Testing, testing, 1,2,3, … how B.C. seniors’ care can win against COVID-19

British Columbia is falling behind other jurisdictions when it comes to COVID-19 tests — how can we fix that?

On December 1, 2020 BC Care Providers Association (BCCPA) hosted its Annual General Meeting (AGM) for the first time via the videoconfercing application Zoom. In addition to updating members on last year’s key accomplishments and future plans for the organization, the AGM provided an opportunity for members to vote on different procedural matters as well as several policy motions.

Article by Michael Kary, BCCPA Director of Research and Policy

One issue that has garnered attention from the media as well as strong support from rank and file members in recent weeks is the call for more testing in long-term care — in particular the use of rapid tests. Along with ensuring proper personal protective equipment (PPE) as well as infection prevention and control (IPAC) measures, it is believed that a key to reducing or mitigating COVID-19 outbreaks in seniors care is testing — particularly as the elderly living in long-term care and staff are at elevated risk from COVID-19.[i]

In our article below we contrast what some regions are doing compared to British Columbia when it comes to rapid testing for the SARS-CoV-2 coronavirus.

  1. Frequency of Testing

Jurisdictions such as the United States have developed guidelines on how often workers should be tested for COVID-19. For example, the U.S. Centers for Medicare and Medicaid Services announced in late August that nursing homes would be required to test workers as part of an overall effort to identify asymptomatic staff who could be infected and spread COVID-19. In particular, it recommended routine testing of staff based on county-level positivity rates from the previous week (i.e. if below 5%, staff should be tested once a month, if between 5% and 10% once a week and if over 10% twice a week).[ii]

An August 2020 research study from the U.S. which compared the effect of various coronavirus surveillance strategies also concluded that weekly testing of at least half of staff members and residents was necessary to minimize outbreaks in long-term care.[iii] Various reports, including from the World Health Organization, have also recommended prioritizing testing among people receiving and providing long-term care services.[iv] Currently, the U.S. Centers for Disease Control and Prevention advocates weekly testing for health-care professionals working in long-term care homes.[v]

One of the main reasons for the necessity of frequent testing of staff is due to the fact COVID-19 can be spread by those who are asymptomatic. A 2020 report by the International Long-Term Care Policy Network, for example, found a high prevalence of asymptomatic and pre-symptomatic cases that would not be detected by a) symptoms screening, and b) one-off testing in long-term care.[vi] The report also highlighted a recent study from Belgium, which showedthat about 73% of staff and 69% of residents who tested positive were asymptomatic, thus, demonstrating the importance of regular testing in care homes instead of relying on symptoms to identify people with potential COVID-19 infections.[vii]

  1. Community Transmission

Along with asymptomatic  spread, one of the primary factors for COVID-19 outbreaks in long-term care and assisted living is higher levels of community transmission.[viii] As seen in an October 2020 report by the American Health Care Association/National Center for Assisted Living, it showed that cases in nursing homes correlate directly to community spread[ix] while another study highlighted that where nursing home staff live is a large and significant predictor of which facilities will experience a COVID-19 outbreak.[x]

While in B.C. there was a decline in number of COVID-19 long-term care outbreaks over the summer reaching close to zero, the province has seen increases over time — particularly as community transmission increases as this is one of the main contributing factors for such outbreaks.[xi] Currently in B.C.. the long-term care population represents less than one per cent of its citizens but accounts for about 70% of deaths from COVID-19.[xii]  By early December, our province also had over 50 long-term care and assisted living sites with COVID-19 outbreaks, while other provinces such as Alberta had even higher rates. In Alberta, for example, the total number of active COVID-19 cases in care homes had gone from 40 to 123 in less than a month.[xiii]

To deal with these higher numbers and high levels of community transmission it is important to look further at increasing testing for workers in the continuing care sector. This includes exploring the use of more testing including rapid antigen tests as discussed below.

  1. Testing in B.C.

During the summer B.C. had undertaken about 300,000 COVID-19 tests  (average testing rate was around 43,000 people for every one million population). This, however, was still less than half of the Canadian average, which was over 100,000 per million people, according to federal statistics.[xiv] In early August B.C. announced plans to ramp up testing capacity to 16,000 per day by November, though the highest number of daily tests undertaken as of mid August was about 3500 tests;[xv] and B.C. remains currently below targets. While increasing overall number of tests for the general public is laudable, there should also be a designated testing strategy developed for B.C.’s continuing care sector staff — particularly as many workers (and residents) can be asymptomatic and unknowingly spread COVID-19.

Overall, the delays in testing programs across Canada (including B.C.) are preventing long-term care homes from quickly identifying infected residents and staff and controlling the spread of infections.[xvi] Fast turnaround of test results (ideally within 24 hours) is crucial to preventing and managing outbreaks in long-term care homes, and other congregate settings where the elderly are most vulnerable to the virus. Currently, multiple health regions across the country (including British Columbia) are missing target turnaround times for test results.[xvii]

As greater testing has the potential to reduce COVID-19 outbreaks in long-term care and assisted living, it also has the possibility to allow for a relaxing of some of the visit restrictions and to ensure more safe family visits, an issue BCCPA has also advocated for, including the development of recent a guide for supporting family visits during COVID-19.[xviii]

For these reasons, BCCPA put forward a policy motion at its AGM which was approved by members recommending by the end of December 2020, the B.C. Government develop and fully fund a provincial COVID-19 testing strategy for seniors’ care and living that includes specific targets around the frequency of testing and test result turnaround times for those working in long-term care, assisted living, home health and independent living in order to help prevent or mitigate the spread of COVID-19. Along with providing priority access to testing and quick turn-around of results, the B.C. Government should also prioritize the seniors care sector for point of care and less invasive tests as they become available.

  1. Rapid Antigen Testing

One of the issues that has also been highlighted in the media is the use of rapid antigen tests in seniors care homes.[xix] These tests can detect certain proteins in the virus within 5 to 20 minutes. This timing is significantly faster than the current polymerase chain reaction (PCR) test that takes more than 6 hours. In Canada the first rapid antigen test was approved in October 2020 and have since been distributed to provinces and territories, including B.C..[xx]

Health Canada has approved these tests for use only at point-of-care and are generally intended to supplement but not completely replace lab-based polymerase chain reaction (PCR) testing, which still remains the best option for confirming a negative or a positive result. Likewise, the intention is to administer these tests in high-risk workplaces where rapid initial results could assist in quickly isolating positive cases such as long-term care homes.[xxi]  Given their potential use to detect COVID-19 cases in long-term care, other jurisdictions in Canada are using rapid tests at least to a limited degree.

In late November, for example, Ontario announced that it would be using new COVID-19 rapid tests to provide faster results in regions of high transmission as well as rural and remote areas. In particular, as an additional tool to help keep essential workers safe, rapid tests will also be used to screen staff in long-term care homes and select workplaces. In its media release, it noted that Panbio rapid antigen tests have already been deployed to six long-term care operators for potential use in over 30 care homes.[xxii]

  1. Experiences from other jurisdictions

Modelling studies suggest routine testing in staff of high-risk settings such as long-term care homes or assisted living can prevent outbreaks and COVID-19 cases. A recent pilot initiative in the Toronto District School Board, for example, identified 19 asymptomatic cases as were able to isolate the affected while also keeping the school open.[xxiii]

While Canadian provinces are starting to look further at the use of rapid testing in long-term care, they are already been in place in other jurisdictions including the U.S. and Germany. In the U.S., for example, since late July, the federal government has sent rapid testing machines to more than 14,000 long-term care facilities in an attempt to identify outbreaks faster and stem the tide of the virus, which has had a particularly hard toll on the elderly living in nursing homes and other assisted living facilities.[xxiv]

While welcomed by many sites in the U.S., the main concern expressed by nursing homes has been reliability of the rapid, point-of-care antigen tests after reports that the devices had been producing a lot of false negatives.[xxv]Likewise, despite being used much more widely it is not clear to what extent these tests may have actually curbed spread of COVID-19. A report released in early December 2020 by the American Health Care Association/National Center for Assisted Living, for example, revealed that cases among residents at long-term care and assisted living facilities grew by more than 177% (5877 to 16257) from mid-September to mid-November.[xxvi]

Germany has also been widely using point of care testing, as in mid-October the Federal Ministry of Health announced the introduction of rapid antigen testing to reduce the risk of infection with COVID-19 in care homes and to enable homes to stay open to visitors. Its Ministry also acknowledges that although rapid antigen tests may be less reliable than PCR tests, it has the advantage to identify infection in real-time, with test results being available within 15 to 20 minutes.[xxvii]

In Germany guidelines developed by the Robert Koch Institute recommend point-of-care testing to be made available in care homes and other facilities that deliver health services (e.g. hospital, day surgery facility, dialysis centre) or provide care to vulnerable groups (care home for older people and people with disabilities, domiciliary care providers), if they are located in an area with an infection rate of 50 or over per 100,000 population over the last seven days.[xxviii] While rapid testing has been introduce more broadly in Germany, it has not been without challenges, including as identified in recent study:

  • Some care homes have had difficulty procuring tests due to supply shortages, ending up in a situation not unlike the shortage of PPE;
  • Care homes need to develop their own testing concept, which is time consuming for both the homes and the local health authorities required to review and approve them; and
  • Testing itself can be done quickly if considering a single test but doing hundreds or thousands of them per week require substantial more staffing and resources. Likewise, it also requires appropriate documentation, which also draws on limited resources.[xxix]
  1. Rapid Testing in B.C. – a pilot project for long-term care

In late November 2020, BCCPA released a report on better preparing the seniors care sector for any future COVID-19 waves, including recommending that the Provincial Health Officer establish rapid testing alongside screening protocols for residents and staff in long-term care, assisted living, and independent living. If rapid testing in B.C. is to be expanded to long-term care homes more broadly, it will be important to look at experiences from other jurisdictions such as the U.S. and Germany but also provinces where they are starting to be implemented such as Ontario.

As outlined in a recent article, in B.C. there is already a robust model of routine testing in the film industry where each worker on-set is tested between one-and-three times per week. Likewise, there is sufficient provincial lab capacity in B.C. to test staff one-to-two times per week. As seen from the experience in the U.S. one of the reasons for the general reluctance to implement rapid tests in B.C. is due to accuracy concerns particularly for asymptomatic individuals. While routine rapid testing will not stop staff from being infected it can, however, lead to early identification and isolation of cases, which can ultimately prevent an outbreak.[xxx]

In particular, while the rapid tests are not perfect and have limitations, the deployment of these tests will likely detect most asymptomatic cases, prevent transmission to staff and residents, reduce the frequency of catastrophic outbreaks and alleviate the detrimental physical and mental health impacts of social isolation.[xxxi] An article published in the journal Science Advance last month by researchers at the University of Colorado-Boulder and Harvard[xxxii] also concluded frequent, widespread testing with quick turnaround times — even of asymptomatic people — is the cheapest, most effective way of reversing soaring coronavirus caseloads.[xxxiii]

As noted by BCCPA, one way to proceed could be to undertake a pilot project on rapid testing in long-term care with the health authorities.[xxxiv] It is also important that any rollout of a rapid testing program would also be done in conjunction with health authorities and should include a research component so that we can learn best practices.

Ultimately, it is the hope that new measures like rapid tests to reduce COVID-19 will result in fewer long-term care home outbreaks particularly as we urgently find ways to reconnect families to their loved ones in care.[xxxv] Overall, it can and should it be looked as another layer or potential tool in the province’s COVID-19 prevention efforts.

— Michael Kary is BCCPA’s Director of Policy and Research

END NOTES

[i] The Coronavirus and the Risks to the Elderly in Long-Term Care. Journal of Aging and Social Policy. William Gardner and Nicholas Bagley. March 2020. Accessed at: https://www.tandfonline.com/doi/full/10.1080/08959420.2020.1750543

[ii] McKnight’s Long-Term Care News. CMS releases county COVID data for staff testing requirements. September 2020. Accessed at: https://www.mcknights.com/news/cms-releases-county-covid-data-for-staff-testing-requirements/.

[iii] Journal of Post Acute and Long-Term Care Medicine.  Evaluation of Testing Frequency and Sampling for Severe Acute Respiratory Syndrome Coronavirus 2 Surveillance Strategies in Long-Term Care Facilities. Charlotte Lanièce Delaunay, Sahar Saeed and Quoc Dinh Nguyen. August 2020.  Accessed at: https://www.jamda.com/article/S1525-8610(20)30709-X/fulltext

[iv] World Health Organization. Preventing and managing COVID-19 across long-term care services: Policy brief, 24 July 2020. Accessed at: https://www.who.int/publications/i/item/WHO-2019-nCoV-Policy_Brief-Long-term_Care-2020.1.

[v] The Province. Scott Lear: It’s time for routine COVID-19 testing in our long-term care homes. December 3, 2020. Accessed at: https://theprovince.com/opinion/scott-lear-its-time-for-routine-covid-19-testing-in-our-long-term-care-homes

[vi] Salcher-Konrad M and Comas-Herrera A (2020) International evidence on care home COVID-19 outbreak responses, summary of key findings. LTCcovid, International Long-Term Care Policy Network, 12 June 2020.

https://ltccovid.org/wp-content/uploads/2020/06/Evidence-on-approaches-to-control-care-home-outbreaks.pdf

[vii] Comas-Herrera A, Ashcroft E and Lorenz-Dant K. (2020) International examples of measures to prevent and manage COVID-19 outbreaks in residential care and nursing home settings. Report in LTCcovid.org, International Long-Term Care Policy Network, CPEC-LSE, 11 May 2020.

https://ltccovid.org/wp-content/uploads/2020/05/International-measures-to-prevent-and-manage-COVID19-infections-in-care-homes-11-May-2.pdf.

[viii] Journal of American Geriatrics Society. Characteristics of U.S. Nursing Homes with COVID‐19 Cases. Hannah R. Abrams, Lacey Loomer, Ashvin Gandhi, and David C. Grabowski. June 2020.  Accessed at: https://onlinelibrary.wiley.com/doi/full/10.1111/jgs.16661

[ix] American Health Care Association and National Centre for Assisted Living. REPORT: COVID-19 Cases in U.S. Nursing Homes. Updated October 19, 2020. Accessed at: https://www.ahcancal.org/News-and-Communications/Fact-Sheets/FactSheets/Report-Nursing-Homes-Cases-Oct19-2020.pdf

[x] McKnight’s Long-Term Care News. COVID outbreaks tied to where nursing home staff live, researchers say. September 2020. Accessed at: https://www.mcknights.com/news/clinical-news/covid-outbreaks-tied-to-where-nursing-home-staff-lives-researchers-say/

[xi] Journal of American Geriatrics Society. Characteristics of U.S. Nursing Homes with COVID‐19 Cases. Hannah R. Abrams, Lacey Loomer, Ashvin Gandhi, and David C. Grabowski. June 2020.  Accessed at: https://onlinelibrary.wiley.com/doi/full/10.1111/jgs.16661

[xii] The Province. Scott Lear: It’s time for routine COVID-19 testing in our long-term care homes. December 3, 2020. Accessed at: https://theprovince.com/opinion/scott-lear-its-time-for-routine-covid-19-testing-in-our-long-term-care-homes. B.C. CDC indicates 239 of the 354 COVID-19 deaths have been residents of care homes.

[xiii] CBC News. COVID-19 outbreaks more than triple at Alberta continuing-care centres in 3 weeks. December 2, 2020. https://www.cbc.ca/news/canada/calgary/long-term-care-centres-outbreaks-alberta-covid-conroy-1.5825374

[xiv] Vancouver Province. COVID-19: Long lines developing to get tested in B.C. August 18, 2020. Denise Ryan.  Accessed at: https://theprovince.com/news/long-lines-developing-to-get-covid-tests/wcm/7178d7fb-7487-411a-beef-6a1b9a15271d

[xv] Vancouver Province. COVID-19: Long lines developing to get tested in B.C. August 18, 2020. Denise Ryan.  Accessed at: https://theprovince.com/news/long-lines-developing-to-get-covid-tests/wcm/7178d7fb-7487-411a-beef-6a1b9a15271d

[xvi] Globe and Mail. Delays in COVID-19 testing results putting long-term care homes at greater risk. October 20, 2020.  Accessed at: https://www.theglobeandmail.com/canada/article-delays-in-covid-19-testing-results-putting-long-term-care-homes-at/

[xvii] Globe and Mail. Delays in COVID-19 testing results putting long-term care homes at greater risk. October 20, 2020.  Accessed at: https://www.theglobeandmail.com/canada/article-delays-in-covid-19-testing-results-putting-long-term-care-homes-at/

[xviii] BCCPA. The Best Visit Possible: A guide for supporting family visits during COVID-19. September 2020. Accessed at: https://bccare.ca/wp-content/uploads/2020/09/The-Best-Visit-Possible-Sept-21.pdf

[xix] CTV News. Push for rapid testing as B.C. care homes battle 4 major COVID-19 outbreaks. November 27, 2020. Accessed at: https://bc.ctvnews.ca/push-for-rapid-testing-as-b-c-care-homes-battle-4-major-covid-19-outbreaks-1.5207785

[xx] Mondaq. Canada: Accelerating the Fight Against COVID-19: Antigen Rapid Testing Technologies and the Workplace. December 2, 2020. Accessed at:  https://www.mondaq.com/canada/operational-impacts-and-strategy/1011600/accelerating-the-fight-against-covid-19-antigen-rapid-testing-technologies-and-the-workplace

[xxi] Mondaq. Canada: Accelerating the Fight Against COVID-19: Antigen Rapid Testing Technologies and the Workplace. December 2, 2020. Accessed at:  https://www.mondaq.com/canada/operational-impacts-and-strategy/1011600/accelerating-the-fight-against-covid-19-antigen-rapid-testing-technologies-and-the-workplace

[xxii] Ontario Government. Ontario Deploys Rapid Testing to Support COVID-19 Response. November 24, 2020. Accessed at: https://news.ontario.ca/en/release/59330/ontario-deploys-rapid-testing-to-support-covid-19-response

[xxiii] The Province. Scott Lear: It’s time for routine COVID-19 testing in our long-term care homes. December 3, 2020. Accessed at: https://theprovince.com/opinion/scott-lear-its-time-for-routine-covid-19-testing-in-our-long-term-care-homes.

[xxiv] ABC News. Some states raising doubts about federal tests sent to nursing homes, citing shaky reliability. October 14, 2020. Accessed at: https://abcnews.go.com/Health/states-raising-doubts-federal-tests-nursing-homes-citing/story?id=73591354

[xxv] McKnight’s Long-Term Care News. More states question reliability of point-of-care testing devices supplied by feds. October 15, 2020. Accessed at: https://www.mcknights.com/news/more-states-question-reliability-of-point-of-care-testing-devices-supplied-by-feds/

[xxvi] McKnight’s Long-Term Care News. ‘Situation will only get much worse’: COVID cases rise by 177% in nursing homes. December 2, 2020. Accessed at: https://www.mcknights.com/news/situation-will-only-get-much-worse-covid-cases-rise-by-177-in-nursing-homes/

[xxvii] International Long-Term Care Policy Network. Rapid COVID-19 testing in care homes in Germany: Easier said than done. Dr Stefanie Ettelt. November 24, 2020. Accessed at: https://ltccovid.org/2020/11/24/rapid-covid-19-testing-in-care-homes-in-germany-easier-said-than-done/

[xxviii] International Long-Term Care Policy Network. Rapid COVID-19 testing in care homes in Germany: Easier said than done. Dr Stefanie Ettelt. November 24, 2020. Accessed at: https://ltccovid.org/2020/11/24/rapid-covid-19-testing-in-care-homes-in-germany-easier-said-than-done/

[xxix] International Long-Term Care Policy Network. Rapid COVID-19 testing in care homes in Germany: Easier said than done. Dr Stefanie Ettelt. November 24, 2020. Accessed at: https://ltccovid.org/2020/11/24/rapid-covid-19-testing-in-care-homes-in-germany-easier-said-than-done/

[xxx] The Province. Scott Lear: It’s time for routine COVID-19 testing in our long-term care homes. December 3, 2020. Accessed at: https://theprovince.com/opinion/scott-lear-its-time-for-routine-covid-19-testing-in-our-long-term-care-homes.

[xxxi] Times Colonist. Comment: To improve residents’ lives, we need COVID-19 rapid testing at care homes. Ted Rosenberg. December 4, 2020. Accessed at: https://www.timescolonist.com/opinion/op-ed/comment-to-improve-residents-lives-we-need-covid-19-rapid-testing-at-care-homes-1.24250206

[xxxii] Science Advances. Test sensitivity is secondary to frequency and turnaround time for COVID-19 screening. November 20, 2020. Daniel B. Larremore et al. Accessed at: https://advances.sciencemag.org/content/early/2020/11/20/sciadv.abd5393.1

[xxxiii] Yahoo News. How Quebec is finally using rapid testing to screen for COVID-19. December 4, 2020. Accessed at: https://ca.news.yahoo.com/rapid-testing-covid-19-comes-090000551.html

[xxxiv] CTV News. Push for rapid testing as B.C. care homes battle 4 major COVID-19 outbreaks. November 27, 2020. Accessed at: https://bc.ctvnews.ca/push-for-rapid-testing-as-b-c-care-homes-battle-4-major-covid-19-outbreaks-1.5207785

[xxxv] Medicine Matters. Seniors care homes need rapid COVID-19 tests now: BC Care Providers Association. Terry Lake. November 30, 2020. Accessed at: https://medicinematters.ca/seniors-care-homes-need-rapid-covid-19-tests-now-bc-care-providers-association/