Interim Approach to testing for COVID

Following the move to the ‘delay’ phase of the COVID-19 pandemic response individuals displaying symptoms of a new onset continuous cough and/or high temperature are required to self-isolate at home for 7 days and family contacts of household symptomatic cases are required to self isolate for 14 days.

The most common symptoms of COVID 19 are recent onset of:

  • New continuous cough+/or
  • High temperature

In older age groups atypical presentation of COVID 19 is common.

Staff exposures

Health and Care Workers (HCWs) who come into close contact with a patient with suspected or confirmed COVID-19 (or their body fluids) while not wearing personal protective equipment (PPE) can remain at work. This is because in most instances this will be a short-lived exposure, unlike the ongoing exposure in a household setting.

HCWs should:

not attend work if they develop symptoms while at home (off-duty), and notify their line manager immediately who will arrange for a test to be undertaken in the next 24 hours.

self-isolate and immediately inform their line manager if symptoms develop while at work and a test should be arranged.

If the HCW’s symptoms do not get better after 7 days, or their condition gets worse, they should speak to their occupational health department or local HSC Trust if they work in the care sector or GP. For a medical emergency they should call 999.

The current recommended PPE that must be worn when caring for patients with COVID-19 is described in the infection prevention and control guidance.

All health and care workers are eligible for testing.

These are guiding principles and there may need to be an individual risk assessment based on staff circumstances, for example for those who are immunocompromised.

Testing Laboratories

Currently testing of HCWs and Key Workers is undertaken in either hospital laboratories or via the National Initiative in “Drive Through” centres.

Hospital Laboratories

Hospital laboratory capacity for testing is c1600 tests/day (with a slight reduction at weekends) with most testing being undertaken by the Regional Virology Laboratory in BHSCT with local testing in the NHSCT, SHSCT and WHSCT. The priority for laboratory testing is the mainenance of turnaround times for hospitalised patients and samples from HCWs and key workers may have longer turnaround time than those from hospitalised patients. In general results are available within 24 hours. Some Trusts have developed local arrangements for testing of HCWs and some key workers eg MOT centres in Ards and Boucher in Belfast.

National Initiative

A national initiative to support testing of HCWs and Key workers is being implemented in N Ireland using a private laboratory (Randox) and is being co- ordinated by Deloitte. The current testing capacity is 750 tests/day. Three drive through testing centres are open in Belfast, Derry and Craigavon. These centres are also used to test health care workers and key workers in non health agencies who are self isolating. Initially testing of key workers was restricted to government departments but has been extended to key workers in other sectors eg agriculture, food processing, royal mail. The results of testing are e mailed to the person who has been tested and they are advised to share them with their employer. In general results are available within 72 hours. Discussions are ongoing to arrange for the electronic transfer of results from DHSC to PHA/BSO.

A digital platform is available to enable self referral for testing for workers who are self isolating https://self-referral.test-for-coronavirus.service.gov.uk/ The digital platform also allows the person who requires testing a choice between a postal service where they self administer the swab at home and send to laboratory under special arrangement with Royal Mail or the drive through option in the 3 N Ireland sites.

An employer portal is now available.

Mobile testing units are also planned for May 2020 to allow rapid deployment of testing in the event of clusters of cases or outbreaks.

As the response to pandemic evolves, the balance of testing of HCWs undertaken by HSC laboratories and the 3 national initiative testing sites will be kept under review.

Eligible Groups for testing

Group 1 patient requiring critical care for the management of pneumonia, ARDS or influenza like illness (ILI), or an alternative indication of severe illness has been provided, for example severe pneumonia or ARDS

Group 2 all other patients requiring admission to hospital for management of pneumonia, ARDS or ILI

Group 3 HCWs who are self-isolating. Symptomatic family members causing the HCWs to self-isolate and symptomatic

Group 4 Clusters of disease in residential or care settings, for example long term care facilities and prisons.

Group 5 Care Homes: Symptomatic residents in care homes should be tested. In older people atypical presentations of COVID 19 are common.

(NEW) From 24 April 2020, in all new outbreaks in care homes (nursing and residential), all residents and staff should be tested for COVID-19 as part of the initial risk assessment of each outbreak.

In a situation where a care home is reporting one possible case, the dutyroom in PHA will arrange for a swab to be undertaken for the symptomatic patient. If the test results for the single case is positive or any additional cases are reported during the monitoring period than further testing is advised for all staff and residents in line with the new guidance for testing.

All HSC Trusts should assist care homes in their respective areas with immediate implementation of this testing. Care home staff are likely to need support to undertake the necessary swabbing, and to ensure the correct information is collected about each resident and staff member tested. It is essential that the name of the home is clearly marked on all documentation relating to the outbreak, in particular on all forms accompanying swabs submitted for testing. Laboratory services will need to have clear arrangements in place for identification and recording of outbreaks in care homes. This should include consideration of 2D barcodes on specimens collected from care homes. It is essential that all tests processed, whether for residents or staff, can be clearly identified as connected to the relevant care home.

Additionally, in advance (48 hours) of hospital discharge to a care home the patient must be tested for COVID-19. This new testing requirement must not hold up a timely discharge. The information from the test results, with any supporting care information, must be communicated and transferred to the relevant care home. Some care providers will be able to accommodate individuals with a confirmed COVID-19 positive test result through effective isolation strategies or cohorting policies. If appropriate isolation or cohorted care is not available with a local care provider, the local HSC Trust will provide alternative appropriate accommodation and care for the remainder of the required isolation period. This alternative accommodation should also be used in the exceptional cases of test results not being available at the point of discharge.

(NEW) All new admissions to care homes from community settings, including from supported living accommodation and from the patients/residents own home, should have their COVID-19 status checked 48 hours before admission to the care home. The same conditions apply to patients admitted to care homes from community settings as apply to patients discharged from hospital to a care home.

Group 6: Cancer Patients

  • New planned admissions for cancer surgery from the 20th April should be tested 48 hours before surgery.
  • Systemic Antic Cancer Therapy (SACT) patients who are symptomatic
  • On recommendation of the Multidisciplinary team before starting treatment
  • Patients with acute leukaemia for chemotherapy to be tested 48 hours before treatment
  • Haematology patients requiring admission to be tested 48 hours before admission if recommended by clinical team
  • Symptomatic acute oncology and haematology patients
  • Bone marrow transplant recipients to be tested 72 hours before conditioning

Group 7 (NEW) Acute admissions to hospital (non elective and elective)

From the 27thApril all elective and non-elective patients admitted overnight into hospital should be tested for COVID 19. This includes patients who are asymptomatic. This should include making preparations to cohort patients as possible COVID cases who need to be admitted whilst they await a test result. Appropriate infection prevention control recommendations should be followed.

https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attach ment_data/file/881489/COVID-19_Infection_prevention_and_control_guidance_complete.pdf

Group 8 (NEW) Key worker testing
Testing is available to all essential key workers and to members of their household if they have symptoms that cause a key worker to self isolate. This includes teachers, hospital cleaners, key workers in food production and food retail, transport, utilities, communications, and financial services, public servants and the emergency services as well as other critical infrastructure staff.

Key workers can now book tests for themselves and their household via an online portal. This new service also offers home postal test kits (numbers limited at the moment) which may be useful for non-drivers.

https://self-referral.test-for-coronavirus.service.gov.uk/

Group 9 (NEW) Hospital Admissions for Paediatrics, Learning Disability and Mental Health

From the 5th May 2020 HSC Trusts should put arrangements in place for all new overnight admissions to paediatrics, learning disability and mental health in-patient wards to be swabbed within 24 hours of admission.

How to Manage Results

The significance of the actual result has to be considered on a case-by-case basis for HCWs given the uncertainty of negative predictive value and the how this will change depending on the level of circulating Sars-CoV-2 in the community, the stage of disease and the exposure of the HCW.

COVID-19: management of exposed healthcare workers and patients in hospital settings

In HSC Trusts staff should liaise with Occupational Health when self isolating and when agreeing a return to work date.

It is important to support care home staff and domiciliary workers during the pandemic who may not have access to an occupational health service. Staff working in care homes should be able to contact their local Trust for advice on the significance of the test results.

Staff who test negative for SARS-CoV-2 can return to work if they are medically fit to do so following discussion with their line manager and appropriate local risk assessment. If they become unwell again, they should self-isolate and may need to be tested again.

Staff who test positive for SARS-CoV-2 and symptomatic staff who have not had a test can return to work if:

  • on day 8 after the onset of symptoms if clinical improvement has occurred and they have been afebrile (not feverish) for 48 hours
  • if they are afebrile and a cough is the only persistent symptom on day 8, they can return to work (post-viral cough is known to persist for several weeks in some cases)

HCWs may require evidence of viral clearance prior to working with extremely vulnerable people. This is subject to local policy

The following 3 scenarios are an outline approach to decision making for HCWs.

Scenario 1: Symptomatic HCW – Sars-CoV-2 positive

Could return to work based

  • on Day 8 after the onset of symptoms if clinical improvement has occurred and they have been afebrile (not feverish) for 2 days
  • if a cough is the only persistent symptom on Day 8, they can return to work (post-viral cough is known to persist for several weeks in some cases)

No further clearance testing required. These members of staff may be expected to be immune (although the duration of such immunity is still undefined.) HCWs who test positive and recover from the infection can be redeployed to care for COVID-19 patients during the peak of outbreaks, although they must still use appropriate PPE.

Based on current evidence any HCW who has tested positive for COVID 19 and recovered will be exempt from further requirements for isolation.

Scenario 2: HCW on home isolation because of a symptomatic family member – symptomatic family member Sars-CoV-2 negative

The negative predictive value of this test will depend on the prevalence of disease in the community. It may be pragmatic to accept the result (assuming a well taken sample) and allow a HCW to return to work. As Covid progresses and other respiratory infections diminish, this will be kept under review

Scenario 3: Symptomatic HCW – Sars Cov-2 negative

Negative predictive values may change over time. Using a negative result in a symptomatic HCW to facilitate a return to work has to be considered carefully. The safest approach may be to apply the HCW guidance ie return to work once symptom free for 48 hours. If further symptoms develop repeat testing is indicated and the HCW should self isolate.

Stay at Home Guidance: COVID-19: guidance for households with possible coronavirus infection – GOV.UK

In a medical emergency dial 999.

PHE have summarised the approach to interpreting results in following diagram.

Operational Support

The 6 Trusts have protocols in place for taking samples (nasal and throat swabs as one combined sample unless person is producing sputum). The correct form for SARS CoV-2 testing must be used which can be found in the documents and forms section of the website www.RVL-Belfast.hscni.net and the NHSCT virology form.

Contact details for organising testing in Trusts are:

BHSCT – telephone 028 96152828
WHSCT – email [email protected]

SEHSCT – telephone 028 92 680803 press option 1 for screening and testing and option 2 for advice by a registered nurse.

NHSCT – [email protected] SHSCT – [email protected]

NIAS telephone 07717781954, [email protected]

Samples must be clearly identified on the request form as HCW samples (or family member of HCW) so priority can be applied. H&C of HCW or family member must be on request form.

If person is producing sputum then sputum sample is preferred to swabs

For swabbing – a nose and throat swab is sent as a single specimen (2 swabs in one tube), various swabs, containers and media are available in different trusts and areas and dry swabs in universal container is an acceptable specimen.

Nasal swab – Take one specimen. Insert swab into nostril parallel to the palate, rotate gently for a few seconds to absorb secretions and collect nasal epithelial cells.
Throat swab – Take one specimen. Swab both posterior pharynx & tonsil areas, avoid tongue.

Place BOTH the nasal and throat swabs into the same container
Label the tube with the patient’s name & DOB or Hosp No and use the specific request form for COVID testing from the www.RVL-Belfast.hscni.net (SARS-CoV-2 testing form) Unlabelled tubes will not be tested.

Testing in Community Settings

Primary care staff refers to:

  • GP frontline staff working in GP Practices, GP Out of Hours Services and COVID centres
  • Community Pharmacy frontline staff working in community pharmacies
  • Dental staff working in Urgent Care services
  • Optometry staff
  • Care home staff and domiciliary workers

Referrals to the national initiative from primary care staff can be booked on line at https://self-referral.test-for-coronavirus.service.gov.uk/ Some Trusts are also able to facilitate testing for community staff and some key staff in their testing facilities.

Contact Tracing (NEW)

Large-scale, integrated contact tracing and testing will play a key role in managing the rate of COVID-19 transmission, and maintaining R below 1 when social distancing measures are relaxed.

SAGE have indicated that a successful contact tracing strategy requires around 80% of contacts of symptomatic cases to be traced and isolated rapidly, ideally within two days of symptom onset for the index case. This potentially requires at least 30 contacts per symptomatic case to be traced, and possibly some contacts to be tested (policy to be confirmed) based on experience from other countries.

An approach to contact tracing that rapidly identifies and quarantines the vast majority of cases and their contacts in theory could reduce R by the order of 30- 60%.

A pilot contact tracing service is underway in the PHA since 27th April, to test logistics and approach to contact tracing which will need to be in place in advance of changes which may be made to social distancing.

Surveillance (NEW)

Robust and timely surveillance information is essential to understand the epidemiology of disease by time, person and place, track the spread of the infection in the community and hospitals, and assess the impact on the population.

The PHA’s Health Protection surveillance team, in collaboration with other partner organisations, has already established a number of surveillance systems which are used to monitor COVID-19 activity in Northern Ireland. These systems provide information on the intensity, geographic spread, impact on healthcare system and severity of COVID disease.

These surveillance systems also allow us to monitor trends, inform public health measures to reduce COVID-19 transmission, and to measure the impact of public health measures to reduce COVID-19 transmission in both hospital and community settings.

Three surveillance programs are currently underway for COVID 19 in N Ireland

  • Sentinel spotter practices in primary care;

  • ED surveillance being piloted in RVH Emergency Department with a view to repeating this in other ED Departments;

  • Outbreaks in nursing homes