I am ushered into a large ballroom filled with military gear-clad figures covered by full personal protective equipment (PPE). I am given my COVID-19 test kit and directed to a soldier who administers the test. A curette is inserted into nostril until it touches my pharynx (the back of my nose). It feels like it is lodged in my brain. The swab is then rotated five times. Just thinking about it makes my nose twitch involuntarily. My colleagues have endured being tested several times weekly by different long term-care facilities (LTCF). Some clinicians openly wonder if this can continue so frequently.
As states go through the reopening process, skilled nursing facilities will be dealing with extreme pressures to do so also. Particularly from family members who have not seen their loved ones, since most long-term care facilities (LTCF) closed to visitors March. Point prevalence surveys (PPS) of residents and healthcare providers mandated by the state of Pennsylvania are to be completed by 7/24/20. If the PPS reveals positive cases the facility must retest until there are no new positives. Once a LTCF reopens to visitors, they will be faced with more complex challenges.
LTCF’s are a fertile ground for COVID-19. Even if the prevalence of COVID-19 in a specific community is low it can cause havoc if it gets into the LTCF. Testifying before Congress on June 23, 2020, Dr. Robert Redfield suggested that for every one symptomatic individual with COVID-19, there are 10 infectious asymptomatic individuals. An asymptomatic person can introduce COVID-19 into a LTCF. Data from AMDA shows that COVID-19 has a 30% mortality rate in a LTCF. So, a COVID-19 outbreak in a LTCF with 100 residents can kill 30 residents four weeks later. These are alarming numbers!
Even one confirmed case of COVID-19 in a LTCF leads to increased absenteeism, utilization of agency help, anxiety, and spend rate on PPE (to name just a few). All of this while concurrently trying to implement the most stringent infection prevention and control processes (IPC) possible. Even the highest performing LTCF risk some degree of failure performing the mandated PPS.
The Commonwealth of Pennsylvania has 700 skilled nursing facilities numbering approximately 80,000 residents and 120,000 healthcare professionals (HCP). The state set a goal to perform 8,500 tests per day. If this goal were met and only LTCF residents and staff were being tested, all the testing could be completed in approximately 24 days. However, there are many other organizations lobbying for the limited number of COVID-19 tests including hospitals, universities, professional sports leagues, and other municipalities. I am informed by other medical directors that test kits are in short supply.
There are other costs to universal testing. My organization noted a $120 average cost for each test. One PPS in a facility with 1350 HCP’s and residents adds up to $162,000. This does not count the cost of repeated testing if necessary. The CARES Act carves out financial support for baseline and surveillance testing, but this is not the only hurdle. Repeating this uncomfortable test on a weekly basis may not be tolerated by residents and HCP’s. What about the demented resident who cannot understand why this is even being done? PCR testing can also create panic when a COVID-19 case is discovered. PCR tests can remain positive long after the virus is cleared and person is no longer infectious. Staff would then be needlessly excluded from work for approximately 10 days. This lack of staff will be magnified by others quitting or going on a leave of absence.
If the goal of mandated testing is to get a clearer picture of the prevalence of COVID-19 in LTCF’s, I believe an initial antibody test is appropriate. This can be ordered rapidly for staff and residents. It would give retrospective understanding of the prevalence of COVID-19 in the facility. Individuals with a positive IgG should be excluded from PCR testing. Individuals who do not show IgG production should be tested with a PCR. The PCR test is just a snapshot of what is happening but when combined with IgG serology we get a clearer picture of what has been occurring. The IgG positive staff will not need to be excluded from work and will likely feel less anxiety about working on a COVID-19 unit. This would be extremely valuable since their lack of contagiousness and susceptibility allow them to work with COVID positive and negative residents alike.
I am a proponent of universal testing however PCR testing alone only provides limited data. Repeated testing of staff and residence is impractically secondary to limited supplies and the discomfort of testing. There is also a slow turn around in test results which make them less valuable. I strongly encourage the states to consider making IgG titers part of their COVID-19 testing strategy.
Dillard Elmore, DO, CMD, MBA is Chair of PMDA’s Public Policy Committee. Any views or opinions presented in this article are solely those of the author and do not necessarily represent any policy or position of PAMED, PMDA, AMDA, its affiliates and members.