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As the pandemic drags on, when can we get back to work?

Posted By Robert H. Shmerling, MD On April 21, 2020 @ 2:30 pm In Coronavirus and COVID-19,Infectious diseases,Medical Research,Workplace health | Comments Disabled

Along with widespread illness and death, the COVID-19 pandemic is also causing massive economic disruption. Stay-at-home measures and business shutdowns have prevented millions of people from working. In just four weeks, between mid-March and mid-April, 22 million Americans filed for unemployment benefits. These numbers are bound to spiral higher.

Given all the hardships — and new predictions that cases of COVID-19 will begin falling in most states in the coming weeks — when might people be able to return to work? Thus far, the answers are quite uncertain.

Although the Centers for Disease Control and Prevention (CDC) has issued some federal guidelines, you may need to follow stricter state or local regulations and employer policies. Some experts have suggested serologic (antibody) tests to determine who has had the virus and to guide decisions about returning to work. And the experiences of countries that have successfully slowed cases of COVID-19 and loosened restrictions on work will come into play, too. Below I’ve explained a bit about each approach.

Return-to-work recommendations from the CDC

The recommendations vary depending on where you work – in healthcare or critical infrastructure, for example – whether you had symptoms of COVID-19, and whether a test confirmed that you had COVID-19. (Tests are not widely available in some areas of the country.)

  • Workers in critical infrastructure (such as emergency services, the nuclear reactor industry, or defense) who have no symptoms, but were exposed to someone with confirmed or suspected COVID-19 Recent guidelines permit continuing to work if the worker has no symptoms, no fever, wears a mask for 14 days from last exposure, maintains six-foot physical distancing from others (“as work duties permit”), and disinfects and cleans work spaces well. This relaxes previous requirements that urged such workers to remain in quarantine for 14 days before returning to work.
  • Workers in healthcare settings (such as hospitals, medical practices, or nursing homes) with suspected or confirmed COVID-19 The guidelines allow discontinuation of isolation and returning to work once fever has resolved, symptoms have improved, and swab tests for the virus are negative twice at least 24 hours apart. However, there are additional points to consider:
    • If follow-up testing is not performed Those who had COVID-19 should wait until they’ve had three or more days of improved symptoms without fever and ten days have passed since symptoms began.
    • If no symptoms were ever present but a test was positive A person can discontinue isolation if a lack of symptoms continues and it’s been 10 days since the first positive test or if two follow-up tests for the virus are negative at least 24 hours apart.
    • If testing was never performed for a person with suspected COVID-19 A person can discontinue isolation once they have had three or more days of improved symptoms without fever and ten days have passed since symptoms began.
    • If isolation was recommended following exposure to someone who had COVID-19 A person can discontinue isolation if swab testing is negative; a second test may be recommended when suspicion remains high.
  • Workers outside of these settings Currently the guidelines for people who work in healthcare settings apply here, too.

Because local regulations or employer policies may be more stringent than these recommendations, it’s important to check with your employer and primary care physician before going back to work. Return to work guidelines cannot entirely prevent the spread of COVID-19. They may change in coming months as public health officials respond to rising or falling levels of the virus.

What about using serologic (antibody) tests to guide our return to work?

Serologic tests identify antibodies in your blood that your immune system produced to fight off the virus and to be ready in case you’re exposed to it again. If present, they indicate that you were previously infected, even if you were unaware of it. These tests are quite different from nasal swab testing performed to identify current infection.

If you never had symptoms or your symptoms completely resolved, a positive serologic test likely indicates that you have some protection from re-infection (for at least a while) and are unlikely to be contagious. So, positive results might let you know that it’s safe for you to return to work (and to be around others at home or work who may be susceptible to the virus).

Additionally, if your body made antibodies in high amounts, you may be a plasma donor candidate, as your antibodies could be used to help someone who is struggling to recover from COVID-19.

Sounds great, right? It is if you are feeling well and your serologic tests are positive. But what if they are negative? And what else do we need to consider?

Negative antibody tests: Good news and bad news

A negative serologic test generally means you haven’t been exposed to the virus. So, congratulations, it seems you successfully avoided infection and were never a threat to spread it to others! On the other hand, you still may catch the virus from someone else. A negative result is not helpful in knowing when it’s okay to return to work or to relax certain physical distancing measures.

Until widespread serologic testing is performed, we won’t know how many people are already immune to the virus that causes COVID-19, but it’s possible that most people will have a negative result.

Why? For one thing, mitigation efforts seem to have been effective at limiting exposure. And while we tend to hear about the “hot spots” where infection is spreading rapidly, many areas of America and the world have had low infection rates.

In the US, projections in mid-April by the University of Washington suggest that we’ll have up to a million cases of confirmed COVID-19 by August 2020. If there are 10 times as many unconfirmed cases of COVID-19 as confirmed cases, as Angelo Borrelli, a government official in Italy, believes, another 10 million people were exposed to COVID-19, but were asymptomatic or never got tested. Given a US population of 330 million people, that means 3% may have positive antibodies and the remaining 97% of Americans may never have been exposed to the virus. All of the people who weren’t exposed would be expected to have negative serologic test results, which aren’t helpful in making decisions in the coming weeks and months about who can safely return to work.

Serologic testing raises several other issues, as well:

  • Early testing has been plagued by inaccuracy
  • It’s not yet confirmed that positive antibodies are protective
  • Even if they are protective, it’s not known how long that protection will last
  • And finally, it’s likely that we can’t do antibody testing for enough people in the near term to provide reassurance about the safety of returning to work soon.

Once enough people (perhaps 60% to 70% of the population) have protective antibodies due to infection or vaccination, there will be more confidence in the safety of returning to work. But a vaccine is a year or more away.

Where does this leave us in returning to work?

While there are no uniform guidelines to rely upon for most workers, here’s how some experts, public officials, and other countries have responded to the question of when employees might return to work:

  • Spain recently allowed certain industries, including manufacturing and construction, to resume operations as long as protective equipment is provided and physical distancing measures are maintained. China is also beginning to relax restrictions, including in Wuhan, where the pandemic began.
  • Dr. Anthony Fauci, head of the National Institute of Allergy and Infectious Diseases and member of the White House’s coronavirus task force, recently predicted a gradual reopening of parts of the country, perhaps starting as soon as May 2020. However, he has repeatedly warned that the timeline depends on the behavior of the virus and the effectiveness of mitigation efforts.
  • Relying on serologic testing to decide who can return to work has been a focus of government leaders, including those in New York (such as Governor Cuomo), Great Britain, and Italy. You can expect to see a big push in the coming weeks for widespread serologic testing, though as discussed above it remains unclear how helpful this will be.

“Reopening the economy” is likely something that will happen gradually, along with ongoing monitoring for renewed outbreaks. For example, restaurants and smaller offices might reopen at partial capacity, with employees hired back in gradually increasing numbers if all goes well. Later, sporting events and concert venues may reopen. This will probably vary by geography: areas with fewer cases of COVID-19 may ramp up toward higher employment levels more quickly than those hit hardest by the outbreak. As workers return to their jobs, many of the current precautions will likely remain in place, such as frequent disinfectant cleaning and avoiding unnecessary crowding and physical contact.

The bottom line

In the coming weeks and months, a drop in cases of COVID-19 is expected across the US, according to models from the University of Washington. Once that happens, public health experts and national, state, and local leaders will likely give the go-ahead for employers across many industries to gradually reopen, and employees will return to work. That could happen in some areas as soon as May or June.

But, the decision to allow businesses to reopen must be made despite considerable uncertainty: if businesses reopen too soon, the outbreak may flare up again. Wait too long and many businesses and the people who work in them may never recover financially.

Since you can’t return to your job until your place of work resumes operations, workers everywhere have to wait for that to happen. Even after it does, it may be a while before we know if it was too soon, too late, or the right move.

Follow me on Twitter @RobShmerling

Related Information: Harvard Health Letter

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