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As questions arise about vaccine efficacy and how effective they’ll be against the growing list of COVID-19 variants, the United States might have to rely more and more on another mitigation method: testing.
With all the coverage about COVID-19 vaccinations, it could appear that another pillar of SARS-CoV-2 mitigation—testing—has been overlooked. Well, it has … but it hasn’t. When the Centers for Disease Control and Prevention (CDC) in July updated masking recommendations as a result of the infectiousness of the Delta variant, lost in the maelstrom of media coverage of that move was the fact that the CDC also updated testing recommendations at the same time.
Specifically, the CDC recommended that “fully vaccinated people who have come into close contact with someone with suspected or confirmed COVID-19 to be tested 3-5 days after exposure, and to wear a mask in public indoor settings for 14 days or until they receive a negative test result.”
Robbie Hilliard, MSN, RN, CIC, is the infection control coordinator at the Carl Vinson VA Medical Center in Dublin, Georgia, and a member of Infection Control Today®’s (ICT®’s) Editorial Advisory Board (EAB). Hilliard tells ICT® that “the sooner a COVID-19 diagnosis can be confirmed, the sooner contact tracing/notification of exposed persons can begin, which is what ultimately stops others from being exposed. Also, those who have been vaccinated may have fewer symptoms of COVID-19 so they may be infected and able to pass the virus on and testing is the only way to know for sure.”
ICT® EAB member Heather Saunders, MPH, RN, CIC, couldn’t agree more. “The faster we identify and isolate cases and contacts, the less opportunity the virus will have to spread,” says Saunders, the director of infection control at the Johns Hopkins Office of Population Health. “Particularly in settings prone to outbreaks, such as nursing homes, frequent, routine testing has aided in the prevention and control of COVID-19 through the early identification of cases which allows for the prompt isolation of the infected individuals and those exposed.”
While Saunders, Hilliard, the CDC, and most other medical experts appreciate the importance of COVID-19 testing, nonetheless the vaccines are viewed as the lifesavers, and seem to dominate media coverage. That happened again in early August when some developed countries announced that they would provide COVID-19 vaccination booster shots to its older and more vulnerable citizens, about the same time that the United States reached the milestone of having at least 70% of its population vaccinated with at least 1 dose of a vaccine.
The move elicited an immediate response from the World Health Organization who called for a moratorium on COVID-19 booster shots until poorer countries can catch up to richer countries in getting first and second doses of COVID-19 vaccines into the arms of citizens.
Then came revelations about breakthrough infections and increasing concerns about the Delta variant (B.1.617.2). The variant had been burning through regions in the US where vaccination rates lagged. But not only in unvaccinated regions. The Delta variant can do damage even in sections of the country with high vaccination rates, and that people who’ve already been infected by SARS-CoV-2 do not have as much protection against breakthrough infections than those who’ve gotten vaccinated.
The Delta variant, as of this writing, is the dominant COVID-19 variant in much of the world, including the US.
CDC Director Rochelle Walensky has said that “the Delta variant behaves uniquely differently from past strains of the virus that cause COVID-19. Information on the Delta variant from several states and other countries indicate that in rare occasions, some vaccinated people infected with the Delta variant after vaccination may be contagious and spread the virus to others.”
Waiting in the wings: the lambda variant. This one keeps some public health care officials up nights because initial preprint studies suggest that it can shrug off the COVID-19 vaccines.
ICT® EAB member Sharon Ward-Fore, MS, MT(ASCP), CIC, FAPIC, says that “testing is an important epidemiological tool that lets us know where COVID is and where it is going in our community. That’s why symptomatic people should still get tested. Vaccinated people who have been exposed should also get tested. Without testing, we won’t have any idea of how we are doing against this virus.”
The importance of COVID 19 testing got a jolt on July 29, when President Biden announced that unvaccinated federal employees should submit to regular COVID-19 testing and adhere to other mitigation measures, such as social distancing. Biden said that “anyone who … is not vaccinated will be required to … [get a COVID-19] test one or two times a week to see if they’ve acquired COVID….”
Private industry jumped on the testing bandwagon. Companies that require employees be vaccinated include United Airlines, Walmart, Google, Facebook, Netflix, Morgan Stanly, BlackRock, Disney, Tyson, and the Washington Post. The list grows on and includes hospitals and other health care systems including such heavy hitters as Johns Hopkins Hospital, Penn Medicine: University of Pennsylvania Health System, New York-Presbyterian Columbia University Medical Center in New York, Accension Health, and many more.
Health care professionals aren’t always on board. Houston Methodist Hospital was one of the first to mandate COVID-19 vaccinations, with the result being that 153 of the institution’s employees were either fired or resigned for refusing to do so. Infection preventionists (IPs) often find themselves trying to educate hesitant fellow hospital employees of the importance of getting the vaccine.
As with the case with the CDC’s recommendations, vaccine recommendations (or mandates) often come with testing mandates. For instance, at Goldman Sachs, unvaccinated employees must be tested regularly on site, and those who test positive must leave the premises. Citigroup wants unvaccinated employees to use an at-home rapid test three times a week, which has been called an effective strategy.
The Equal Employment Opportunity Commission (EEOC) has ruled that the Americans With Disabilities Act “does not interfere with employers following recommendations by the CDC or other public health authorities regarding whether, when, and for whom testing or other screening is appropriate.”
Safe and Accurate
In guidelines that the EEOC updated on May 28, the agency says that employers need to ensure that the tests are safe and accurate. “Because the CDC and FDA may revise their recommendations based on new information, it may be helpful to check these agency websites for updates,” says the EEOC. “Employers may wish to consider the incidence of false-positives or false-negatives associated with a particular test.”
COVID-19 testing will almost certainly come to the fore as the efficacy of the current vaccines seems to wane for certain populations after 5 months (partly evidenced by breakthrough infections), data mount about just how infectious some of the newer variants can be—especially among asymptomatic carriers who can unknowingly spread the disease—we learn more about the effects of long COVID, and as we come to terms with dealing with an endemic problem that even exists in animal hosts.
ICT® EAB member Kevin Kavanagh, MD, asserts that “as we are learning more about the Delta variant and how it can evade immunity, causing breakthrough infections, we realize that expanding our testing activities is imperative. In Germany, everyone in schools and industry are tested twice weekly.”
Kavanagh also points out that in the United Kingdom, people who live where the Delta variant is spreading are encouraged to get tested twice a week, and China tests every citizen in Wuhan.
“We need to do much more testing, and we also need to monitor the accuracy of our tests on each of the new variants,” says Kavanagh.
ICT® EAB member Lisa Waldowski DNP, RN, CIC is a regional director in infection prevention and control at Kaiser Permanente. “COVID-19 testing is critical to our success in stopping COVID-19 transmission and guides diagnosis, screening, and surveillance activities,” she says.
ICT® EAB member Linda Spaulding RN, BC, CIC, CHEC, CHOP, says that COVID-19 variants make testing a crucial mitigation tool. “The Delta variant has now taken over as the dominant variant of COVID, but right behind Delta is the lambda variant of COVID that was first identified in Peru and now identified in South America,” says Spaulding. “Lambda is, like Delta, highly infectious and more resistant to vaccines. This virus has had human incubators for almost 2 years and that is giving it a chance to mutate in a very effective way.”
Spaulding also cites the CDC guidance that stresses testing for vaccinated as well as unvaccinated individuals.
“But the important thing to stress is that those people who are vaccinated are less likely to need hospitalization and they are less likely to die,” says Spaulding. “The majority of the hospitalized patients and death currently are the unvaccinated. We are beginning to see an increase in infections among children from the age of 11-day old babies to young or middle-aged adults. Continued testing of as many people as possible is very important to keep track of the new and very concerning variants.”
Vaccination and testing aren’t the only tools needed, however.
ICT® EAB member Mary Jean Ricci MSN, RNBC, says that “testing and quarantining will assist with maintaining the health care capacity so all who need health care can receive [timely] care.” Ricci, the director of clinical education at Drexel University College of Nursing and Health Professions, notes that “COVID testing has dropped off as more and more people are getting vaccinated. Now, people are only getting tested if they note the signs and symptoms of an infection. Testing is important. Testing provides protection to keep the coronavirus from spreading.”
Kavanagh says that “to live with this virus, we all have to … wear high quality masks in public, frequent twice weekly testing and become vaccinated. Each is a layer of armor against the virus, and all three interventions are needed to quell this pandemic. Finally, we need to be genetically sequencing a large portion of our specimens and closely monitoring for the emergence of new variants.”
It sounds easy, and that might be the crux of the tragic consequences of COVD-19, says Spaulding. “It’s so simple get vaccinated and wear a mask and continue living. So simple yet so difficult to accomplish.”