بازگشت به كار در بيماران كويد- 19: مروري بر دستورالعمل هاي موجود

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

زمينه و هدف: با شروع پاندمي كرونا ويروس2019 (كويد-19) محدوديتهاي وسيعي در سراسر دنيا به منظور مهار گسترش اين ويروس وضع شده اند. بديهي است محيط هاي كاري از اين محدوديتها مستثني نبوده اند. هزينه ضرر و زيان اجتماعي – اقتصادي اين بيماري به طور دقيق قابل تخمين زدن نيست اما مسلما اين بيماري مي تواند به سلامت شاغلين چه افرادي كه در اين شرايط مجبور به حضور در محيط كار خود هستند و چه افرادي كه مجبور به ماندن در خانه هستند لطمات فراواني را وارد كند. با توجه به اثرات مستقيم و غيرمستقيم اين مسئله بر فعاليتهاي اقتصادي ، تعيين زمان بازگشت به كار شاغلين - به گونه اي كه روند قطع زنجيره انتقال هم چنان حفظ گردد- از اهميت ويژه اي برخوردار است. درواقع ارزيابي تخصصي بازگشت به كار شاغلين مي بايست هم جنبه اطمينان از پايان سرايت پذيري عفونت به سايرين را مورد توجه قرار دهد و هم فرد را از نظر عوارض بيماري كه مي تواند عملكرد وي را تحت تاثير قرارداده يا او را نسبت به مواجهات محيط كاري آسيب پذيرتر مي كند بررسي نمايد. هدف ما از نگارش اين مقاله مروري، بررسي دستورالعمل هاي موجود درمورد چگونگي تعيين زمان اتمام قرنطينه و بازگشت به كار شاغلين مبتلا به كويد-19 مي باشد. روش بررسي: پايگاههاي اطلاعاتي Google Scholar, PubMed, Scopus از سال 2019 تا 2020 و همچنين دستورالعمل هاي مركز كنترل بيماريها، سازمان ايمني و سلامت شغلي آمريكا، سازمان ملي بهداشت انگلستان و وزارت بهداشت ايران با روش جستجوي موضوعي بررسي شد. يافته ها: بر اساس بررسي انجام شده، تصميم گيري جهت تعيين بازگشت به كار افراد بهبود يافته از بيماري كويد19 ، بر دو محور اصلي علائم باليني فرد و تست واكنش زنجيره‌اي پليمراز ترانس‌كريپتاز معكوس (RT-PCR: Reverse Transcription Polymerase Chain Reaction) استوار است. در مورد انتخاب يكي از دو رويكرد مبتني بر علائم يا مبتني بر تست، بايد مورد به مورد تصميم گيري شود چرا كه هر يك محدوديتهاي مربوط به خود را دارد. اخيرا استفاده از تست هاي سرولوژي بررسي كننده سطوح آنتي بادي ها نيز مورد توجه قرار گرفته اند. اما بنابر محدوديتهايي كه در مورد اين تست ها مطرح شده است نتايج تست هاي سرولوژي بايستي در كنار تست RT-PCR تفسير گردند در غيراينصورت گمراه كننده خواهند بود. مسئله ديگري كه علاوه بر تستهاي آزمايشگاهي فوق در تعيين بازگشت به كار حائز اهميت است درنظر داشتن مواجهات شغلي در افراد بهبود يافته اي است كه بايد به وظايف شغلي پيشين خود بازگردند. بدين منظور، انجام خطرسنجي از ملزومات حياتي پيش از شروع به كار مجدد اين افراد است. نتيجه گيري: بر مبناي دستورالعمل هاي موجود، اتفاق نظركلي جهت بازگشت به كار فرد بهبوديافته در يك بازه زماني 14-10روزه پس از شروع علائم و بهبود وضعيت باليني در رويكرد مبتني بر علائم وجود دارد. در مورد رويكرد مبتني بر تست نيز وجود دو تست RT-PCR منفي به فاصله حداقل 24 ساعت به عنوان شاخص قابل قبول جهت از سرگيري فعاليتهاي شغلي ذكر شده است. در حال حاضر تستهاي سرولوژي به عنوان معياري جهت تصميم گيري در مورد بازگشت به كار افراد توصيه نمي گردند.

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.