COVID-19 infection came to many of our Lancaster County long-term care facilities, leaving a trail of illness and death.
New COVID-19 infections continue in the community and long-term care, and there is a visceral fear of resurgence in the near future or a return in the fall. Our challenge is to detect infections sooner and intervene as soon as possible.
COVID-19 is a stealthy infection that can be completely asymptomatic. If multiple cases occur in a long-term care facility, we easily recognize them and assume that all residents and staff are possibly infected. But if asymptomatic and contagious infections enter a building without previous infection, it is challenging to recognize and respond to a silent disease.
COVID-19 swab testing of all long-term care staff and residents is proposed by county and state leaders to manage infection and allow the reopening of society. This testing is starting in Lancaster County facilities. The early results confirm many asymptomatic positive tests in staff and residents, even in facilities without previously documented infections.
On a conceptual level, COVID-19 swab testing makes sense, and I support this as an evolving remedy. On a practical level, there are many unanswered questions about how this will succeed.
Our current nasal swab test is a polymerase chain reaction technology that detects viral genetic material present when a person is actively infected. It is a very sensitive test, able to identify as few as 15 viral particles, when someone with infection has hundreds of thousands of these particles.
Like all medical tests, it has limitations. It may turn positive only after several days of illness and after the individual has become contagious. It must be obtained appropriately from the nose or throat, or it can be falsely negative. Currently, the swab must be shipped to a lab, the test completed and the results returned to the testing location. This time delay may impede appropriate precautions at the care facility.
Due to the urgency of the unfolding pandemic, the U.S. Food and Drug Administration allowed these tests to be marketed without extensive testing or formal FDA authorization. There are now more than 120 different tests, and significant questions about quality and reliability. Tests done in a hospital system are the most accurate, but experts continue to debate how to use the results.
These tests remain positive as the individual recovers. Most COVID-19 infected individuals will not be contagious after 14 days from the start of illness. But the nasal swab may remain positive for 28 days or more. There likely is a time period when the swab test remains positive but the individual is not contagious, but we do not know exactly when this occurs in the disease process.
Thus, a positive test in an asymptomatic individual indicates only that he or she was infected in the recent past. He or she may be infectious due to asymptomatic shedding of the virus or because he or she will show symptoms tomorrow. Alternatively, he or she may have previously had the infection and may or may not still be contagious. The tests do not tell us what restrictions are necessary or when those restrictions can be discontinued.
These tests give only a snapshot of a facility’s infections at the moment they are done. They may miss someone in an early stage of infection and cannot predict the next week’s infections. They allow management decisions today but provide no direction for next week. Only regular and repeated retesting can truly track the current status. That is logistically challenging for the thousands of Lancaster County nursing home residents and staff members.
State guidelines recommend testing all residents and then grouping them based on their test status: positives with positives and negatives with negatives. Repeat testing next week may require people to move again. The outcome may be multiple room changes on short notice, with concern for the emotional disruption that accompanies such moves.
If we test all of our asymptomatic staff members and the tests are positive, they will need to be off work for 10 days, even though it is unclear if they are truly contagious. This potentially causes a shortage of staff for resident care.
A different COVID-19 test, the antibody blood test, may help to determine who was previously infected and who may be protected against future infection. During a viral infection, the body produces multiple different antibodies. We do not yet know which are protective and which give future immunity.
While some antibody tests are available currently, there has not been adequate research to determine the implications of these results. We cannot assume an individual is susceptible or immune based on the current antibody tests. We cannot yet make recommendations for isolation, return to work or infection safety based on current antibody tests.
Our knowledge about COVID-19 testing is not yet mature. Nasal swab testing is increasing, but we need precise guidelines that interpret these results. Antibody tests will likely be an important part of future management but are not yet standardized for use in long-term care or the broader community.
We are all impatient for solutions to make COVID-19 release its grip on our lives. We must not make this pandemic worse by rushing to make decisions that are not fully processed. But we also must begin the journey forward. Best medical practice takes time to evolve and must always change to incorporate new knowledge. This is not incompetence or faulty science. Rather, this is how best care develops.
Dr. Leon Kraybill is the chief of Penn Medicine Lancaster General Health’s geriatric division and post-acute care, and medical director at Luther Acres in Lititz.