NICD’s virologist: COVID-19 can affect anyone. How should we respond? (LISTEN: podcast)

The peak of the COVID-19 pandemic is yet to be felt in South Africa. However, it is imperative that we responsibly restore the economy while continuing to work to flatten the COVID-19 curve.

As the level of lockdown is lifted and people return to the workplace, it is inevitable that we, or the people we work with, will be affected by COVID-19. How should we manage our response to a colleague who shows symptoms of the disease while at work? And what do we need to understand about returning to work once we have recovered from COVID-19?

Dr Ahmad Haeri Mazanderani is a clinical virologist within the Centre for HIV and STIs at the National Institute for Communicable Diseases (NICD), a division of National Health Laboratory Service, in Johannesburg. In a podcast interview conducted for Discovery he explains all that employers and employees need to know about COVID-19 in the context of the workplace.

Dr Mazanderani’s podcast

Let’s explore his key messages:

Why is it imperative that employers act responsibly in bringing employees who have had COVID-19 back to work?

As the epidemic ramps up, we can expect to have increasing number of people in our population who are infected with COVID-19. We expect that the majority of people who are infected will make a complete recovery, and can return back to the workplace safely. And they should be welcomed back.

How long should employees who contract COVID-19 stay away from work?

The period of isolation for patients depends on the clinical course of their disease. We can expect the majority (four out of five) of patients to have a mild course of disease and their care should be managed at home. If people have a mild course of disease, they should be isolated for 14 days from date of the onset of symptoms. That means from the day that they started to get sick, they should stay at home or in a healthcare facility and should only leave and de-isolate 14 days after their symptoms begin. The upper limit of the incubation period is 14 days.

People who have severe disease and require hospitalisation could have extended shedding of the virus. We recommend they can then de-isolate 14 days after the date their symptoms resolve or after the date from which they no longer require oxygen therapy. People who are completely asymptomatic and test positive for COVID-19 can safely de-isolate 14 days from the date that they tested positive.

If an employee has a fever and a cough, but then gets better without COVID-19 testing or medical care, are they allowed to return to work when their symptoms have resolved?

It’s important to consider the criteria for testing, which are being updated constantly. Currently, we require all persons who have symptoms of COVID-19 – whether that be a fever, a cough, a sore throat or shortness of breath – to be tested. Again, it’s important to keep within the current guidelines and criteria for testing.

• Check out the clinical criteria for testing here and learn why tests are reserved for patients who meet them.

If an employee is medically confirmed to have COVID-19 and is showing symptoms, when are they allowed to return to work?

We can look at three different clinical scenarios for patients with COVID-19:

• People who have had a mild course of illness (we expect the majority of people to have mild disease). They can return to work 14 days after the onset of symptoms.
• People who have had severe disease or moderate disease, but required admission to hospital. They can return 14 days after symptom resolution or from when they no longer required oxygen therapy.
• Persons who test positive for COVID-19 but are asymptomatic. They can safely return to work 14 days from the date that the sample that tested positive was taken.

Would a person need to do a second test during the 14-day isolation or hospitalisation period to make sure that they have been cleared of the virus?

That is a very good question. We are currently not recommending individuals get a second test if they have already tested positive. The reason for this is that the test we use to establish the presence of COVID-19 is a polymerase chain reaction (PCR) test and does not indicate a live, viable virus. It detects the viral nucleic acid (viral genetic material). We know that individuals can test positive for weeks after symptom resolution, but the person is not necessarily infectious. So, our current recommendations are that persons who have tested positive do not get a repeat test. Rather follow the guidelines for de-isolation according to whether you had mild, asymptomatic or moderate-to-severe disease.

• Don’t be fooled – there is only one way to test for COVID-19

In light of this guidance, is it possible for an employer to say that an employee may not return to work unless they return a negative test result?

I think we can expect employees who have tested positive to be issued with a letter from an appropriate healthcare facility to confirm when they can safely go back to work. It would be inappropriate for employers to demand repeat testing within the context of our current guidelines.

How do the guidelines differ for staff who are in a corporate setting versus healthcare workers?

Ideally, we need our working healthcare staff to be present at work but, while they are there, healthcare workers themselves are at risk of being infected as well as infecting other members of the healthcare facility and their patients. It’s imperative that all individuals who have signs or symptoms in keeping with COVID-19 are tested and await the result before reporting for duty. They should essentially isolate themselves until they receive their result and act according to whether that result is positive or negative. It’s also important to consider that people who are infected can get false negative results. In that case, should symptoms develop further or not resolve, then repeat testing is important while the individual remains isolated.

You’ve mentioned false negatives. Why does this happen and can you also get false positives?

Within the context of COVID-19 testing, we expect more false negatives than false positives. That is because the sampling is difficult.

False positives can, in a minority of instances, occur through a range of pre-analytic or pre-testing considerations like sample swab issues and contamination issues.

False negatives happen as a result of variables that affect test sensitivity:

• COVID-19 has a variable incubation period so if you test a person too early – say when they are asymptomatic – you could get a false negative result. That is why the routine testing of asymptomatic persons is not recommended.
• The sampling process is difficult and technical. For most patients, testing requires a nasopharyngeal or oropharyngeal swab, which is quite technical and difficult to do. It can affect the test result if done incorrectly.
• The conditions in which the sample is stored
• Variable times between when the sample is taken and received at the testing lab.

It’s really important that individuals who are symptomatic, but who get a negative test result, repeat the test prior to de-isolating, if their symptoms do not resolve.

In the workplace, a person who has contracted COVID-19 but is asymptomatic can come into contact with surfaces on which the virus can live for an extended period. How do we ensure the safety of other staff who use the same areas or spaces once we know that the person has tested positive for COVID-19?

A person who has tested positive for COVID-19 can potentially be infectious from a few days before symptom onset up until two weeks after symptom onset. So, if an employee has subsequently been found to be positive, then essentially all of those close contacts in the workplace and in other situations such as the household, need to be notified and asked to quarantine for a period of 14 days.

In terms of cleaning down surfaces, the virus can remain viable for variable periods of time on different types of surfaces. It’s really important to clean surfaces with an appropriate detergent or alcohol-based cleaning material and essentially within the workplace, physical distancing, and good hand hygiene should be prioritised at all times.

With the advice that is currently being provided to the population to wear fabric masks, that will also be a mitigating factor in preventing the spread in the workplace, especially for people who are coughing, so that they do not cough into the environment and allow infectious material to basically be on various surfaces.

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Do people who have recovered from COVID-19 need to behave in any particular way once they return to work?

At the moment, we are not clear on whether there is potential for reinfection and whether having been infected will necessarily confer immunity. I think it is likely that being naturally being infected with COVID-19 would confer a degree of immunity, but it’s important for those who have been infected to continue with the same advice for the population at large in terms of preventing their own acquisition of this virus again.

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We cough all the time: how would a person know that their cough could be related to COVID-19?

It’s really important that people realise that you cannot clinically or symptomatically distinguish COVID-19 from a common cold or influenza. That’s why currently we are recommending that all individuals who have any cough – no matter how severe it is – or any fever, shortness of breath or sore throat, be tested. They currently meet the criteria for testing and should be encouraged to access testing services and to isolate themselves until they receive the result. If you have any symptoms in keeping with acute respiratory infection, you should be tested and act as if you are potentially infectious.

Should high-risk employees be protected in any additional way while at work if they work with someone who has recovered from a confirmed case of COVID-19?

According to the best data that we have, individuals who have recovered from COVID-19 will not be infectious in the workplace. We are providing guidance that, for cases with mild disease, they can safely de-isolate two weeks after symptom onset. Because, as far as we know, there have been no cases of infectious virus shed from an individual for more than that period of time.

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Does an employee have a right to confidentiality if they have contracted or recovered from COVID-19?

The individuals who have had close contact with a person who has COVID-19 will be notified and will be required to follow the guidelines, whether that is quarantine (self-isolation) and or testing, based on their symptoms. Similarly, employers will be notified of when individuals can safely return to work.

I don’t think an employer can expect to access an individual’s medical history. I can expect that an employer has a reasonable expectation to be informed with regards to potential risk of infection and they should be informed in terms of the steps they should take to both protect themselves and the workplace. For an employer to demand a test result is probably inappropriate.

Do office layouts need to be reconfigured going forward to allow for permanent physical distancing and preventive conditions to be met? Do we need to implement properly spaced desks, frequent cleaning and sanitising, improved air filtration, permanent hand sanitiser stations and other such conditions to prevent the spread of pathogens, over and above our usual behaviour at work?

It’s clear that COVID-19 is spread mostly through droplets. I believe that hand hygiene is an essential component of providing a safe working environment. We should also ensure that individuals who are symptomatic do not come to work.

There should be daily symptom monitoring. And, also daily informing the workforce that individuals who have a fever, a cough, a sore throat, or shortness of breath should ideally not come to work, they should access testing facilities and isolate themselves as they wait for that result.

In terms of the physical distancing of the workplace, I think that that is something that all workplaces should consider to ensure that people are not overcrowded in rooms and I think that this is the new normal that we have to entertain.

• Free online COVID-19 consultations available to all South Africans through Vodacom and Discovery partnership

Is it advisable that for the foreseeable future people who can work remotely do so to limit the number of people in an office at any given time?

Yes, if it’s not necessary for people to be in crowded offices, if work can be performed effectively, it can certainly be something that should be considered.

The fact that we are going to be experiencing an upsurge in COVID-19 cases will highlight the need to urgently reconsider how we work and we will need to ensure that we mitigate risk in the workplace as best we can without overly compromising the work that is done. If work can be done effectively remotely, then that should be prioritised.

There is much fear around contracting COVID-19 and this can lead to discrimination against and stigmatisation of those who have contracted COVID-19, recovered and returned to work. How can employers ensure that this sort of response is overcome?

Employers can communicate the information that individuals that have had COVID-19 are not going to be infectious after, for the majority of people, two weeks from symptom onset. And that requiring or demanding individuals to test negative is not appropriate and not informative.

The public at large must understand and appreciate that persons who have had COVID-19 and recovered, will not necessarily be of any greater risk than anyone else in the workplace.

Employers can also work to avoid stigma in the workplace by explaining that this is a respiratory infection that we are all vulnerable to. None of us have natural immunity to the virus that causes COVID-19. We are all at risk. Contracting COVID-19 need not be stigmatised. Persons who have contracted the disease should not be treated differently once they are no longer potentially infectious. They can return to work safely.

I also think that there will be potential concern because there can be some remaining symptoms for individuals, after the two-week period from symptom onset. There may still be a mild cough, and that does not necessarily mean that that person is infectious. However, they should still maintain appropriate respiratory or cough etiquette and hygiene. This not cause for concern.

The only cause for concern would be in the case of individuals remaining feverish after two weeks – for which they should seek medical assistance. Nobody should be de-isolating if they remain feverish. The challenge is that persons can also be predisposed to other infections and they may have secondary viral or bacterial infections after having COVID-19. They should be seeking the appropriate medical assistance if that is the case.

So-called ‘immunity passports’ have been suggested by scientists and politicians for European staff as a way of getting people who have had the 2019 coronavirus and recovered, back into the workforce more quickly and allow them to exempted from restrictions on their activity. Is this recommended?

At the moment it’s not clear whether the presence of antibodies against the SARS-CoV-2 virus necessarily correlates with immunity and prevention of reinfection, although I do believe it is probable. Essentially, for certain cadres of our workforce an immunity passport may be considered, especially if testing for antibodies against the SARS-CoV-2 virus would indicate immunity. I’m thinking specifically amongst our essential services and healthcare professionals and healthcare workers in general.

Having said that, our current prevalence of community transmission is low. We can expect that the vast majority of people who reside in South Africa do not have any antibodies to the SARS-CoV-2 virus so at this juncture, I don’t think immunity passports to the public at large make any sense. But certainly, once our prevalence ramps up, it is something to consider, pending the evidence that antibodies to SARS-CoV-2 do confer immunity.

• Read the WHO’s Scientific Brief on “Immunity Passports” in the context of COVID-19, published 24 April 2020

It has been suggested that the toll that COVID-19 takes on the body (pneumonia, for example, can have long-term effects on the lungs ) could see people who rush back to work after being cleared of the illness find themselves exhausted and need to take time off again soon. Do people who have had COVID-19 need to be cautious in this regard? Can the symptoms take several weeks to settle?

Certainly, the symptoms can take several weeks to settle. The global experience with this virus is limited as it has really only been around for a few months. Anyone who has had COVID-19 should take it easy. They could be exposed to secondary viral and secondary bacterial infections and essentially they should be following up with an appropriate healthcare provider should their clinical condition or symptoms deteriorate.

Employers can expect to be informed of when an individual can return to work by the employee’s healthcare provider. Should employees complain of worsening symptoms, they need to immediately seek appropriate medical help. I am sure employers would allow this.

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