Discussion

Well into the fourth year of the COVID-19 pandemic, SARS-CoV-2 continues to cause substantial morbidity and mortality. Many hospitals and clinics are heavily populated with patients at increased risk of adverse outcomes due to advanced age or underlying comorbid conditions. ⁶ Therefore, particularly early in the pandemic, many institutions required HCPs with COVID-19 to avoid returning to work until testing negative for SARS-CoV-2 or completing a prolonged isolation period. Subsequently, hospitals adopted time-based return to work at 10 days. However, to maintain critical services during COVID-19 surges, most hospitals resorted to contingency (crisis) standards that allowed for earlier return to work. ⁴ More recently, as vaccination increased, treatment options improved, severe cases decreased, and national public health measures were relaxed, many HCPs and hospital administrators questioned the stringent return-to-work criteria.

Our survey demonstrated that hospital return-to-work practices vary widely and that most diverge from CDC guidance. Possible reasons for this divergence from recommendations are of great interest. First, despite the perception that the pandemic is over, hospitals remain under great stress regarding workforce, necessitating contingency procedures and early return to work for HCPs. Furthermore, healthcare facilities are under financial duress ⁷ and are unwilling to limit activities that are revenue generating (eg, cancellation of elective procedures) to alleviate staffing pressures. Second, despite data indicating that a substantial proportion of HCPs have high levels of viral shedding at day 5 of illness, there is a perception that transmissibility is limited. Most facilities, whether or not they are operating in contingency status, allow HCPs to return to work after 5 days of isolation. ^{Reference Kolodziej, Hordijk and Koopson8} The facts that data are limited and that questions continue concerning duration and significance of viral shedding and its correlation with transmissibility point to profound deficiencies in our ability to study critical questions and resolve important practical issues, particularly during times of national emergency. Third, there is belief that HCPs recovering from COVID-19 and who return to work early do not pose a risk for nosocomial transmission if they wear a mask or a N-95 respirator. The fact that we continue to debate the importance and effectiveness of respiratory personal protective equipment in preventing viral transmission at this stage of the pandemic indicates deficiencies in our investigative capacity. ^{Reference Jefferson, Dooley and Ferroni9} However, analysis and study of these issues has been made more challenging by a “moving pandemic target” influenced by population immunity, emergence of viral variants, and shifting availability of resources such as testing capacity and drug and vaccine supply.

Our survey results have profound implications regarding the authority and credibility of public health agencies. Most academic medical centers and large health systems responding to our survey are not adhering to CDC guidance. Before the pandemic, this widespread nonadherence would not have been observed. The variability in practice may suggest a need for evidence-based, practical guidance and the need for public health agencies (ie, CDC), research-based agencies (ie, NIH, AHRQ, NSF, etc), and academia to partner and collaborate to answer pressing and practical questions in a timely manner.

Our study had several limitations. The survey was limited in sample size and was directed toward academic medical centers and large healthcare systems, thus limiting its generalizability. There was no independent validation of data. Although all respondents noted that nosocomial transmission of SARS CoV-2 was monitored, details regarding surveillance methods were not sought (eg, use of viral sequence data to ascertain patterns of transmission), and underdetection or underreporting is possible. Finally, this is a rapidly changing landscape and institutional practices are in constant evolution as facilities respond to changing conditions; thus, our results will be quickly outdated.

In conclusion, our findings indicate substantial deviation between CDC return-to-work guidance for HCPs with COVID-19 and points to profound issues of how we deal with ambiguity in times of outbreaks and pandemics.