Q&A: Variants Make COVID-19 Testing More Problematic

Vaccinations for, and variants of, coronavirus disease 2019 (COVID-19) dominates the news these days. However, a key ingredient for reaching some sort of post-pandemic normal must include COVID-19 testing. That’s especially true since the rise of the COVID variants, says Linda Spaulding RN, BC, CIC, CHEC, CHOP, an infection prevention consultant and a member of Infection Control Today®’s Editorial Advisory Board. “Will it continue to mutate, in which case, there’s a possibility in the future—probably near future—that the swabs that we’re currently using for the PCR [polymerase chain reaction] tests may not pick it up,” warns Spaulding. “The new challenge is going to be: Who are we admitting to the hospitals that have COVID? And so medical professionals are going to have to watch the literature really close to find out if our tests are still valid for these variants.” As has been the case throughout the pandemic, standard precautions need to be maintained. “When it comes to infection prevention and what infection preventionists need to do with their line staff on all units, not just the ICU, is to start reinforcing standard precautions and contact precautions and droplet precautions, for that matter,” Spaulding warns ICT®. “Any patient admitted to a hospital, who has cold symptoms or who is likely to cough in your face, and you’re not really sure if they have COVID or not, it’s going to be better to put them on contact and droplet precautions than to find out later they had COVID and you did nothing.” She notes that ICU admissions have been dropping across the United States and that’s a good thing, so long as it’s not the result of a lack of PCR tests.

Infection Control Today®: OK. Vaccinations. Variants. Do these change the way infection preventionists on the ground go about their business? Or will it just be business as usual? I mean as usual as it can get for health care professionals during a pandemic these days?

Linda Spaulding RN, BC, CIC, CHEC, CHOP: Well, right now, we’re waiting to see what kind of literature is published related to these variants. Because we’re going to see more than one variant. The one that’s being talked about a lot right now it is the B.1.1.7. Within that variant, it has a component that makes it increase the attack rate from what we’ve been dealing with for the past year. We know that—I think it’s like 36 states—are seeing this variant. It was announced on the news yesterday that they feel that is the one that’s going to become prominent here in Florida where I am. I was giving that a lot of thought and when you look at COVID, OK, we’re not going to change anything that we do as far as patient treatment once they’re admitted to the hospital. But now the new challenge is going to be will we get definitive answers that the COVID tests that we’re currently doing will pick this variant up? Will it continue to mutate, in which case, there’s a possibility in the future—probably near future—that the swabs that we’re currently using for the

PCR [polymerase chain reaction] tests may not pick it up. The new challenge is going to be: Who are we admitting to the hospitals that have COVID? And so medical professionals are going to have to watch the literature really close to find out if our tests are still valid for these variants. A lot of health care workers have been vaccinated, and that’s a good thing. A lot of teachers are getting vaccinated. Now, a lot of the elderly population has been vaccinated. The outstanding question is: With B.1.1.7, or other variants that are coming down the pike, are we all still protected? I have seen some personal evidence of the vaccine preventing household spread. I had a friend that had two family members come down with COVID. And that person had gotten his second shot of the Pfizer vaccine two weeks ago, and that person did not come down with COVID. And they were in the same household all the time. So that gave us a lot of hope. And then B.1.1.7 shows up. And then other variances are being talked about. The United States also has that South African variant at this point, which is much more deadly. So, big difference between will it spread faster with B.1.1.7? Or will it kill faster with the South African variant? We’re going to have to wait and see. When it comes to infection prevention and what infection preventionists need to do with their line staff on all units, not just the ICU, is to start reinforcing standard precautions and contact precautions and droplet precautions, for that matter. Any patient admitted to a hospital, who has cold symptoms or who is likely to cough in your face, and you’re not really sure if they have COVID or not, it’s going to be better to put them on contact and droplet precautions than to find out later they had COVID and you did nothing. But saying that…. I want to go back to standard precautions for a minute because I have thought this for years. You know, way back when we had [the original] SARS years ago, a lot of health care workers died. It was more emergency health care workers because people would come in—we didn’t know SARS was there—they would come in, they’d have respiratory issues. And that was transmitted to the staff before we even knew SARS existed. Problem is standard precautions; the basic thing of infection prevention says anytime somebody is likely to cough in your face, you should have on a mask and eye protection. Those are the entry points of COVID, the original SARS, MERS [Middle East Respiratory Syndrome], the flu, any of those. If we had just gotten really good at standard precautions, then we would prevent the spread of this, especially within the health care facilities now.

ICT®: You’re the first expert that I talked to who’s talking about testing when it comes to the variants because everybody else seems to be focusing on: Will the vaccines be effective against the variants? But you went right to testing. Is that a common reaction among infection preventionists?

Spaulding: Oh, I would assure you that for many people, that’s gone through their heads. Whether it’s the emergency management group at the hospital, or infection preventionists, but even line staff have to be starting to think about that. Because that’s going to be a real key here. We’ve all gotten vaccinated. Will this vaccine work? Some people say yes it might. Some people say we don’t know because there was still so much we don’t know about the original COVID. And when they start saying, “Well, the new one can be transmitted easier.” Well, what does that mean? We’ve gone with the fact that if you’re with somebody longer than 15 minutes without a mask on, that’s considered an exposure. Well, in reality, you could have been with that person for five minutes if they’re coughing and sneezing, you could have picked it up even quicker than 15 minutes. So, what does, “It transmits faster” mean with the variants? Because there’s more than one variant out there. Remember, we have given this virus a year now. And we have given it an incubator in millions and millions of people. The virus has been able to figure out what is the DNA of human beings and then manage its way around treatments or vaccines. Had we not given it millions of bodies to incubate in and to learn how to migrate through the human body, then we wouldn’t be sitting here worrying about variants. Because when you look at the coronavirus itself, there are many versions of it. There’s not just one coronavirus. And even when you look at the disinfectants, they’ll say works with this coronavirus and this coronavirus, but they don’t say all coronaviruses. Everybody’s got to be keeping that in the back of their mind now. And until we have data to show hospitals are seeing the variance and we’re confident that it wasn’t the original coronavirus, then we’re going to have to be on high alert. And the problem with it is now that some people have the vaccine, they think, “Oh, now I can do anything. I’m covered by the vaccine.” And IPs have to really be out there in people’s faces and say, “Wait a minute. Just because you have the vaccine doesn’t mean that you’re protected.” We don’t know yet. Because there are too many variants out there and we don’t know which is going to become the predominant variant. The coronavirus that we’ve been dealing with is probably about to be taken over by a different variant of that. And then it’s learning all over again. Do our vaccines work or not?

ICT®: You used the phrase: Maintain your standard precautions. Isn’t that kind of a given? Aren’t health care professionals and infection preventionists doing that throughout this pandemic? But then I think you’ve just answered the question for me by saying, they might let their guard down when they get vaccinated, right?

Spaulding: Exactly. I talked to a group of 10 people the other day that were sitting outside of a hospital, having lunch. Ten people within arm’s length of each other with their masks off. And when I talked to them about it, their first response was, “I’ve already been vaccinated. I don’t have to worry about that anymore.” And at least 5 of those 10 were physicians. So, misinformation. We’re given paperwork when we get the vaccine that covers all that. That says, “You still have to wear your mask. You still have to social distance.” Problem is if people aren’t reading the paperwork they’re getting…. They’re getting it and they’re tossing it on their desk, or in their car, or whatever. But they’re not actually reading the information. They’re just going by assumption, “Oh, I’m vaccinated. Now I’m good to go.” And that’s where we’re going to find problems.

ICT®: If that attitude is prominent among health care professionals, do you think it will also manifest itself with the general public?

Spaulding: Oh, it’s going to happen. It’s probably already happening. And I think, how do you get the information to the general public? You know, sure, we have the news media, but not everybody believes everything they hear anymore. We have a group of people in the United States that don’t even watch election news. Never, ever. They don’t read a newspaper. How do you get information to those people? Those people are only going to go by the information they get by word of mouth, and if somebody’s giving them incorrect information, that’s the information they’re going to believe. That’s why the pandemic has gone on for so long, when we could have stopped it nine months ago by simply putting on a mask. It was so easy to stop this and we wouldn’t be standing here talking about variants. And does the vaccine work? Or do the swabs work? And it’s a difficult situation. And if you watch the news…. We talked about standard precautions. Standard precautions you would think is pretty basic. Somebody’s going to cough in your face, put on a mask, put on eye protection. You’re going to come into contact with bodily fluids, put on a gown, put on gloves if the patient’s not controlling their bodily secretions. Yet, I’ve watched the news every night. And I see nurses and physicians that are going into these COVID positive rooms with their gowns hanging down off their shoulders. They’re not watching out for each other close enough. Nurses and doctors need to watch the backs of their co-workers. If somebody doesn’t have their gown tied and they’re in a room with a patient, tie their gown. That’s the basics of it. As soon as that person turns around and touches the side rail of a bed or something else in the room, then their scrubs are going to possibly have COVID, or other things on it. And IPs really need to start watching not only for COVID but watching for these drug-resistant organisms that are being spread from patient to patient because everybody’s just focusing on COVID. And now we’re having outbreaks of fungal infections and other MDROs [multi-drug resistant organisms] that we have never seen before. We have to stop just thinking COVID. IPs need to be monitoring cultures and everything for cross transmission of the multi-drug resistant organism, because the person might survive COVID and then find out they have a multi-drug resistant organism that they’re going to be dealing with the rest of their life. So much focus has been on COVID and now we’re starting to see the consequences of that in outbreaks of resistant organisms.

ICT®: And some of those are superbugs, right? When you saw those health care professionals eating lunch outside—and I guess we should mention that you’re in Florida—when you questioned them, what was their response? I’m especially interested in hearing the response of the doctors.

Spaulding: Well, it was interesting, because the first person I walked up and I said, “Hey, guys, you know, COVID is still here. You’re not social distancing. You don’t have your mask on if anybody at this table has COVID, then the rest of you could have it by the time you’re done eating.” And a physician turned around she said, “We don’t have to worry about that. I’m a doctor and I know we’ve already had both of our vaccines.” People at the other end of the table quickly put their masks back on, acknowledging that they had heard me. And then they started making jokes of it. And I said, “You know, you can joke about it all you want. But the reality of the situation is, if anybody sitting at this table has COVID today and they’re asymptomatic? You could potentially get it.” The vaccine does not protect you from getting COVID. It protects you from dying of COVID or getting severe disease of COVID and having issues for the rest of your life. And then once they started joking about it, I just thought, “Well, it’s not worth my time talking to them, because….” But every time I see them, I will mention it to them again. Because it’s not right.

ICT®: I believe in a previous conversation you said that being immune to COVID, either from being vaccinated or having COVID and recovering from it, doesn’t preclude you from being an asymptomatic carrier of COVID.

Spaulding: No, it doesn’t. You can still become an asymptomatic carrier from the information we know right now. What we don’t know is: Will you still spread it if you’re an asymptomatic carrier as easily as if you weren’t vaccinated? There’s still a lot of research that has to be done on those of us that have been vaccinated. What happens to the people that were vaccinated? Did any of them get COVID? If they did, what were the circumstances, so we can tell people, “OK, you won’t get it if you do this. But you will get it, or you have a higher potential of getting it, if you do X, Y, and Z.” And that’s a bad place for health care people to be because a lot of health care people want black and white. Infection prevention is never black and white. We live in a gray area.

ICT®: Let me allow me to paraphrase that advice that I think you just gave your fellow infection preventionists. Get the vaccine, but go about your day-to-day business as if you didn’t get the vaccine. Is that a fair paraphrase?

Spaulding: Exactly. And somehow, we have to be creative to get health care workers that won’t get vaccinated…. We have to somehow be creative to get the information to them that they’re lacking to feel comfortable to get the vaccine. Because a lot of health care workers are not getting the vaccine, and a lot of us are jumping to be the first ones in line. I don’t know what it’s going to take.

ICT®: And, again, the point you raised at the beginning of our conversation is how important testing is in these situations. What’s the situation with tests? Are there enough available? PPE [personal protective equipment] availability has always been a focus throughout this pandemic. What’s the deal with testing?

Spaulding: Testing is kind of like PBE. From one day to another, we don’t know if we’re going to have enough tests. We always check in the morning how many tests do we have. Are we good to go? Can we send as many people who we need to be tested? And it’s always the reagents that are the problem. Well, we didn’t get any more reagents. So, we can’t do any more testing until the reagents come in. I’m hoping over the next two or three weeks that we see an increase in products that we need in order to do the testing, whether it’s the reagent or the swabs. And then hopefully, we’ll see a lot more centers opening up for vaccination. But vaccination is only as good as the people that will go get it. Now what I’ve noticed is there does seem to be a decline in the number of COVID positive patients across the United States right now. Finally, we’re kind of coming down. If we have fewer positive people, we have fewer ICU admissions. And I’m hoping that the millions of people that have been vaccinated so far is starting to put an impact into that. And it is decreasing the number of people that it’s being spread to. It could be a high hope. But right now, there’s something that’s starting to bring the rates down a little bit. And if it’s because we have more people vaccinated, then that’s the best news we’ve had in a year. But nobody’s come out and actually said that, yet. Because I’m sure they’re trying to collect more data and making sure that people aren’t cutting back on tests. Hence, that’s why our number of positive people are dropping. But we do know we’re starting to see a little relief in the ICU.

ICT®: Any final advice for your fellow infection preventionists? Or your fellow health care professionals in general?

Spaulding: For all health care professionals, watch out for each other. If somebody doesn’t have their PPE on right, go to them and help them. We can’t all tie our ties in the back of our gowns. And if you’re really busy, you walk by somebody that isn’t tied up, then tie their gown for them. We have to protect each other. A lot of health care workers have died during this pandemic. And a lot more will have the potential of dying. We’re getting too lax on just tossing our PPE on and having our front covered and nothing else. And I think that’s just people are getting tired of so many people being in isolation. We have to watch out for each other. IPs make rounds every day in those areas. Help people. Remind people to help each other make sure they have their PPE on correctly.

This interview has been edited for clarity and length.