We are three physicians who share an apartment in Boston, and after months of wondering where we might catch Covid-19 — the crowded grocery store checkout line? the gas station? — we found out: at work.
One of us recently tested positive for SARS-CoV-2 after an exposure at work, part of a cluster of Covid-19-positive health care workers at Brigham and Women’s Hospital. This scenario is not unique; there have been outbreaks in hospitals in Washington state, central Massachusetts, and elsewhere over the past few months.
These outbreaks are shedding light on many of the systems issues that U.S hospitals are dealing with nine months after Covid-19 first emerged here. From the beginning of the pandemic, there have been cries for a nationally coordinated Covid-19 response. Instead, with the exception of some unevenly distributed funding and deliveries of personal protective equipment, hospitals have been left to fend for themselves.
The Centers for Disease Control and Prevention has issued guidelines, but there has been little federal coordination or funding to assist in their implementation. A Boston Globe article highlighting “battle-weary staff” as the cause of the Brigham and Women’s outbreak completely misses the larger systems issues that hospitals and hospital workers are up against.
The ideal response to a Covid-19 outbreak is identifying people infected with SARS-CoV-2, the virus that causes the disease, and isolating them, done by systematic contact tracing. For community members, national guidelines recommend quarantining for 14 days after exposure to someone positive for SARS-CoV-2, even if he or she does not have any symptoms.
It’s more complicated for health care workers. While the CDC recommends that they quarantine after high-risk exposures, many major hospitals tell staff to keep working unless they have symptoms of Covid-19. Testing is recommended but not mandated, and there is little guidance around home quarantine or repeat testing after a negative test.
These rules are designed to keep the workforce functioning — hospital systems would be substantially strained if all exposed employees quarantined for 14 days — but they create major risks for essential hospital workers, their close contacts, and their patients.
Why is it so challenging to conduct effective and efficient contact tracing within a hospital? First, despite clear evidence of asymptomatic transmission, routine testing of health care workers has not been broadly implemented, even though many professional schools and undergraduate institutions are routinely testing students, as often as three times a week, to ensure the safety of in-person classes.
One argument against routinely testing health care workers is that universal masking of patients and employees is extremely effective in preventing transmission. The problem is that our patients — especially those who are confused or short of breath — do not always use masks appropriately, and we can’t really expect them to. In addition, despite universal masking policies, hospital workers must unmask to eat. We cannot leave our floors to eat elsewhere if we are frequently checking in on sick patients, so we eat where we can, often in cramped workspaces. Many hospital workers, like us, also live with other health care professionals and don’t wear masks at home.
At many hospitals across the country, the testing process takes anywhere from 24 to 72 hours from scheduling a test to receiving results. While this may be faster than for community members, it is too slow to encourage frequent testing for minor symptoms and to stop outbreaks. It can be exceedingly difficult to know if it’s a new runny nose that could represent Covid-19 or just another day with seasonal allergies. A health care worker with a pending test result is liable to miss up to three days of work, burdening his or her co-workers and affecting patient care. This lengthy furlough period may disincentivize essential workers from reporting minor symptoms, leading to the risk of working while infected with SARS-CoV-2.
Until hospitals employ rapid, widely accessible Covid-19 testing, the country will not be able to get this pandemic under control. When health care workers are exposed to Covid-19 at work and are unable to get tested in an expedient way that would permit early isolation and quarantine of infected contacts, they will cause further spread.
To avoid this, major changes are needed. Hospitals must publicly endorse national policies for health care workers, including regular testing and quarantine after high-risk exposure. This should include a test at days five to seven, when false-negative rates after exposure are thought to be lowest. Routine testing, weekly or biweekly, must be considered for all health care workers, just as many professional and undergraduate schools are doing, understanding that universal masking policies are imperfect.
Health care workers need widely available rapid testing — less than 24-hour turnaround — to encourage frequent testing for even minor symptoms. This requires coordinated national support and funding for rapid testing platforms. They also need appropriately distanced workspaces and areas in which to eat, perhaps by reopening portions of buildings unused by staff who are working remotely.
It is a failing of our health care system and national response that despite months of anticipation and one prominent surge in the Northeast, we are still woefully underprepared for the next surge, which is already underway.
As three essential health care workers in Boston, we love our jobs, we love taking care of our patients, and we’re not weary — we just need more support. We need routine, rapid testing, we need better contract tracing, and we need safe spaces to eat. We owe it to our patients.
Kathryn Holroyd is a fourth-year chief neurology resident in the Mass General Brigham neurology program. Neha Limaye is a fourth-year resident in internal medicine and pediatrics at Brigham and Women’s Hospital and Boston Children’s Hospital and a member of the Global Health Equity residency. Hallie Rozansky is a fellow in addiction medicine at Boston Medical Center and a graduate of the internal medicine/primary care residency program at Brigham and Women’s Hospital. The opinions expressed here are solely their own and do not necessarily reflect the views and opinions of their employers.
