Do we put frontline healthcare workers at more risk with the current CDC and WHO recommendations for ending isolation and precautions?

To the Editor—Coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has been a global health threat for nearly a year. ¹ In China, ∼4% of confirmed cases in the first month of the COVID-19 outbreak occurred among healthcare workers, with even higher rates in Europe. ² With the current surge of COVID-19 cases, we are seeing an increasing number of inpatients with COVID-19. The mean hospitalization period (HP) revealed in one meta-analysis can be 14.88 days, and some studies indicate a mean HP >20 days. ³

In our hospital, we also have patients who have been hospitalized for >20 days or remain hospitalized beyond 20 days of symptom onset. Recently, isolation and precautions of an ICU patient hospitalized beyond 20 days of symptom onset were removed by infection control advisers based on Centers for Disease Control and Prevention (CDC) recommendations that patients with more severe to critical illness or severe immunocompromise likely remain infectious no longer than 20 days after symptom onset, and extending duration of isolation and precautions for up to 20 days after symptom onset for severe cases is warranted. ⁴ A 46-year-old female patient with a past medical history of essential hypertension initially presented with fever, shortness of breath, diarrhea, and cough. She tested positive for SARS-CoV-2 and required medical ICU care for multi-organ failure secondary to COVID-19. Isolation precautions were removed on day 21 of her symptom onset. Examination, medication administration, and procedures including terminal extubation were performed without precaution until her death 25 days after onset of symptoms. Notably, a repeated SARS-CoV-2 PCR test on day 23 of her symptoms was positive. After ending the isolation precautions, 1 ICU resident developed fever, cough, and shortness of breath within 2 days after exposure and tested positive for SARS-CoV-2. She is currently hospitalized for severe COVID-19. In addition, 3 ICU nurses also tested positive for SARS-CoV-2, with symptoms of cough, fever, anosmia, and dysgeusia. Furthermore, 3 of 5 other ICU residents developed transient mild symptoms, including diarrhea, cough, and myalgia within 2–7 days after exposure, but they were not tested for SARS-CoV-2. These staff members did not have any other known exposure to SARS-CoV-2. Universal masking, eye protection, gowning, gloves, hair cover, and shoe covers were implemented for all patient encounters, and appropriate personal protective equipment was used for patients with suspected or confirmed COVID-19.

COVID-19 patients who have been infectious for >20 days have been reported in a peer-reviewed journal, ⁵ and severe COVID-19 infection has been associated with prolonged viral shedding. ⁶ WHO recommendations on isolation cited the range of viral shedding as 0–20 days from a personal communication published on a preprint website instead of in a peer-reviewed journal, ^7,8 or from a study of asymptomatic patients ⁹ or animal models. ¹⁰ In the setting of an unprecedented global pandemic, this reckless recommendation on ending isolation and precautions may put frontline healthcare workers at an unnecessary higher risk of being infected and thus may exacerbate critical staff shortages. Using an abundance of caution, we should rethink the recommended criteria for releasing COVID-19 patients from isolation.