Coronavirus

SARS-CoV-2 Testing Strategy: Considerations for Non-Healthcare Workplaces

Note: This document provides guidance on the appropriate use of testing and does not dictate the determination of payment decisions or insurance coverage of such testing, except as may be otherwise referenced (or prescribed) by another entity or federal or state agency.Purpose The purpose of this document is to provide employers with strategies for consideration…

Note: This document provides guidance on the appropriate use of testing and does not dictate the determination of payment decisions or insurance coverage of such testing, except as may be otherwise referenced (or prescribed) by another entity or federal or state agency.

Purpose

The purpose of this document is to provide employers with strategies for consideration of incorporating testing for SARS-CoV-2, the virus that causes COVID-19, into a workplace COVID-19 preparedness, response, and control plan.

Employers are encouraged to collaborate with state, territorial, tribal and local health officials to determine whether and how to implement the following testing strategies and which one(s) would be most appropriate for their circumstances. These considerations are meant to supplement, not replace, any federal, state, local, territorial, or tribal health and safety laws, rules, and regulations with which workplaces must comply. These strategies should be carried out in a manner consistent with law and regulation, including laws protecting employee privacy and confidentiality. They should also be carried out consistent with Equal Employment Opportunity Commission guidance regarding permissible testing policies and procedures. Employers paying for testing of employees should put procedures in place for rapid notification of results and establish appropriate measures based on testing results including instructions regarding self-isolation and restrictions on workplace access.

Considerations for use of a strategy to test for SARS-CoV-2 infection

SARS-CoV-2 testing may be incorporated as part of a comprehensive approach to reducing transmission in non-healthcare workplacesSymptom screening, testing, and contact tracing pdf icon[58 pages] are strategies to identify workers infected with SARS-CoV-2, the virus that causes COVID-19, so that actions can be taken to slow and stop the spread of the virus.

Employees undergoing testing should receive clear information on:

  • the manufacturer and name of the test, the type of test, the purpose of the test, the reliability of the test, any limitations associated with the test, who will pay for the test, and how the test will be performed, and
  • how to understand what the results mean, actions associated with negative or positive results, who will receive the results, how the results may be used, and any consequences for declining to be tested.

Individuals tested are required to receive patient fact sheets as part of the test’s emergency use authorizationexternal icon.

The Occupational Safety and Health Administration has issued interim guidanceexternal icon for enforcing the requirements of 29 CFR Part 1904external icon with respect to the recording of occupational illnesses, specifically cases of COVID-19. Under OSHA’s recordkeeping requirements, COVID-19 is a recordable illness, and thus employers are responsible for recording cases of COVID-19, if the case meets certain requirements. Employers are encouraged to frequently check OSHA’s webpage at www.osha.gov/coronavirusexternal icon for updates.

Testing for SARS-CoV-2 infection

Viral tests approved or authorized by the Food and Drug Administration (FDA) are used to diagnose current infection with SARS-CoV-2, the virus that causes COVID-19. Viral tests evaluate whether the virus is present in respiratory or other samples. Results from these tests help public health officials identify and isolate people who are infected in order to minimize SARS-CoV-2 transmission.

Antibody tests approved or authorized by the FDA are used to detect past infection with SARS-CoV-2. CDC does not currently recommend using antibody testing as the sole basis for diagnosing current infection. Depending on when someone was infected and the timing of the test, the test may not find antibodies in someone with a current SARS-CoV-2 infection. In addition, it is currently not known whether a positive antibody test indicates immunity against SARS-CoV-2; therefore, antibody tests should not be used at this time to determine if an individual is immune.

Categories for SARS-CoV-2 testing

CDC describes strategies for SARS-CoV-2 viral testing for five categories of people:

Testing individuals with signs or symptoms consistent with COVID-19

Employers may consider conducting daily in-person or virtual health checks (e.g., symptom and/or temperature screening) to identify employees with signs or symptoms consistent with COVID-19 before they enter a facility, in accordance with CDC’s General Business FAQs. Employers should follow guidance from the Equal Employment Opportunity Commissionexternal icon regarding confidentiality of medical records from health checks.

Workers with COVID-19 symptoms should be immediately separated from other employees, customers, and visitors, and sent home or to a healthcare facility, depending on how severe their symptoms are, and follow CDC guidance for caring for oneself. To prevent stigma and discrimination in the workplace, make employee health screenings as private as possible. Consistent with CDC’s recommendations, workers with COVID-19 symptoms should be referred to a healthcare provider for evaluation and potential testing. Waiting for test results prior to returning to work is preferred to keep potentially infected workers out of the workplace.

Employers are encouraged to implement flexible sick leave and supportive policies and practices as part of a comprehensive approach to prevent and reduce transmission among employees. The Families First Coronavirus Response Act (FFCRA or Act) requires certain employersexternal icon to provide their employees with paid sick leave or expanded family and medical leave for specified reasons related to COVID-19. Employers with fewer than 500 employees are eligible for 100% tax creditsexternal icon for Families First Coronavirus Response Act COVID-19 paid leave provided through December 31, 2020, up to certain limits.

Positive test results using a viral test indicate that the employee has COVID-19 and should not come to work and should isolate at home. Decisions to discontinue home isolation for workers with COVID-19 and allow them to return to work may follow either a symptom-based, time based, or a test-based strategy (see Testing to determine resolution of infection below).

Testing asymptomatic individuals with recent known or suspected exposure to SARS-CoV-2 to control transmission

Case investigation is typically initiated when a health department receives a report from a laboratory of a positive SARS-CoV-2 viral test result or a report from a healthcare provider of a patient with a confirmed or probable diagnosis of COVID-19pdf iconexternal icon.

Viral testing may be recommended for close contacts (people who have been within 6 feet for a total of 15 minutes or more) of persons with COVID-19 in jurisdictions with testing capacity. Because of the potential for asymptomatic and pre-symptomatic transmission of SARS-CoV-2, it is important that individuals exposed to people with known or suspected COVID-19 be quickly identified and quarantined. Viral testing can detect if these individuals are currently infected. The health department may reach out to the employer for assistance in identifying close contacts of the worker as well as possible contacts. Employers are encouraged to work with public health departments investigating cases of COVID-19 and tracing contacts to help reduce the spread of SARS-CoV-2 in their workplaces and communities.

Because there may be a delay between the time a person is exposed to the virus and the time that virus can be detected by testing, early testing after exposure at a single time point may miss many infections1. Testing that is repeated at different points in time, also referred to as serial testing, may be more likely to detect infection among close contacts of a COVID-19 case than testing done at a single point in time.

Even if close contacts are monitored with serial testing, it is critical that they strictly adhere to other preventive measures including social distancing, wearing cloth face coverings for source control if the hazard assessment has determined that they do not require personal protective equipment such as a respirator or medical facemask for protection, and practicing hand hygiene.

Testing may also be considered for possible close contacts of persons diagnosed with COVID-19 in collaboration with the local health department if resources permit. A risk-based approach to testing possible contacts of a person with confirmed COVID-19 may be applied. Such an approach should take into consideration the likelihood of exposure, which is affected by the characteristics of the workplace and the results of contact investigations. In some settings, broader testing (i.e., testing beyond individually identified close contacts to those who are possible close contacts), such as targeting workers who worked in the same area and during the same shift, may be considered as part of a strategy to control the transmission of SARS-CoV-2 in the workplace. The rationale is that identification of contacts may be imprecise. High-risk settings that have demonstrated potential for rapid and widespread dissemination of SARS-CoV-2 include:

  • High-density critical infrastructure workplaces
  • Workplaces where employees live in congregate settings (e.g., fishing vessels, offshore oil platforms, farmworker housing or wildland firefighter camps)
  • Workplaces with populations at risk for severe illness if they are infected, such as nursing homes

Employers are encouraged to consult with state, local, territorial, and tribal health departments to help inform decision-making about broad-based testing.

If employees are tested after close contact or possible close contact with someone who has a confirmed or probable diagnosis of COVID-19, care should be taken to inform these employees of their possible exposure to SARS-CoV-2 in the workplace while maintaining confidentiality of the individual with COVID-19, as required by the Americans with Disabilities Actexternal icon (ADA) and consistent with the U.S. Equal Employment Opportunity Commission (EEOC) guidance regarding What You Should Know About COVID-19 and the ADA, the Rehabilitation Act, and Other EEO Lawsexternal icon.

Testing asymptomatic individuals without known or suspected exposure to SARS-CoV-2 for early identification in special settings

Viral testing of workers without symptoms may be useful to detect COVID-19 early and stop transmission quickly, particularly in areas with moderate to substantial community transmission. When communities experience moderate to substantial transmission, workplace settings for which these approaches may be considered include:

  • Workplaces where physical distancing is difficult and workers are in close contact with co-workers or the public
  • Workplaces in remote settings where medical evaluation or treatment may be delayed
  • Workplaces where continuity of operations is a high priority (e.g., critical infrastructure sectorsexternal icon)
  • Workplaces providing congregate housing for employees (e.g. fishing vessels, offshore oil platforms, farmworker housing or wildland firefighter camps)

Approaches may include initial testing of all workers before entering a workplace, periodic testing of workers at regular intervals, and/or targeted testing of new workers or those returning from a prolonged absence. Several factors may be helpful in determining the interval for periodic testing including:

  • The availability of testing
  • The latency between exposure and development of a positive SARS-CoV-2 viral test
  • Businesses that fall into one of the workplace categories described above
  • The rate or change in rate of people getting infected in the surrounding community
  • How many employees tested positive during previous rounds of testing
  • Your relevant experience with workplace outbreaks

State, local, territorial, and tribal health departments may be able to provide assistance on any local context or guidance impacting the workplace. Before testing a large proportion of asymptomatic workers without known or suspected exposure, employers are encouraged to have a plan in place for how they will modify operations based on test results and manage a higher risk of false positive results in a low prevalence population.

Testing to determine resolution of infection

The decision to end home isolation and return to work for employees with suspected or confirmed SARS-CoV-2 infection should be made in the context of clinical and local circumstances. Polymerase chain reaction (PCR) amplification tests have detected SARS-CoV-2 RNA in some people’s respiratory samples after they have recovered from COVID-19. Prolonged viral shedding has been demonstrated without direct evidence for virus capable of replicating or causing infection. Consequently, in most cases, evidence supports a symptom-based strategy to determine when to discontinue home isolation or precautions. For persons who are severely immunocompromised, a test-based strategy could be considered in consultation with infectious diseases experts. For all others, a test-based strategy is no longer recommended except to discontinue isolation or precautions earlier than would occur under the symptom-based strategy.

Under the Americans with Disabilities Act, employers are permitted to require a healthcare provider’s noteexternal icon to verify that employees are healthy and able to return to work. However, as a practical matter, employers should be aware that healthcare provider offices and medical facilities may be extremely busy during periods of community transmission of SARS-CoV-2 and may not be able to provide such documentation in a timely manner. In such cases, employers should consider not requiring a healthcare provider’s note for employees who are sick to validate their illness, qualify for sick leave, or to return to work. Most people with COVID-19 have mild illness, can recover at home without medical care, and can follow CDC recommendations to determine when to discontinue home isolation and return to work.

Public health surveillance for SARS-CoV-2

Testing is considered to be surveillance when conducted to detect transmission hot spots, or to better understand disease trends in a workplace. These goals are consistent with employer-based occupational medicine surveillance programs. Occupational medicine surveillance programs may use testing to assess the burden of SARS-CoV-2 in the workforce, assess factors that place employees at risk for workplace acquisition of SARS-CoV-2, or evaluate the effectiveness of workplace infection control programs. Surveillance should only be undertaken if the results have a reasonable likelihood of benefiting workers.

Footnote

  1. The rate of false negative nucleic acid tests, a type of viral test, after exposure have been reported as: day 1: 100%; day 4: 67%; day 5: 38%; day 8: 20%; day 9: 21%; and then rising to 66% on day 21. See: https://www.acpjournals.org/doi/full/10.7326/M20-1495external icon

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