This study investigated the preference for guided at-home self-collection versus at-28 hospital specimen collection by healthcare workers. 29

Results: Among the 3,709 participants, an at-home swab collection was the preferred setting for 30 2,362 (63.7%), as compared with 1,347 (36.3%) reporting a preference for an at-hospital swab 31 procedure. 32

Conclusion: A high preference for guided at-home self-collection of oropharyngeal/nasal SARS-33

CoV-2 Specimen exists and could be a future norm beyond COVID-19. Organization, 2021). The gold standard method for diagnostic confirmation of SARS-CoV-2 is by 38 reverse transcriptase polymerase chain reaction (RT-PCR) using nasopharyngeal specimens 39 collected by a swab. We (Therchilsen et al., 2020) and others (Tu et al., 2020) have found that self-40 collection of SARS-CoV-2 specimens is a reliable method compared to healthcare worker (HCW) 41 collected samples with acceptable agreement of Cohens kappa 0.82 and without any significant 42 difference in diagnostic sensitivity (84.2% and 89.5%, respectively, p = 0.81). Self-collection has 43 also been found to be acceptable for citizens (Valentine-Graves et al., 2020). Reliability and 44 acceptability has been established, but citizen's preferences towards collection method are 45 unknown and in order to succeed in impeding transmission of SARS-CoV-2 the inclusion of citizen's 46 preferences is essential, as previous research has shown that anticipated use of at home self-tests 47 for other infectious diseases can be misguiding due to behavior that can be uncovered by 48 assessing citizens or patients thoughts (Colfax et al., 2002) . COVID-19 has stressed bed capacity, 49 equipment, and healthcare personnel making healthcare resource allocation a higher priority than 50 usual (Emanuel et al., 2020) . In the Danish population of 5,8 million citizens, Danish health 51 authorities report that more than 35 million PCR tests for SARS-CoV-2 have been conducted at the 52 testing facilities and a PCR test have been carried out on 84% of the Danish population 53 . In Denmark there are 662 test centers (PCR and antigen) resulting in 54 massive employment, which potentially could be carried out at-home (Danish-Regions, 2021). The 55 pressure on the healthcare system can be accommodated by moving diagnostics from at-hospital 56 to at-home. It has previously been shown that a hierarchy of willingness to test for SARS-CoV-2 is 57 ordered by degree of contact required and that at-home specimen collection options could result 58 in around one-third more symptomatic persons being tested without any difference in willingness participants were limited to non-mask wearing jobs and was distributed across various sectors In 81 order to reduce confounding related to recruitment, participation was free-of-charge and we used 82 nationwide advertisement through multiple channels. Participants received surveys by e-mail and 83 reminders by phone (text-messages). All participants conducted one or two at-home swabs 84 according to the trial description prior to reporting preferred setting of swab procedure. 85

Participants who had performed at least one at-home swab procedure and responded to 86 preferred setting for future swab procedures were eligible for the present substudy. Participants 87 received materials and instructions at-home and free of charge. In order to perform the self-88 collected swab procedure at home, a detailed 2-minute video guidance of an oropharyngeal/nasal 89 swab (Therchilsen et al., 2020) procedure carried out by a HCW and a written step-by-step manual 90 were provided (Bundgaard et al., 2020) . Participants returned the test material by a prepaid 91 express courier. At-hospital SARS-CoV-2 testing by swab was free of charge during the study 92 period for all Danes. Surveys were sent by e-mail to assess participants' preference for SARS-CoV-2 93 swab setting for future specimen collections. Participants answered the surveys through Research 94

Electronic Data Capture (REDCap) software (Harris et al., 2009) and the study question was "In the 95 future, what would you prefer if you had to be swab tested?" with three answering categories a) 96

Self-swab at home -and I think it was easy, b) Self-swab at home -but I think it was difficult or c) 97 procedure for SARS-CoV-2 testing was the preferred setting for 2,362 (63.7%), as compared with 110 1,347 (36.3%) reporting a preference for an at-hospital swab procedure by a HCW (p<0,0001) 111 ( Figure 2) . Among the citizens who preferred at-home testing a total of 1,651 (69.9%) reported 112 that the swab procedure at-home was easy when guided by a video, whereas 711 (30.1%) found 113 the test difficult, but still preferred to perform the test at-home (p<0,0001). 114 115 Discussion: This study found a high preference for at-home oropharyngeal/nasal swab collection 116 among participants having carried out an at-home collection during the DANMASK-19 trial. These 117 findings of participants´ preferences are supportive of recently released FDA statement on at-118 home testing and the preference for at-home testing may potentially be even higher for direct test 119 results. Home collection does however raise several issues of importance. These include whether 120 lay people can properly perform the swab procedure and if specimen transportation from home to 121 laboratory is safe, fast enough and under proper conditions (e.g. heat) -both in terms of sample 122 integrity and to keep the time from specimen collection to result short. Previous studies have 123 validated and found that self-collected oropharyngeal/nasal swab for SARS-CoV-2 testing is 124 reliable compared to HCW-collected samples (Therchilsen et al., 2020; Tu et al., 2020) . Where 125 sample integrity to some degree can be addressed using a robust DNA/RNA preservation buffer, 126 the logistics for delivery of swap materials to and from participants necessitate local 127 arrangements. The high preference supports that self-collection -especially at-home -of SARS-128

CoV-2 specimen could offer one solution to reduce healthcare personnel resources for testing, 129 reduce personal protective equipment usage and avoid infected individuals from transmitting the 130 virus in the community or to hospital personnel when leaving their home for an at-hospital test. 131

Self-testing could potentially be a future norm beyond COVID-19, similar to HIV or pregnancy self-132 tests (Boum et al., 2021) . This study has several strengths and limitations. Although COVID-19 has 133 drawn considerable attention for most people, the DANMASK-19 trial may have recruited people 134 with a very high interest in testing for COVID-19, or people concerned about own SARS-CoV-2 135 infection status. Furthermore, we had a slight overrepresentation of females. Participants were 136 not aware of the reliability of at-home specimen collection, which might have influenced their 137 response. The study was based on free delivery of guidance material, test material and a free help-138 line. Participants represented broad societal groups, a broad age-span above 18 years of age, and 139 several occupational areas across the whole country. These aspects should be taken into account 140 when considering the generalizability of the study. 141 142

Conclusions: The preferred setting for testing for SARS-CoV-2 among citizens is the guided at-143 home self-collection. Since at-home collection previously has been found to be a reliable test 144 method as compared to testing in the healthcare system, healthcare authorities should consider 145 adopting at-home collection options for the current as well as future pandemics. The Salling 146

Foundations supported the study. 147

The authors declare that they have no known competing financial interests or personal 150 relationships that could have appeared to influence the work reported in this paper. 151 152

Funding Source 153

The Salling Foundations supported the study with an unrestricted grant with no influence on study 154 design, conduct, or reporting (grant number: NA). 155

Ethical Approval 157

The protocol of the DANMASK-19 trial was presented to the independent regional scientific ethics p<0.0001

Beyond COVID-19 -will self-sampling and testing become the 165 norm?

167 Effectiveness of Adding a Mask Recommendation to Other Public Health Measures to Prevent 168 SARS-CoV-2 Infection in Danish Mask Wearers

What happened to 170 home HIV test collection kits? Intent to use kits, actual use, and barriers to use among persons at 171 risk for HIV infection

Danish Regions -testing overview 2021

Fair Allocation of Scarce 177 Medical Resources in the Time of Covid-19

COVID-19) Update: FDA Authorizes First COVID-19 Test for Self-Testing at Home

Research electronic data capture 182 (REDCap) -a metadata-driven methodology and workflow process for providing translational 183 research informatics support

Willingness to seek laboratory 186 testing for SARS-CoV-2 with home, drive-through, and clinic-based specimen collection locations

Danish Health Authorities -Corona figure reportings

Danish Health Authority: COVID-19 guidelines -Prevention against spread of 191 infection 2020

Danish Health Authority: General guidance (english version)

Collected versus Healthcare Worker-Collected Swabs in the Diagnosis of Severe Acute Respiratory 198 Syndrome Coronavirus 2

Swabs Collected by Patients or 200 Health Care Workers for SARS-CoV-2 Testing

At-home self-collection of 202 saliva, oropharyngeal swabs and dried blood spots for SARS-CoV-2 diagnosis and serology: Post-203 collection acceptability of specimen collection process and patient confidence in specimens

World Health Organization. WHO Coronavirus (COVID-19) Dashboard 2021

Personal measures taken to avoid COVID-19 n.d