The implementation of an early return-to-work program with a decreased quarantine period for clinicians who remain asymptomatic after exposure to SARS-CoV-2 may help to mitigate hospital staffing shortages without increasing the risk for transmission. These findings were published in the American Journal of Infection Control.
Between January and June 2021, an observational quality improvement study was conducted at a multi-facility health care system in Pennsylvania. Researchers sought to evaluate the effect of an early return-to-work program among clinicians (N=384) who experienced a high-risk SARS-CoV-2 exposure within the past 4 days. The program allowed clinicians who remained asymptomatic through day 7 of quarantine to return to work after 8 days. The primary outcomes were the mean number of days in quarantine and the mean day during quarantine at which point a participant was deemed eligible to return to work. Secondary outcomes included the number of participants eligible to return to work after 8 days and the number of missed workdays saved.
A total of 333 (86.7%) participants remained asymptomatic through day 7 following a high-risk SARS-CoV-2 exposure, of whom 323 (97%) tested negative for infection between days 5 and 7 and were eligible to return to work after 8 days. Of these participants, 297 (92%) returned to work within 10 days or fewer. The mean quarantine period was 8.16 days, the median day at which a participant returned to work was day 8 (range, 6-9), and mean workdays saved was 1.84, with an overall total of 546.48 workdays saved.
Limitations of this study included the lack of baseline SARS-CoV-2 screening at the time of exposure, the nature of the exposures were not quantified, and limited generalizability due to the inclusion of only vaccinated clinicians.
To provide further insight into these findings and their implications for clinical practice, we interviewed lead author Graham M. Snyder, MD, MS. Dr Snyder is an associate professor and Medical Director of Infection Prevention and Hospital Epidemiology at the University of Pittsburg’s School of Medicine.
This study was the first of its kind that assessed the effect of a reduced quarantine period for clinicians exposed to SARS-CoV-2, is that correct?
Dr Snyder: Yes. And we’ve learned quite a bit about when clinicians get sick, and how frequently they do or don’t get sick after various types of exposures. So, with that data, and prior to this study, we had already moved the 14-day quarantine period [at our institution] to a 10-day quarantine period. We suspected that we could safely move it to a 7-day period with [further] testing.
In early 2020 of the COVID-19 pandemic, we learned that the incubation period, the time from exposure to illness, was between 2 and 14 days. That’s a pretty broad range for a respiratory virus. And so, we started the pandemic with the more safety-oriented, conservative approach. We took the longer end of that incubation period (14 days) and kept people out of work until we knew that they wouldn’t become contagious. This approach was particularly important with SARS-CoV-2 because you may be contagious before you show symptoms, and you could be contagious without symptoms. We started this pandemic, before we had vaccines, before we had effective therapies, with a very, very high priority for safety.
As the pandemic continued, not only did we begin to have vaccines, antivirals, and monoclonal antibodies to keep us safe, but we also learned a little bit more about the distribution of the time from exposure to contagiousness and illness. We discovered that a 14-day [incubation period] is uncommon — most people get sick sooner — so we took that clinical knowledge, and then applied it to clinicians. We also learned a little bit about the natural history of polymerase chain reaction (PCR) testing and COVID-19. One of the early lessons was that a PCR [result] can remain positive for quite some time, and that made us wonder how to know when an infected individual is no longer contagious.
I think with the emergence of the COVID-19 pandemic, and with a posture toward being very, very, very cautious about transmission, it took us some time to start to adapt.
Do you believe a reduced quarantine policy has broad applicability, or would institutions such as acute care or skilled nursing facilities need to decide on their own whether to reduce their quarantine period to a similar degree?
Dr Snyder: It depends on the level of [known] risk at each facility. In our health care system, we have acute care facilities that take care of very vulnerable patients, and we are pretty risk averse. We don’t want any risk for transmission. Prior to conducting this investigation, we believed the risk for SARS-CoV-2 transmission would be very minimal if we reduced the quarantine period for clinicians, and the data showed this to be correct.
Although many health care facilities are considering a reduced quarantine period, I think the more important aspect of this investigation is not necessarily what it could mean for the COVID-19 pandemic in the short term, but how we approach future pandemics and [outbreaks of] infectious diseases.
Rather than taking the [14-day] incubation period, and assuming that’s how long we have to quarantine exposed individuals, we might use a test-based approach or this learning-health system approach and figure out how to maintain a very low risk, but also bring people back to work or back to their day-to-day lives more quickly.
In designing and implementing this early return-to-work program, did you experience any opposition from clinicians at your facility?
Dr Snyder: This has been a pandemic in which we have all felt some anxiety to a greater or lesser degree about our own well-being, and the well-being of loved ones around us, and of course the patients that we care for. Throughout the pandemic no matter what the issue has been, whether it’s testing, employee health, vaccination, or treatments, we’ve had a lot of people who want to know what’s the right thing to do and how to stay safe.
We learned the importance of transparency and making decisions based on our own evidence. The published evidence has been the focus in our organization, and this [study] is a part of that. As we implemented this early return-to-work program, we explained to people why we believed this would be a safe approach. The health-care workforce is really committed to the patients. By and large we had folks saying, “I’d like to be at work and contributing during this pandemic, and if it’s safe for me to do so I’m happy to do so.”
[We found that] messaging was an important part [of implanting this program]. We communicated to people why we were making this change [and] why we thought it was as safe as we anticipated it would be.
How might these findings apply to the emergence of future COVID-19 variants?
Dr Snyder: We may have to make adjustments to this [program] and the key variable is the incubation period of the variant. [During the Omicron wave,] there was a lot of anecdotal and clinical information [circulating that indicated it had] a shorter incubation period. Overall, we didn’t see anything that challenged the full 14-day incubation period. If a new variant with a longer incubation period emerged, I think we’d all have to revisit our approaches to make sure people are safe after an exposure.
The important aspect of our investigation [was] that as a learning-health system we may have to adapt, and the same is true with future variants. For example, if the frequency at which people with asymptomatic [infection who subsequently] test positive changes over time, that would indicate that we may need to change our approach.
Is there anything that you wish you would have done differently in regard to the design of this study, or an outcome that you wish you had measured?
Dr Snyder: No, this worked as planned. One of the challenges that we anticipated and observed was that not all of the clinicians went through the testing process to return to work early, and not all were tested within the timeline [days 5-7] that we had anticipated. Those are typical operational challenges. For a program where we try to conserve our resources and do things efficiently, I think the program worked really, really well.
On the other hand, what we learned in this program [has] already [been] applied. For example, the Centers for Disease Control and Prevention (CDC) had also subsequently suggested a test-based strategy in addition to resolution of symptoms to allow people to return to work early. [Following this study,] we implemented a 5-day return-to-work program built on the operational learnings of this [study].
What is the applicability of this study’s findings in regard to patients with immunocompromised conditions?
Dr Snyder: What we’ve learned about immunocompromised patients is that the duration of viral replication and contagiousness may be longer. [Our study included] clinicians and [they] generally tend to be younger and healthy. A [symptomatic] clinician with an immunocompromised [condition] would not have been a candidate for a 10-day return-to-work [program]. Instead, we would use a 20-day rule for a person that is immunocompromised.
On the other hand, for immunocompromised people who remain asymptomatic after an exposure, we’ve also learned that the likelihood that they’ll be contagious is pretty small. It is possible that for person [with an] immunocompromised [condition] [who remains] asymptomatic after an exposure, this same approach could be effective to shorten their period of quarantine.
Ruscetti A, Chrisman M, Wagester S, et al. Healthcare personnel early return-to-work program after higher-risk SARS-CoV-2 exposure: a learning health system quality improvement project. Published online February 3, 2022. Am J Infect Control. doi.10.1016/j.ajic.2022.01.027