COVID-19: Staging environment

A systematic review of 131 studies found that fever and cough were the most common symptoms, followed by nasal congestion, fatigue and sore throat, while approximately 19% of children were asymptomatic (EClinicalMedicine, June 26, 2020).

In addition to the symptoms most commonly associated with COVID-19, other atypical symptoms/signs should be considered in children (MOH, September 21, 2020). These symptoms/signs include:

• Fatigue, lethargy or malaise
• Decreased or lack of appetite
• Age-specific tachycardia
• Difficulty feeding in infants
• Multisystem inflammatory vasculitis in children (for more information, see Emerging evidence: COVID-19 transmission, paediatric symptoms, and Rx research > Multisystem Inflammatory Syndrome in Children (MIS-C))

For suggested criteria for assessing the severity of COVID-19 disease in children, see The acute management of paediatric coronavirus disease 2019 (CPS, April 20, 2020).

It’s important to monitor atypical symptoms because COVID-19 presents itself differently among older adults. For example, an older patient may not experience a fever or may experience unexplained or an increased number of falls (RGP, April 2, 2020; MOH, September 21, 2020).

Refer to the Atypical COVID-19 Presentations in Frail Older Adults (RGP, April 2, 2020) for a summary of what to look for such as:

• Milder symptoms
• Delirium or acute functional decline
• Little or no temperature elevation
• Mild hypoxia (O2S <90%) without respiratory symptoms
• Unexplained or increased number of falls

Testing is available for the following populations:

1. All people with at least one symptom of COVID-19.
2. Asymptomatic people who have received a positive antigen point-of-care test result.
3. Asymptomatic people who have been exposed to COVID-19, including people who are contacts of or may have been exposed to a confirmed case.
4. Asymptomatic people who are at risk of exposure to COVID-19, including workers, residents and visitors of high-risk settings (e.g., long-term care homes, homeless shelters and other congregate settings). This includes residents and workers at specific outbreak sites.
5. Asymptomatic people from certain populations but without known high-risk exposure may be considered for testing. This includes any individual identifies as part of a targeted testing campaign. For a list of groups, see COVID-19 Provincial Testing Guidance Update (May 26, 2021).

Adapted from COVID-19 Provincial Testing Guidance Update (MOH, May 26, 2021) and Additional Direction on Testing Strategy (MOH, May 24, 2020).

Testing in the primary care office/clinic can only be performed if the primary care provider is able to:

• follow Droplet and Contact precautions outlined by the Ministry of Health (November 9, 2020);
• has the appropriate tools and knowledge of how to test; and
• can ensure coordination of sample delivery to the Public Health Ontario Laboratory or an alternative laboratory providing COVID-19 testing.

A single upper respiratory tract specimen will be accepted for COVID-19 testing, including nasopharyngeal swab (NPS), deep nasal swab, anterior nasal swab or viral throat swab. NPS is the preferred specimen when swabs are available, followed by deep nasal swab. Due to global shortages, Public Health Ontario (April 30, 2021) has provided information on alternative collection kits that are acceptable for COVID-19 testing (see Specimen Collection and Handling).

Nasopharyngeal swab collection is not considered an aerosol generating procedure and can be performed in the office/clinic with appropriate contact/droplet precautions of gloves, gown, surgical/procedure mask, and eye protection (e.g., goggles, face shield). This is important as many people will cough or sneeze when the nasal swab is done. Links to resources on properly conducting NP swabs are available under ‘COVID-19 Care’ on OCFP’s Clinical Care- Office Readiness page.

If testing is conducted in the office/clinic, it is important to conduct the nasopharyngeal swab properly to minimize the risk of a false negative sample:

• Pre-label the swab so, once obtained, it can be placed in the bag without further handling.
• Place the specimen in the bag, and place the completed requisition in the attached pouch.

Diagnosing COVID-19 is done by laboratory testing (NAAT result by PCR or nucleic acid sequencing) on at least one specific genome target.

Symptomatic patients

• A single positive result is sufficient to confirm COVID-19.
• A single negative result is sufficient to exclude COVID-19.

Asymptomatic patients

• A positive result might represent one of the following scenarios:
  • current COVID-19 infection that is asymptomatic or pre-symptomatic, OR
  • prior COVID-19 infection (+/- symptoms) as testing can remain positive for several weeks after infection, OR
  • false positive result.
• If a patient has a medium/high pre-test probability of infection, a single positive result is sufficient to confirm current or prior infection.
• If a patient has a low pre-test probability of infection, a positive result should be immediately retested and may be cleared with a single negative retest (MOH, May 6, 2021). The patient must be managed as if they have current COVID-19 infection (i.e., immediate self-isolation) until cleared.
• A single negative result is sufficient to exclude COVID-19.

In a patient who tested positive for COVID-19 AND was cleared, retesting should generally not be done due to persistent shedding (viral detection has been identified in some cases well beyond 4 weeks (>70 days) in some cases).

If the patient is within their 14-day self-isolation due to known exposure, the patient should remain in self-isolation for the rest of the 14-day period, regardless of the negative result.

See COVID-19 Quick Reference Public Health Guidance on Testing and Clearance (MOH, May 21, 2021) for more detailed information.

A recent study retroactively compared the results from 353 patients who received both OP and NP simultaneously, and found that 73.1% of NP-positive cases were negative in OP swab. The authors concluded that while use of both swabs slightly increased the positive rate over using NP swab only, NP swabs “may be more suitable” than oropharyngeal swab (Int. J. Infect. Dis., April 22, 2020).

Testing for COVID-19 involves sending a respiratory tract specimen – nasopharyngeal swab (NPS) or viral throat swab; NPS is preferred– to a PHO laboratory or other suitable laboratory with capacity for RT-PCR testing. RT-PCR is a type of nucleic acid amplification testing (NAAT), the gold standard used in Canada and abroad for the diagnosis of active COVID-19 infection, that tests for the presence of viral RNA during active infection (Health Canada, May 26, 2021). At this time, serology testing and antigen testing should not be used for diagnosis of acute COVID-19 infection (MOH, May 26, 2021).

Click here for a list of testing devices authorized by Health Canada.

The turnaround time for COVID-19 testing at a PHO Laboratory is for 60% of results to be completed within 24 hours and 80% to be completed within 48, but will vary depending on what laboratory performs the testing (PHO, April 30, 2021).

As of September 10, 2020, PHO Laboratory implemented a validated pooling approach to testing, which will allow an increase in testing throughput without greatly compromising sensitivity (PHO, March 30, 2021) . For pooled testing, a portion of three individual specimens are combined into a single pool and run on the SARS-CoV-2 PCR assay as a single test.

• If the pool result is NOT DETECTED, all three specimens are individually reported as NOT DETECTED.
• If the pool result is DETECTED, INDETERMINATE or INVALD, each individual specimen is tested individually and reported based on individual result obtained. ­­­­

Health Canada is prioritizing the review of point-of-care tests intended to diagnose COVID-19, including both nucleic acid-based tests and antigen-based tests, and have authorized several tests (Health Canada, May 26, 2021).

Click here for a list of testing devices authorized by Health Canada.

At this time, a positive result on a rapid test is considered a preliminary positive and should have a parallel sample taken for a confirmatory laboratory-PCR test (MOH, May 26, 2021).

Serology testing is only available for clinical use under specific clinical indications listed below. Serology testing should not be used for screening and diagnosis of acute COVID-19 infection, and a positive serology test does not mean a patient is immune to COVID-19 (MOH, May 26, 2021).

Clinical indications:

• Patients presenting with symptoms compatible with Multisystem Inflammatory Syndrome in Children (MIS-C) who do not have laboratory confirmation of COVID-19 by PCR.
• Patients with severe illness who have tested negative for COVID-19 by PCR and where serology testing would help inform clinical management and/or public health action. Serology testing for these patients requires consultation and approval by the testing laboratory.

• A study retrospectively analyzed the results of tests administered to more than 15,000 individuals in order to identify the prevalence of false negative results. Of those results studied, 2,699 individuals who tested negative initially were subsequently tested again, and 60 (2.2%) of these individuals were determined to have false negative results in their initial test. The study led the researchers to recommend repeat testing for suspected COVID-19 patients, particularly those with symptoms and other clinical factors consistent with COVID-19 and during periods of high COVID-19 incidence (Open Forum Infect Dis, Nov 24, 2020; Johns Hopkins Center for Health Security, December 4, 2020).
• The findings in a recently published systematic review (PLoS One, December 10, 2020) further reinforces the need for repeated testing in patients with suspicion of COVID-19 infection given that up to 54% of COVID-19 patients may have an initial false-negative RT-PCR. This is based on very low certainty of evidence.
• A cohort study has found that even rigorous RT-PCR testing protocols might miss a substantial proportion of SARS-CoV-2 infections, perhaps in part due to difficulties in determining the timing of testing in asymptomatic individuals for optimal sensitivity (Lancet, January 19, 2021).
• A recent study has determined that most false negative results were found to be due to low amounts of SARS-CoV-2 virus concentrations in patients with multiple specimens collected during different stages of infection. Post-test clinical evaluation of each patient is advised to ensure that rtRT-PCR results are not the only factor in excluding COVID-19 (Virol J, January 9, 2021).
• A recent retrospective observational cohort study identified clinical characteristics associated with false negative SARS-CoV-2 testing. The study found that negative test results were associated with anosmia/ageusia, having a COVID-19 positive contact, and having an elevated lactate dehydrogenase level. Demographics, symptom duration, other laboratory values, and abnormal chest imaging were not significantly associated with false negative test results in multivariable analysis (Infect Control Hosp Epidemiol, April 19, 2021).

For patients experiencing respiratory tract infection (RTI) symptoms who have tested negative for COVID-19, a viral RTI is the most likely diagnosis. These patients can usually be treated virtually with supportive management. For information on when an in-person visit might be indicated, see The Cold Standard 2nd Edition (Choosing Wisely Canada, October 15, 2020).

The following are being implemented as part on Ontario’s six-point variant action plan (Government of Ontario, January 29, 2021):

• Mandatory testing of travelers: On-arrival testing for international travellers at Toronto Pearson International Airport will be mandated starting February 1. Additional testing measures at Pearson International Airport and land border crossings will be explored in the coming weeks.
• Enhanced screening and sequencing: Led by Public Health Ontario (PHO), the provincial diagnostic lab network will screen all positive COVID-19 tests in Ontario for known variants within 2 to 3 days of initial processing starting February 3. By February 17, PHO will be sequencing up to 10% of all positive tests in an effort to identify new and emerging variants.

For more information on the COVID-19 variants, see COVID-19 Variants and vaccines

• Maintain cool environment.
• Topical moisturizers and petroleum jelly or baby napkin cream (only if use does not interfere with proper fit).
• Use alternate mask type if one type is particularly irritating.
• Take breaks from respirator use, with careful attention used when donning and doffing (especially when the respirator is being re-used).
• Caps, headbands or fabric with buttons for straps of masks may reduce ear irritation but may increase pressure on front of face. This should only be done if it does not interfere with the proper fit of the PPE. These items must be integrated into proper donning/ doffing cycle and reprocessed or laundered appropriately with other PPE.

• Use full face-shield.
• Change to shorter, rotating shifts.
• Lubricants to reduce friction between skin and goggles.
• Avoid tight equipment.
• Wet compression for severe skin indentations.
• Avoid irritating agents when washing face.

• For overheating: Avoid plastic gowns, maintain hydration, use shorter, rotating shifts and over-tight equipment.
• For irritation: wear a barrier between body and PPE (unless overheating is issue) and avoid over-tight equipment.

• Ensure hands are dry before donning gloves.
• Choose non-irritating gloves (avoid latex).
• Choose correct glove size.
• Moisturize often, but avoid moisturizing immediately prior to donning gloves. Moisturizer is not sterile and can interfere with glove integrity.

• Avoid hot water.
• Rinse soap well.
• Use hypoallergenic products (including at home).
• Pat hands dry with paper towel instead of rubbing.
• Moisturize often using a fragrance-free lotion or cream that contains humectants, fats and oils at least twice a day for prevention, and as often as feasible (including at work) for treatment.
• Barrier cream efficacy unclear, such products are expensive, not removed by handwashing, and may = glove breakdown.
• Avoid use of hand sanitizer immediately before or after handwashing.
• Hand sanitizer is less likely to cause initial skin irritation than soap and water, but is more likely to cause acute pain once irritation occurs.
• Ensure hands are dry before donning gloves.

• Patients and visitors should be screened over the phone before coming to the clinic.
• Where patients present in-person without phone screening, patients and visitors should be screened upon arrival at the clinic.
• If they screen positive, appointment should be deferred if possible and the individual referred for testing. If the appointment is urgent, refer the patient to the emergency room.
• If a patient screens negative, appointment can be made. Remind the patient that if they develop symptoms between the time of the phone screening and the appointment, they should call the clinic for further instructions instead of coming in person.
• Patients and visitors should be screened on-site before entering the clinic.
• Patients and visitors should wear their own face covering. If they do not have one, provide one prior to entrance.
• In-person screening must include staff protection as follows:
  • Best option: staff should be behind a plexiglass barrier.
  • Second option: If a barrier is not available, a 2-metre distance should be kept between screening staff and individuals being screened.
  • Last resort: if a barrier is not available and 2-metre distance is not possible, screening staff should wear PPE according to Droplet and Contact precautions.
• If an individual screens positive, appointment should be deferred if it will not compromise patient safety, and the individual referred for testing.
• Visitors who screen positive should not be permitted to accompany or visit the patient, pending test results. If the patient cannot attend the visit without the visitor, reschedule the visit for when an alternative visitor can accompany the patient.

• Information about screening should be included on outgoing voicemail and email signatures, appointment confirmations, and clinic website, with links to the provincial online self-assessment tool where applicable.
• Signage must be posted at the entrance to the clinic and in the reception area, requiring all patients and visitors to wear face coverings (if available and tolerated), perform hand hygiene, and report to reception to self-identify.
• Signage should be accessible to all patients and visitors, reflecting the cultural context of the region and patient community. Download signage on MOH site, or see CMA’s resources in English, French, Arabic, Cantonese, Mandarin, Punjabi, and Spanish.

• Before every patient interaction, healthcare workers must conduct a point-of-care risk assessment to determine the level of precautions required.
• Healthcare providers may provide care to patients who screen positive for COVID-19 only if they have the PPE required to follow Droplet and Contact precautions ((Surgical/procedural mask, isolation gown, gloves, eye protection -goggles or face shield)and the sufficient knowledge to follow proper donning and doffing procedures. Practice donning and doffing with a buddy if staff are still being trained on procedures.
• If your setting does not meet these requirements, divert the care of the patient:
  • to the emergency department if the medical reason for the appointment is urgent
  • to assessment centre for assessment and testing if the medical reason for the appointment is not urgent. In the instance where the assessment centre is only able to provide a swab, and not manage the clinical presentation, a follow up appt should be booked when swab result is negative to finish assessment and management
• Patients who screen positive should be given a surgical mask and perform hand hygiene.
• The patient should be isolated.
• If an exam room is available, place the patient in the room with the door closed, avoiding contact with other patients if possible.
• If an exam room is not available, instruct the patient to wait outside the clinic and call/text them when a room is available.
• In the exam room, the patient should have access to tissues, hand sanitizer, and a touch-free/foot pedal-operated wastebasket.
• Instruct patient to take their mask home with them (do not leave in waiting room) and provide information on doffing procedures.

• Mask required and eye protection recommended for interactions with and within 2 meters of patients who screen negative.
• No gown or gloves unless consistent with Routine Practices for specific patient symptoms.
• Request all patients and visitors keep masks on.

• All patients with at least one symptom should be tested.
  • Asymptomatic patients who are concerned they have been exposed to COVID-19 should be tested.
  • Asymptomatic patients who are at risk of exposure through their work (essential workers) should be tested.
• If your setting is equipped, testing can happen on-site. All testing requires full droplet and contact PPE, even if the patient is asymptomatic.
• If not equipped to offer testing, cases should be referred elsewhere (an assessment centre, Telehealth, etc.)

• Use the Readiness assessment for primary care settings to develop strategies to mitigate risk of COVID-19 transmission.

• Have written measures for staff safety, including infection monitoring and control.
• Ensure stable supply of essential supplies (drugs, PPE, hand hygiene and cleaning supplies).
• Source and provide PPE through the regular supply chain, including regional leads or the provincial PPE Supplier Directory.
• Ensure adequate staffing for services. Use information from Readiness assessment for primary care settings to ensure staffing needs are aligned with PPE availability. Consider preserving staff capacity where possible in preparation for future outbreaks.
• Ensure service offerings align with related services such as laboratory diagnostics, rehabilitation, etc.
• Work collaboratively with local region and other primary care providers where possible to ensure coordinated service offerings.

• Ensure there is sufficient space to maintain 2-metre social distancing between people.
• Redesign physical settings and interactions to minimize contact.
• Provide face coverings where physical distancing is not possible.
• Request all patients and visitors wear face coverings if they have them.
• Provide tissues and lined garbage bins for patients and staff.
• Ensure sufficient supplies for proper hand hygiene: hand washing stations and 70% alcohol hand sanitizer.
• Post signage about symptom screening, hand hygiene, proper mask use, and respiratory etiquette. CMA has signage on high-level protections and symptoms available in English, French, Arabic, Cantonese, Mandarin, Punjabi, and Spanish.

• Employers and healthcare workers should determine which visitors are essential, and restrict all other visitors from entering the clinic.
• Where possible, schedule symptomatic patients for end-of-day visits.
• Minimize the time patients spend in the waiting room. If possible for patient, have them wait outside or in the car – otherwise, stagger appointments so that social distancing can be maintained.
• Minimize staff in the healthcare setting. Consider which roles can be performed remotely, or develop shifts to meet the necessary number of on-site staff while ensuring social distancing.
• Ensure healthcare workers, staff, and patients use proper PPE across clinic settings and have adequate observed training in donning and doffing.
• Healthcare providers should preserve the use of PPE by applying other mitigation strategies identified through the Readiness assessment for primary care settings.
• If a patient comes into the setting and later tests positive, contact local health unit for advice and guidance about the risk of possible exposure for healthcare workers.

• Staff should self-monitor for symptoms and not come to work if they develop symptoms. Consider using a daily screening form, log or app for staff as a prompt for this.
• Ensure there is space to isolate healthcare staff who develop symptoms.
• If a healthcare worker develops symptoms at work, they should put on a mask if not already wearing one, isolate, and they should be sent home as soon as possible.
• If they are critical to operations, healthcare workers who have returned from travel within the last 14 days (outside of Canada or from a COVID infected area within Canada) or had a confirmed exposure to a COVID-19-positive patient must self-monitor for symptoms but may continue to work with specific precautions.

• After every patient visit (symptomatic or asymptomatic), sanitize treatment areas, horizontal surfaces and equipment before another patient is brought in. Remember to include administrative equipment – mouse, keyboard, printer, etc.
• All common areas should be regularly cleaned, at least twice daily.
• Plexiglass barriers should be integrated into cleaning schedule and cleaned daily.
• Non-essential items should be removed from patient care areas to avoid contamination.

Answer 1

Answer 2

Answer 3

As per Directive #3 for Long-Term Care Homes under the Long-Term Care Homes Act, 2007 (MOH, June 4, 2021), short term absences are defined as leaving the LTCH’s property for social or other reasons that does not include an overnight stay.

• A request must be submitted and approved by the LTCH.
• Upon return to the LTCH, residents must be actively screened (refer to Active Screening of All Residents above) but are not required to be tested or self-isolate.
• Residents must be provided with a medical mask to be worn when outside of the LTCH (if tolerated) and reminded about the importance of public health measures including maintaining a safe distance of at least 2 metres from others and hand hygiene.

As per Directive #3 for Long-Term Care Homes under the Long-Term Care Homes Act, 2007 (MOH, June 4, 2021), temporary absences are defined as leaving the LTCH’s property for social or other reasons that includes one or more nights.

• A request must be submitted and approved by the LTC.
• Upon return to the LTCH, residents must be actively screened (refer to Active Screening above) and self-isolate for 14 days.
• Residents must be provided with a medical mask to be worn when outside of the LTCH (if tolerated) and reminded about the importance of public health measures including maintaining a safe distance of at least 2 metres from others and hand hygiene.

As per Directive #3 for Long-Term Care Homes under the Long-Term Care Homes Act, 2007 (MOH, June 4, 2021), medical absences defined as leaving the LTCH’s property for medical reasons (i.e., outpatient visits, single night emergency room visit).

• LTCHs cannot deny a resident’s request to leave the LTCH for medical visits.
• Upon return to the LTCH, residents must be actively screened (refer to Active Screening above) but are not required to be tested or self-isolate.
• Emergency room visits that take place over a single night (e.g., assessment and discharge from the emergency department spans one overnight period) are considered equivalent to an outpatient medical visit.
• Residents must be provided with a medical mask to be worn when outside of the LTCH (if tolerated) and reminded about the importance of public health measures including maintaining a safe distance of at least 2 metres from others and hand hygiene.

• Complete the Infection Prevention and Control (IPAC) modules from Public Health Ontario. Includes a Personal Risk Assessment in Long-term Care module.
• Consider completing training modules on working in LTCHs such as the Ontario Centres for Learning, Research and Innovation in Long-Term Care’s materials (May 8, 2020) and watching webinars from ECHO Care of the Elderly for LTC (April 16, 2020) that support the upskilling of primary care providers and other healthcare workers working with residents in a team-based setting.
• Review communication techniques for speaking with older patients, such as the use of person-centred language. See Top resources below for more information.
• A consult line is available 24 hrs a day/7 days a week for primary care physicians & nurse practitioners working in LTC who need to speak to a general internal medicine specialist at 1-833-824-3578 (Ontario Health, 2020).
• Conduct a self-assessment for symptoms of COVID-19. If you have any symptoms of COVID-19, do not conduct the visit and contact the home to cancel or reschedule pending test result. Follow Primary Care Operations in the COVID-19 Context > Infection monitoring and protocols for healthcare workers if tested positive.
• Review clinical management of older adults including:
  • Dementia (CEP, 2016), falls prevention (CEP, 2016), frailty (Advanced Care Planning, 2016) and other health concerns. See Top resources below for more information.
  • For COVID-19 specific care (symptom management, navigating difficult conversations, and providing end-of-life care) see Managing COVID-19: Outpatient management and resolution and  Managing COVID-19: Palliative care.

• Introduce yourself to the administrator and participate in the screening process. If you fail the screening, immediately leave the site, proceed to self-isolate (PHO, April 10, 2020) and conduct virtual visits only.
• Have a discussion with the care staff to establish understanding of specific protocols and procedures within the LTCH.
  • Ensure you know how to summon assistance for a fire, cardiac arrest, and other emergencies. The colour codes used are the same for all of Ontario. If you do not know the colour code when you hear one, please ask.
• Determine which HCWs and staff are available to assist with any assessments or hands-on care, if necessary. Can communicate with staff or refer to a schedule, if available.

• Perform hand hygiene (PHO, March 16, 2020) before and after every resident/patient interaction.
• Conduct a personal risk assessment (AHS, 2018) and don appropriate PPE before engaging with patients/residents.
• Review patient’s history and what medications they are currently on.
• If the patient has dementia and/or other cognitive disorders that impair decision-making ask LTCH staff to engage with Substitute Decision-Maker (SDM) via virtual means or telephone.
• Ensure the proper storage of the resident’s records according to the protocols of the facility.

• If more than one site will be visited in a single day, repeat the self-assessment process prior to arrival at the next site.
• Self-monitor (PHO, May 17, 2020) for 14 days following your last on-site visit.

Positive test result

Work self-isolation could start after a minimum of 72 hours after illness resolving, defined as resolution of fever (without the use of fever-reducing medications) and improvement in respiratory and other symptoms.

Negative test result

May return to work 24 hours after symptom resolution. If the healthcare worker was self-isolating due to an exposure at the time of testing, return to work should be under work self-isolation (see below) until 14 days from last exposure.

Positive test result

If there has been a recent potential exposure (e.g. tested as part of an outbreak investigation or other close contact to a case), work self-isolation (i.e. return to work) could start after a minimum of 72 hours from the positive specimen collection date to ensure symptoms have not developed in that time, as the positive result may represent early identification of virus in the pre-symptomatic period.

If there is a low pre-test probability (e.g. there has been no known recent potential exposures such as tested as part of surveillance and no other cases detected in the facility or on the unit/floor, depending on the facility size), see Management of Cases and Contacts of COVID-19 in Ontario (MOH, May 6, 2021) for repeat testing guidance. If follow-up testing is negative, the HCW is cleared and can return to work as per usual.