Return to Work in COVID-19: Review of Current Guidelines

Background and aims: Coronavirus Disease 2019 (COVID-19) is mainly a respiratory disease which is caused by the SARS-CoV-2 Virus. The outbreak first began in Wuhan, China, in December 2019 and then expanded globally. COVID-19 can result in illness ranging from mild to severe. However, some of the affected individuals might be asymptomatic. Symptoms of the disease may appear in as few as 2 days or as long as 14 days after exposure. The main rout of disease transmission is person to person contacts. Nevertheless, touching contaminated surfaces is also asserted to be the alternative way of transmitting the virus. Since the emergence of COVID-19 pandemic, due to the high rate of person to person transmission of SARS-CoV-2, widespread restrictions have been introduced all over the world to prevent the disease expansion. Apparently, work settings have not been exempted from these restrictions as well. The precise socioeconomic burden of the pandemic has not been precisely estimated so far, however, it apparently contributes to many adverse health- related issues in either the individuals who have to be present in their workplaces in this circumstance or the ones who must stay home. A considerable proportion of the affected individuals are working people who have to return to their workplace after the end of the isolation period. Considering the direct and indirect impacts of this situation on economic activities, it is crucial to decide on employees’ returning to work in a way that cutting the chains of transmission is maintained. In other words, while evaluating an individual’s return to work the duration of the disease transmission ought to be taken into consideration. Furthermore, this should assess the individual in terms of the disease complications which may have an impact on his performance or might make him more vulnerable to hazardous occupational exposures. The objective of this article is to carry out a review of the current guidelines about deciding on the end of the isolation and return to work of employees recovered from COVID-19. Methods: The Google Scholar, PubMed, and Scopus databases were reviewed from 2019 to 2020.  Furthermore, other relevant websites were also scrutinized including Centers for Disease Control and Prevention (CDC), Occupational Safety and Health Administration (OSHA), National Health Service (NHS) and Iran Ministry of Health and Medical Education guidelines. Results: Based on this review different strategies may be pursued regarding work resumption. In many countries making decision is mainly based on CDC guidelines. However, national health policy has been the major contributing factor in defining the return to work strategies in other parts of the world. Generally, determining the timing of return to work in employees recovered from COVID-19 is mainly based on clinical symptoms (symptom-based strategy) and or Reverse Transcription Polymerase Chain Reaction) RT-PCR (test (test-based strategy). In the light of the potential limitations, deciding on choosing either symptom-based or test-based strategy should be made on a case-by-case basis. For instance, considering that RT-PCR test may remain positive for even three months after the onset of the symptoms it is likely that test-based strategy unnecessarily prolongs the period of isolation and work absence. In other words, prolonged virus shedding might not necessarily be an indicator of contagiousness or transmissibility. On the other hand, relatively high price of this molecular test alongside its inconclusive sensitivity are other factors limiting RT-PCR test. Recently, serology tests investigating antibodies (immunoglobulin G and M) have also been addressed in addition to the aforementioned assessments. Immunoglobulin G and immunoglobulin M (IgG and IgM) are usually detectable in serum after the second week of the disease but the exact duration in which these antibodies can be found following infection is not known. Notably, due to the fact that some individuals do not develop detectable IgG or IgM at all, negative serology test result does not necessarily rule out that they have previously been infected. It is noteworthy to mention that some cross reactions have been determined between SARS-CoV-2 and other types of coroviruses which might contribute to false positive serology test results. On account of current limitations of such tests, their results should be interpreted alongside RT-PCR test, otherwise they would be challenging and misleading. In the light of the fact that the risk of Covid-19 transmission is not similar for all job categories, as well as different tasks in one work setting, another factor which should be taken into account is occupational exposures. Hence, performing detailed risk assessment by experts has a vital role in deciding on work resumption. This process should be meticulously carried out on an individual basis for all specific work places and also for each job or group of jobs within a work setting. Each risk assessment should consider the environment, the task, the threat, and the available resources, as well as ongoing preventive measures such as risk elimination strategies, engineering controls (such as physical barriers or proper ventilation) and personal protective equipment. On top of that, employers should be informed about the significance of the employees’ participation in this process which can apparently guarantee the success of implementing preventive measures in the workplace. It is noteworthy that while deciding on an individual’s return to work, the severity of the disease should also be taken into consideration since a severe illness can have a considerable impact on the person’s work ability and performance. This is specially the case for those who were admitted to intensive care units (ICU) due to their critical illness. Therefore, gradual return to the previous tasks and activities, in terms of work intensity and duration, should be encouraged in such cases. Conclusion: There is a general consensus on ending isolation and return to work of the recovered individuals in a 10 to14-day period after the onset of symptoms and clinical improvement in the non-test-based strategy. Regarding test-based strategy, current guidelines require two consecutive negative RT-PCR tests with at least 24-hour interval. Presently, serologic tests are not recommended for making decision about returning persons to the workplace in the guidelines. Other important factors that ought not be overlooked include detailed risk assessment and the disease severity.