Strategic testing, and plenty of it, may be WA’s best chance of managing future outbreaks of SARS CoV-2
Whichever way you look at it, and especially if you’re looking at it from overseas, Australia has done an enviable job in containing what has proved to be a nasty, destructive viral pandemic.
The unity of the early days of the Australian response has started to fragment as understandably each state deals with its own set of circumstances and conditions. However, one fundamental area that is far from consistent, and arguably should be, is testing.
In this regard, WA is very much at the low end of the scale. While other states are in the hundreds of thousands, in Victoria more than 100,000 in the space of a week, WA recorded a total of just over 67,000 as of May 20. The genuine fears of PPE and testing kit shortages several months ago have long abated, so why is WA not doing more strategic asymptomatic testing?
It is a question the AMA WA president Dr Andrew Miller has been asking for some weeks now. He is not advocating a free-for-all but he is particularly concerned that with the inevitable lifting of interstate borders, WA will see flare-ups that will need to be managed especially for vulnerable patients I hospitals and aged care facilities and key, frontline workers.
“The testing is a puzzle to me. I still don’t feel like I have a complete understanding of why the restrictions on testing were in place at the start, or on private pathology being involved, when they weren’t in other states,” he said.
“And I still don’t understand why doctors can’t just order COVID tests as they would for any other test – to eliminate as much as confirm. We must have very high testing rates targeted towards at-risk populations as we ease restrictions. Clearly schools are one area as are health care workers and pre-operative or pre-admission patients.
“We know that people who have procedures when they’re in the prodromal phase of COVID-19 have very bad outcomes. With seemingly low community spread, it’s unlikely we’re going to find a positive asymptomatic patient in the community but this targeted testing before patients go into a hospital would be worthwhile.”
Cost v Risk
Dr Miller said that for the cost of a $100 test, it would be a small price for a hospital to pay if it avoided having to evacuate patients and shut down and deep clean wards, as was the case in north-west Tasmania.
“A deep clean and shut down could cost millions of dollars. So, this pre-surgical, pre-admission testing would be a small insurance for facilities. And we shouldn’t leave it up to patients to decide if they need testing. Humans aren’t always honest, even with themselves, particularly if it may mean them missing out on their procedure, or having to go into quarantine for 14 days. It would be naïve to think everyone will come forward if they’ve got symptoms.”
It is clear that COVID testing is very much a controlled activity with penalties for non-compliance (up to $20,000 for doctors and $100,000 for testing facilities).
The spokesperson said the testing in WA reflected both population size and COVID activity in the population:
“In the setting of very limited community transmission that WA has achieved thus far, it is not a priority in and of itself to try to match testing rates … from other jurisdictions that are experiencing outbreaks.”
HoDWA said that it was abiding by the Australian Health Protection Principal Committee suggestion to test “people at risk of exposure who present with atypical symptoms, such as health care workers and residential aged care facility workers”.
In terms of strategic and sustained workforce testing for health care workers (including aged care) and workers in essential industries such as education and mining, HoDWA offered: “We may consider short-term wider testing in the future.”
Regarding pre-surgical testing, HoDWA said: “Testing of asymptomatic patients prior to surgery is only approved for a limited number of patients undergoing specific aerodigestive procedures where prolonged aerosol exposure is expected.”
The mining industry has taken the front step during the first phase of the pandemic response. Being declared an essential service by the Premier, Mark McGowan, it has continued to turn the wheels of the state’s economy and has created an important beach-head on the testing front.
Workplace focus
On May 6, a few days after the government announced its DETECT Schools research testing project (with Telethon Kids to do the science), it announced that the mining sector would be involved in a similar testing program (through Curtin University and the Perkins Institute) called DETECT FIFO.
Medical Forum spoke to Rob Carruthers, the director of policy and advocacy at the Chamber of Minerals and Energy WA, who has been involved in the DETECT FIFO negotiations between the mining companies and the DoH WA.
Given the fly-in, fly-out nature of the workforce, mining companies were screening their workers themselves in various ways in the early stages of the COVID outbreak to “ensure that people were as healthy as they thought they were”, said Mr Carruthers.
From pre-work questionnaires, health assessments and temperature screening, some of the mining companies moved early to PCR antigen testing and one prominent iron ore miner moved to point of care (POC) serology tests at the airport.
“The DETECT FIFO project gives us the opportunity to wrap all of those screening measures into one and ensure that there’s a consolidated approach to both cohort testing and research which will underpin future strategy,” he said.
“We’ve done a tremendous job in Western Australia to see ourselves through the first few months of COVID-19, but our ability and effectiveness to continue to manage industry and businesses during this time is really going to turn on how important the DETECT program, more broadly, and the FIFO component particularly, is to keep our mines safely and effectively operating.”
Mr Carruthers said the pandemic would fundamentally change the way the industry operated.
“For an industry that operates in remote regional parts of the state and relies on being able to move workers from A to B and do it in a safe way, screening as part of this transit will be with us for the foreseeable future. Similarly face masks and other protective equipment may become a standard control for people on aircraft. That’s yet to be determined, but both government and industry are looking into that.”
DETECT snapshot
Asymptomatic people from vulnerable groups in the community will be able to undergo a swab test for COVID 19 until June 10 as part of the WA Government’s DETECT Snapshot program:
School staff, staff of accredited tourism businesses, transport workers (including maritime workers, security and customer service staff working in public transport, and aviation workers), health care workers in public, private, aged care, pharmacies, general practices and disability sectors, WA police staff, meat workers, retail workers and hospitality workers will be able to be tested even if they don’t display any symptoms.
Testing is available state-wide from COVID-19 testing clinics, a drive-through facility in Burswood, and a range of publicly and privately operated pathology providers.
Those tested will be able to resume normal activities immediately and will be informed of a negative result via SMS. Anyone who tests positive will be followed up in line with existing Public Health procedures.
Testing arrangements for everyone else remains the same.
Relocating workers
The closing of the interstate borders created challenges for the mining companies where the quarantining of eastern states and overseas workers for 14 days before every shift would be unviable as well as unacceptable. Mr Carruthers said that a number of companies decided to relocate entire families to WA – more than 2000 at last count.
DETECT FIFO has been fully funded by industry participants, and as Mr Carruthers describes it, they now have “skin in the game” to ensure it delivers on the expected outcomes.
“And we’re really pleased that it is a true partnership in that respect,” he said.
“The cohort testing will be voluntary, but some companies will seek to supplement and go above and beyond that to require the broader workforce to be screened and be cleared to work before they return to site.
“DETECT FIFO gives us the opportunity to look at the accuracy, reliability and sensitivity of different testing methods for early detection and diagnosis. A lot of the technologies that have been applied in COVID screening were not necessarily designed for that purpose. So, DETECT will give us, in the mid-term, a really strong level of competence and confidence that we’re applying the right level of screening techniques.
“I’ve been in the industry a long time, and I’ve never seen co-operation levels, the likes of which have come together in response to this crisis. And that’s not just being between the companies, but also at the government level. There is, again, very strong alignment on the scope and intent of the industry and the government.”
Q&A with The Department of Health Western Australia (DoHWA):
MF: The statement earlier this week from the Australian Health Protection Principles Committee (AHPPC) said widespread testing was one of the reasons Australia has been so successful in containing SARS CoV2. The states testing rates vary wildly, with WA in the low end of the testing scale. What is the rationale behind that decision given the resolution of PPE and testing kit supplies?
DoHWA: The number of COVID tests being performed in WA reflects both population size and COVID activity in the population. WA has tested fewer people proportional to total population because we’ve had fewer people presenting to be tested who met the clinical and epidemiologic criteria. States with higher rates of local transmission will naturally have more individuals who are contacts of previous cases and are also likely to have more persons with mild illnesses presenting for testing due to their enhanced concerns about potential exposure. Despite conducting fewer tests per capita, WA has been able limit community transmission to one of the lowest rates in the nation.
In the setting of very limited community transmission that WA has achieved thus far, it is not a priority in and of itself, to try to match testing rates being reported from other jurisdictions that are experiencing outbreaks, such as the meat worker outbreak in Victoria. WA will reach and, if necessary, surpass, the national average testing rate if this should be indicated in order to maintain our low rate of community transmission.
MF: The AHPPC this week advocated targeted testing of these groups:
- All people presenting with fever or acute respiratory illness. This represents the most important group in which to focus and increase testing.
- People at risk of exposure who present with atypical symptoms, such as health care workers and residential aged care facility workers.
- Contacts of cases, including upstream contacts of those without an epidemiological link (to find the index case), including people who are asymptomatic.
- Vulnerable populations and settings in which a single case or outbreak is identified, such as residential care settings; health care settings; remote Aboriginal and Torres Strait Islander communities; and workers in critical infrastructure. This may include the testing of all people in the relevant settings, including people who are asymptomatic.
- Vulnerable populations and settings where time limited cohorts are tested to assure absence of local transmission, such as, staff of residential care facilities, remote First Nations communities and other communities who may have barriers to access testing.
We are demonstrably fulfilling #1 and I would extrapolate #3. I am particularly interested to know if we are fulfilling #2 and #5
DoHWA: 1. All people presenting with fever or acute respiratory illness. This represents the most important group in which to focus and increase testing.
2. People at risk of exposure who present with atypical symptoms, such as health care workers and residential aged care facility workers.
Yes, we are.
Testing criteria are in accordance with the SoNG <https://www1.health.gov.au/internet/main/publishing.nsf/Content/cdna-song-novel-coronavirus.htm> :
Testing beyond the suspect case definition should be undertaken on persons with: fever (≥38°C)1 or history of fever (e.g. night sweats, chills) OR acute respiratory infection (e.g. cough, shortness of breath, sore throat)2, where no other clinical focus of infection or alternate explanation of the patient’s illness is evident.
Other reported symptoms of COVID-19 include: fatigue, loss of smell, loss of taste, runny nose, muscle pain, joint pain, diarrhoea, nausea/vomiting and loss of appetite. Testing beyond the suspect case definition may, based on the clinical and public health judgement of the treating clinician, include individuals with sudden and unexplained onset of one or more of these other symptoms.
2. Contacts of cases, including upstream contacts of those without an epidemiological link (to find the index case), including people who are asymptomatic.
3. Vulnerable populations and settings in which a single case or outbreak is identified, such as residential care settings; health care settings; remote Aboriginal and Torres Strait Islander communities; and workers in critical infrastructure. This may include the testing of all people in the relevant settings, including people who are asymptomatic.
4. Vulnerable populations and settings where time limited cohorts are tested to assure absence of local transmission, such as, staff of residential care facilities, remote First Nations communities and other communities who may have barriers to access testing.
There is no plan for such testing at the present time as there is no evidence of local transmission of COVID-19 in WA. The deployment of rapid PCR testing GeneXpert machines to regional centres and some remote areas has significantly increased access to testing.
MF: What is WA Health and the WA Government’s position on strategic and sustained workforce testing for health care workers (including aged care) and workers in essential industries such as education and mining, outside of the DETECT research projects, which are limited in scope? What is the rationale of that position?
DoHWA: We may consider short term wider testing in the future.
MF: The anaesthetists’ college has called for testing for patients undergoing elective surgery, given they are particularly exposed to COVID pathogens. Is this being considered?
DoHWA: Prior to surgery, all patients are screened for COVID symptoms and recent exposure. Testing of asymptomatic patients prior to surgery is only approved for a limited number of patients undergoing specific aerodigestive procedures where prolonged aerosol exposure is expected.
Currently in WA, the COVID-19 Testing Directions <https://urldefense.com/v3/__https:/www.wa.gov.au/government/publications/covid-19-testing-directions__;!!Lav448XFWxY!rRf9LYpXRq2_gBy4VjZ4kZ5gYBGBqRJuQShiO3YzWRW7138nfkTM8KT5KoRsFZEjNkTbEZ_O9NZM$> prohibit the testing of asymptomatic people, unless approved by the Chief Health Officer (CHO). The CHO has provided testing approval for the following:
- patients undergoing aerodigestive procedures
- people receiving medical treatment from Indian Ocean Territories
- people isolated or quarantined
- before proceeding with organ donation or organ transplantation
- at point of care in remote clinics
The Australian National University (ANU) and the Australian and New Zealand College of Anaesthetists Clinical Trials Network will coordinate a national study with the following aims:
- determine the prevalence of active and previous SARS-CoV-2 infection among patients admitted to hospital for elective surgery
- pilot a system for tracking prevalence rates of SARS-CoV-2 infection in elective surgical patients throughout 2020
- pilot a system for follow-up and estimation of incidence of SARS-CoV-2 infection in healthcare workers exposed to asymptomatic SARS-Cov-2-infected elective surgery patients
The following WA hospitals will be included:
- Sir Charles Gairdner Hospital
- Fiona Stanley Hospital
- St John of God (Subiaco)
MF: Private pathology companies are prepared and providing limited COVID testing. Are they being considered in an expanded testing regime?
DoHWA: Yes, the Department is working closely with private providers as the testing regime is expanded.