COVID-19 Testing Framework Implementation Plan - May 2022

Version 2.2 COVID-19

COVID-19 Testing Framework Implementation Plan May 2022

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Document COVID-19 Testing Framework Implementation Plan

Purpose To provide best practice guidance to health professionals involved in the testing for COVID-19. This document should be read in conjunction with:

Supporting Documents

National CDNA and PHLN

• CDNA National Guidelines for Public Health Units

• Public Health Laboratory Network guidance on laboratory testing for SARS-CoV-1 (the virus that causes COVID-19)

Queensland Health COVID advice

• Personal protective equipment (PPE) | COVID-19 | Queensland Health

• Queensland Health Infection Control Guidelines

• Guide to informed decision-making in healthcare

Consumer healthcare rights

• The Australian Charter of Healthcare Rights

1 Testing Strategy Summary The Testing framework for COVID-19 in Queensland (testing framework) is intended to outline the recommended testing options for SARS-CoV-2 (the virus that causes COVID-19) for clinicians and decision-makers in Queensland to optimise early institution of treatment in those vulnerable to severe illness, to prevent transmission to those vulnerable to severe illness and to mitigate impact on healthcare and other priority settings.

Objectives To facilitate adoption of a testing strategy that is flexible and adaptable to changes in epidemiology, transmission, and local resources and that:

1. Maintains PCR testing capacity to facilitate: a. Monitoring SARS-CoV-2 severity of disease, hospitalisation and ICU admission

rates. b. Priority testing of high-risk cohorts who would likely benefit from treatment

(e.g. immunosuppressed or unvaccinated) c. Detection of new variants of concern and unassigned sub-lineages through

genome sequencing to facilitate assessment of associated clinical severity and public health significance; provision of advice on minimum PCR testing required to confidently identify new variants

d. Detection of co-infection of SARS-CoV-2 and other respiratory viruses, particularly co-infection with influenza in those susceptible to severe disease

2. Mitigates impact on healthcare and social care settings housing vulnerable people through early case detection (e.g. hospitals, residential aged care facilities (RACFs), disability accommodation, corrective services)

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3. Detects clusters or outbreaks early in specific priority settings (e.g. remote communities)

4. Ensures that testing is accessible and that the most appropriate type of testing is used for each individual’s situation

5. Has regard for the wellbeing, rights and dignity, including a priority focus on consent, advocacy and support for people being tested for COVID-19

Principles The following key principles apply to the testing strategy:

1. Testing does not preclude the need to implement infection control strategies across the hierarchy of controls

2. A risk-based approach is adopted to consider risk of severe disease and risk of transmission to vulnerable people, whilst maintaining critical workforce

3. The testing capacity must be used to best effect including consideration of the need to test for additional respiratory viruses, particularly during periods of known influenza circulation

4. COVID-19 testing capacity should not defer or delay access to urgent healthcare 5. Responsive testing capacity is reliant on effective prevention, clinical screening and

surveillance strategies. 6. The testing strategy and its implementation are underpinned by the principles of the

Australian Charter of Healthcare rights (1)

2 Specimen collection and laboratory services

Types of tests Nucleic acid amplification testing (NAAT)

Reverse transcriptase PCR (RT-PCR) is a laboratory test for SARS-CoV-2 with turnaround times less than 24 – 48 hours). PCR tests are the most accurate tests for detection of SARS-CoV-2. PCR testing capacity should be prioritised for testing of those with:

1. Symptoms of COVID-19 and risk factors for, or evidence of, moderate or severe disease

2. Close contact with person/s at risk of severe disease (including staff who work at a high-risk setting)

3. Likelihood of benefit from specific treatments

4. High risk of new variants of concern

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Rapid antigen testing

Rapid antigen tests (RATs) can provide results within 15 to 30 minutes – however, they have less sensitivity than NAAT tests and may be less specific (2-5). The clinical performance of RATs is significantly affected by community prevalence and pre-test probability of disease. These tests are useful to:

1. Preserve PCR capacity during surges in testing demand

2. Facilitate early identification of disease, particularly in established outbreak settings in congregate living settings, to enable rapid institution of infection control measures – note: in these settings where residents have risk factors for severe disease, RATs are used when there are delays to PCR. A positive RAT in moderate to high community transmission may be considered a case, whilst a negative RAT in a symptomatic resident should not be used to exclude disease and should be, instead, confirmed by a PCR. In periods of influenza circulation, PCR with both COVID-19 and influenza testing is recommended in index cases in an outbreak or if the outbreak is prolonged, in consultation with public health units.

3. Augment clinical screening in high prevalence settings where this may protect vulnerable people at risk of severe disease and protect workforce capacity to deliver healthcare.

Genomic sequencing

Genomic sequencing is performed on positive SARS-CoV-2 PCR results to facilitate assessment of genomic relatedness of COVID-19 cases to identify emergence of new variants of concern and inform public health management of clusters. Where the genomic sequence of the virus can be established, it helps Public Health and the epidemiologist to determine the source of the COVID infection, any known changes in severity, changes to susceptibility to reinfection and transmission capability and focus the response

Serology

Detection of antibody response to infection with SARS-CoV-2 occurs within 1 – 3 weeks following infection, with IgG reliably detected by 21 days post-infection but is influenced by patient factors. It is not useful for acute diagnosis of COVID-19 and is not useful in those who have received COVID-19 vaccination. The main uses of serology are for:

− Identifying historical cases who remain NAAT positive (e.g. people testing positive with unclear epidemiological links)

− Providing potential links in transmission chains in defined cluster outbreaks

Specimen collection There are currently two specimen types validated for use in Queensland for NAAT:

− Oropharyngeal and bilateral deep nasal swab using a flocked swab remains the preferred approach – for a detailed description of the approach to swab collection refer to PHLN guidance (6).

− Saliva testing: when compared to combined oropharyngeal and bilateral deep nasal swabs, saliva testing has a lower percentage of positive results, with this being amplified in settings with low prevalence (7). It may be considered for use, in consultation with Infectious Diseases specialist or public health physician, in patients where traditional sampling would otherwise require sedation e.g.

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persons with cognitive impairment and severe behavioural disturbance or in young children.

In the event of simultaneous mass testing in an accommodation setting, the Public Health Unit or Outbreak IMT will categorise residents / clients to prioritise the collection and processing of PCR tests collected according to exposure risk level.

For RAT, it is important that manufacturer guidance on specimen collection is adhered to.

Personal Protective Equipment during testing PPE should be used in accordance with guidance in Queensland Health’s Infection prevention and control guidelines for the management of COVID-19 in healthcare settings . Consider supply, resupply and the relevant logistics.

3 Testing: clinical guidance

The decision to perform a COVID-19 test and the type of test requested may be informed by the following (see figure 1 and table 1):

1. The purpose of testing – this is determined by the individual and social context and may include:

a. Diagnostic testing to identify current infection in symptomatic people b. Screening testing to identify disease in asymptomatic people c. Public Health Surveillance testing

2. Community prevalence of COVID-19 – this is defined by the Chief Health Officer and considers community transmission rates, hospital and ICU admission numbers and impacts on health service continuity

3. Public health directions

Diagnostic testing Diagnostic testing aims to identify current infection in symptomatic people. As we transition to a living with COVID-19 phase of the pandemic, diagnostic testing using PCR is prioritised in those at risk of or with evidence of severe disease, those who have close contact with vulnerable people and those who would likely benefit from treatment. Diagnostic testing guidance is outlined in figure 1. During influenza season the type of PCR test ordered, where indicated, depends on comorbidities, discharge disposition and pathology platform available. It is important for clinicians to appreciate that ordering SARS-CoV-2 separately from influenza A/B/RSV may significantly impact testing capacity compared to ordering a multiplex panel including SARS-CoV-2 specific to the available pathology platform. It is acknowledged that some pathology providers may not have access to the specific multiplex panels recommended below – where this is the case, liaise with the pathology provider to determine the most appropriate option. Screening testing

Screening testing aims to identify disease in asymptomatic people and is endorsed for testing of:

1. Close contacts in outbreaks in congregate living settings housing vulnerable people after a confirmed case in a staff member, resident or visitors. Testing in this

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circumstance is guided by the local public health unit and published Commonwealth and state guidance for community outbreaks (see table 1) or by the outbreak management team for hospital outbreaks.

2. Patients admitted to hospitals within population catchments at moderate and high community transmission levels, for cohorts outlined in tables 2 and 3. In the setting of community transmission, hospital screening testing will only be successful in minimising hospital-based transmission and protecting vulnerable patients if supported by:

a. Utilisation of infection control strategies that span the spectrum of hierarchy of controls – refer to QH infection control guidance

b. Models of care that: i. Limit avoidable face-to-face interaction through use of telehealth

where clinically appropriate ii. Support clinical risk assessment and rapid testing modalities prior to

patient entry to high-risk clinical environments iii. Support rapid streaming of COVID positive patients to dedicated,

physically appropriate environments, by-passing high risk clinical environments

iv. Support use of technologies to limit crowded waiting rooms or avoidable queueing

3. People in high-risk environments or groups or those in quarantine at the discretion of the Incident Management Team, Public Health Unit or Chief Health Officer Note: screening testing requirements for asymptomatic persons designated as close contacts of a case is defined in the Management of Diagnosed Cases of COVID-19 and Close Contacts Direction.

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Figure 1: Diagnostic testing for people with symptoms of COVID-19

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Table 1: Outbreak management (including testing) guidance for vulnerable community settings

Setting Commonwealth & QH outbreak management guidance Aboriginal and Torres Strait Islander communities

Aboriginal and Torres Strait Islander COVID-19 Point of Care Testing Program Aboriginal Community Controlled Health Services Pandemic Response Toolkit

Correctional Services

CDNA national guidelines for COVID-19 outbreaks in correctional and detention facilities

Disability accommodation

CDNA national guidelines for prevention and management of COVID-19 outbreaks in disability residential services

Residential Aged Care

• CDNA national guidelines for the prevention, control and public health management of COVID-19 outbreaks in residential care facilities

• Acute Respiratory Illness (potential COVID-19 or influenza) • Management of COVID-19 exposure or outbreak in residential aged care

facility

Hospital screening testing

Screening testing strategies across hospitals aim to protect vulnerable patients, reduce hospital transmission, and ensure sustainability of staffing.

Screening testing is only one component of systems aimed at reducing risk of peri-operative COVID-19 morbidity and mortality and staff infection. The following guidance assumes Hospitals and Health Services have implemented the full hierarchy of controls to reduce risk of SARS-CoV-2 transmission in hospital.

Recommended screening testing is outlined in table 2 and perioperative screening in table 2 - this guidance should not replace clinical judgement individualised to the presentation and local modifying factors. No screening test should delay urgent healthcare for patients.

Preoperative screening testing All patients should undergo pre-operative clinical screening for symptoms and epidemiological risks for COVID-19 based on the current CDNA definitions – where symptoms or risk factors are present, pre-operative diagnostic PCR testing for SARS-CoV-2 is indicated. If patients have a positive SARS-CoV-2 PCR or rapid antigen test within the 7 weeks prior to scheduled surgery, evaluation of predicted COVID-19 related risk, urgency of required surgery and expected physiological effects of surgery and anaesthesia on the patient is indicated - refer to ANZCA and RACS guidance for elective surgery. High quality evidence informing endoscopy practice in the current phase of COVID-19 pandemic is lacking. Appropriate clinical judgement should be applied, balancing risks of delay of procedure against the risk associated with the procedure for the patients and the healthcare workforce – refer to GESA guidance to inform decision making. In asymptomatic patients with no epidemiological risks, pre-operative screening testing guidance is outlined in Table 3. In applying this guidance, it is important for clinicians to consider the current level of community

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transmission (as defined by the Chief Health Officer), the vulnerability of the individual patient, the level of PPE to be used by staff, the vaccination status of relevant healthcare workers and the risk of aerosol generation of the procedure.

Table 2: Screening testing1 in hospital settings of asymptomatic people Setting Low levels community

transmission Moderate levels community transmission3

High levels community transmission

Emergency presentations2

No routine screening testing

Vulnerable patients4 requiring admission

Emergency admissions to hospital4, 5,6,7

Frequent day attenders (e.g. hemodialysis, day chemotherapy)

No routine screening testing

Consider screening testing in settings with low rates of up-to-date status for COVID-19 vaccination and / or where there is inability to implement infection control strategies across the hierarchy of controls

Outpatient appointments

No routine screening testing

Aeromedical retrievals

No routine screening testing required for retrieval – receiving hospitals may require screening test as per emergency admission guidance above - this should not delay retrieval

Residents returning to vulnerable facilities

No routine screening Screening testing should be a risk-based decision that considers:

1. Whether there is an existing outbreak at the facility 2. Ability of the facility to isolate the person as confirmed by

RACF clinical manager (note: low threshold to screen cognitively impaired residents who wander)

3. Close contact with confirmed cases

1 Screening testing may involve RT-PCR (standard or rapid) or Rapid Antigen Testing – clinicians should consider the required sensitivity and specificity of the test, as determined by the individuals’ vulnerability3 and procedural risk4, balanced against test availability and turn-around time 2 Emergency presentations are defined as presentations to the Emergency Department, unplanned presentations to walk-in services including maternity, mental health, oral health, or sexual health services 3 This guidance assumes ability to implement appropriate infection control strategies across the hierarchy of controls as guided by local infection control teams (e.g. cohorting vulnerable patients in environments physically distanced from untested patients) to minimise risk of hospital-acquired COVID-19 infection in vulnerable patients – where this is not feasible, implement testing guidance for high level community transmission 4 A vulnerable patient is a patient with increased risk of poor outcome if developing COVID as defined in QH COVID-19 Treatment Guidelines for mild to moderate disease (adults) and QH The management and treatment of children with acute SARS-CoV-2 infection 5 Where screening testing involves use of rapid antigen testing, in jurisdictions where the rate of positive results is < 1% in the population being tested, negative predictive value is significantly reduced; screening testing may then be replaced by a risk-based testing approach, where clinically appropriate. 6 Where patients are symptom-free, have had confirmed COVID-19 infection and are within 12 weeks of release from isolation, repeat testing is not indicated. 7 Where parents, carers or birthing support partners stay with a patient through their hospital admission they will be required to undergo COVID-19 testing, with the type of test determined by the pre-test probability, the community prevalence, turn-around time of available tests in the location of presentation and relevant public health directions.

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8 Where inpatient length of stay is greater than 48 hours, consideration may be given to repeat screening testing Table 3: Pre-operative screening testing guidance

Low levels community transmission

Moderate levels community transmission2

High levels community transmission

Pre-operative screening testing1

No screening testing Screening testing of vulnerable patients3 or those undergoing high-risk procedures4

Screening testing of patients admitted to hospital 4,5,6,7

1 Pre-operative screening testing may involve RT-PCR (standard or rapid) or Rapid Antigen Testing – clinicians should consider the required sensitivity and specificity of the test, as determined by the individuals’ vulnerability3 and procedural risk4, balanced against test availability and turn-around time. 2 This guidance assumes ability to implement appropriate infection control strategies across the hierarchy of controls as guided by local infection control teams (e.g. cohorting vulnerable patients in environments physically distanced from untested patients) to minimise risk of hospital-acquired COVID-19 infection in vulnerable patients – where this is not feasible, implement testing guidance for high level community transmission 3 A vulnerable patient is a patient with increased risk of poor outcome if developing COVID perioperatively – examples include (8-10)

• Unvaccinated for SARS-CoV-2 • American Society of Anaesthetists physical status classification (ASA grade) > 2 • Pre-operative oxygen requirement / respiratory support • Age >/= 60 years • Revised cardiac risk index > 1 • Immune suppression or active malignancy within past 5 years • Pregnancy

4 High risk procedures encompass procedures with either:

• Very high risk of aerosol generation with high viral loads and include prolonged procedures with proximity of providers to aerosol and manipulation of high viral load tissue (Nasopharynx / oropharynx) and aerosolization through use of energy devices – surgeries meeting criteria for this classification are predominantly head and neck surgeries (11, 12).

• Procedures with increased risk of COVID-related morbidity / mortality as defined by the COVIDSurg Collaborative as emergency surgery or major or complex major elective surgery using the BUPA schedule of procedures (9, 13).

4 Where screening testing involves use of rapid antigen testing, in jurisdictions where the rate of positive results is < 1% in the population being tested, negative predictive value is significantly reduced; screening testing may then be replaced by a risk-based testing approach, where clinically appropriate. 5 Clinician discretion may be used to risk-stratify those undergoing low risk day-case procedures – it may be appropriate for young asymptomatic patients with ASA 1-2 and up-to-date with COVID vaccination undergoing low-risk procedures to not undergo screening testing where staff are wearing high-risk level PPE 6 Where patients are symptom-free, have had confirmed COVID-19 infection and are within 12 weeks of release from isolation, repeat testing is not indicated. 7 Where inpatient length of stay is greater than 48 hours, consideration may be given to repeat screening testing

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Public health surveillance testing

Public Health Surveillance testing is testing at the discretion of the Chief Health Officer for monitoring incidence and prevalence of disease to guide planning, implementation and evaluation of public health practice. QH surveillance testing aims to:

• Monitor COVID-19 incidence for existing variants and to track incidence in different age groups and populations at higher risk of developing severe disease in the presence of high case numbers

• Detect and contain outbreaks of new COVID-19 variants – effective identification of new variants requires a robust sampling and sequencing strategy to support timely and accurate genomic surveillance. This must be supported by effective rates of PCR testing to ensure representative sampling as appropriate sample sizes to support timely identification of variants is based on proportion of total cases. Note: QH sampling strategy for SARS-CoV_2 genomic surveillance is guided by The CDGN, PHLN and CDNA Sampling Strategy for SARS-CoV-2 Genomic Surveillance and uses both representative sampling from HHSs across Queensland and targeted sampling across hospitals and high-risk populations.

• Guide the early implementation of public health and social measures (PHSM) and nonpharmaceutical public health interventions (NPI) to slow case growth and enable uninterrupted economic and social activities

• Better understand the impact of co-circulation of multiple respiratory pathogens including COVID-19, influenza and other respiratory viruses. This can be achieved through testing when clinically indicated and through exploring options for sentinel surveillance in the community.

• Protect the health system through early detection of cryptic transmission and subsequent severity indicators for new variants, allowing for timely PHSM and NPI and system capacity preparation

• Protect the health system through early detection of cryptic transmission for new variants, allowing for timely PHSM and NPI and system capacity preparation

Interpreting PCR results

Positive Results All positive results are reported to Public Health Units by laboratories and through NOCS, the Public Health Notification Database.

False Positives False positives are very rare but possible. All potential false positive results should be notified to the ordering clinician or relevant PHU by the laboratory. The medical microbiologist will consider the threshold cycle (Ct value) or will discuss with the treating clinician and / or public health as required, and, in consultation with the treating clinician review any symptoms or potential exposure to COVID-19, and will determine if repeat testing is required. Repeat testing will be supervised by a clinical microbiologist to assist with

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difficult and borderline results. Full instrument data will be made available to the microbiologist for consideration with escalation to rapid testing in a reference laboratory within hours. An Expert Advisory Group (MDT) may be held to make a consensus decision on whether the test represents a case or not.

Negative Results All persons with symptoms should remain isolated until symptoms resolve. Any persons being tested for COVID-19 who is subject to quarantine must meet formal criteria for release from quarantine described in CDNA Public Health Unit guidelines AND must have received formal notification by the relevant public health unit of their clearance for release from quarantine.

False Negatives

False negative PCR results for COVID-19 can occur due to suboptimal specimen collection, testing occurring very early post-exposure, inappropriate specimen type, low viral load, low analytic sensitivity or variability in viral shedding (14). The incidence of false negative results may increase with increasing community prevalence. Where pre-test probability of COVID-19 is high (based on epidemiologic and clinical assessment), infectious diseases or public health physicians should be consulted about continued isolation and retesting.

Interpreting rapid antigen results Accuracy of rapid antigen tests is variable. Sensitivity is higher in symptomatic (64 to 84%) than in asymptomatic people (40-74%) and is highest in those with onset of symptoms within 5 days of testing (5). Specificity is high in both symptomatic and asymptomatic individuals (99%) (15). Predictive validity of the test is significantly affected by community prevalence, with a higher probability of false positives in low community prevalence, and of false negatives in high community prevalence, settings.

Caution is required when using rapid antigen tests to screen asymptomatic individuals or those outside of disease phases associated with higher viral loads. Sensitivity of rapid antigen tests may be improved by restricting use to high pre-test probability symptomatic patients (15), by serial testing (16, 17) and by healthcare worker collection and interpretation of the swab (18, 19).

Implementation of point of care COVID testing Implementation of point of care COVID testing needs to consider:

1. Allocation of appropriate resources at the point of testing to allow safe performance of testing and ensure adequate observation and documentation of results

2. Performance of a risk assessment and appropriate planning of workflow for specimen collection and testing to minimise infection control risks

3. Digital integration of results into existing data management systems to ensure accurate data and appropriate patient follow-up

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Isolation requirement The SoNG: Coronavirus Disease 2019 (COVID-19). CDNA National guidelines for public health units describes the recommendations for isolation requirements for testing strategies. =

All symptomatic persons should isolate whilst awaiting test results and remain isolated until:

• Fever and acute respiratory symptoms resolve AND • their COVID test result is negative.

The need for quarantine and testing during quarantine will be guided by the SoNG: Coronavirus Disease 2019 (COVID-19). CDNA National guidelines for public health units, public health and movement directions, and current State operational guidance instituted by the COVID Incident Management Team and public health units. Each case and cluster will be assessed, and advice provided on quarantine and testing to minimise ongoing COVID transmission.

Communication of results

All people tested by PCR will be advised about the result of their test and how they will be contacted.

All people testing negative will be informed of their result, generally by SMS. Consideration should be given regarding how post-testing messaging is provided back to priority populations – e.g. checking whether the person has access to a phone or whether, with the person’s consent, the information can also be provided to a nominated person or support service. It is also important to ensure that those being tested are clear on what actions are required where the person tests negative or positive – clear communication of need for ongoing isolation or quarantine is imperative for successful management of public health risks.

Data collection

Irrespective of where swabs are tested (public or private laboratories), all PCR test results will be captured by the State-wide Public Health Database, NOCS. COVID testing data from NOCS is used by the COVID Incident Management Team (IMT) to assess testing rates across the pandemic stages and across the HHS regions, and facilitates analysis of epidemiological trends including hospitalization rates, ICU admission rates and deaths. Rapid antigen test results, where the person has not also had a PCR test, are registered by the person here. Data linkage allows rapid antigen results to be uploaded to NOCS.

Ethical and Important considerations in COVID-19 testing Under the Human Rights Act 2019 the Queensland Government recognises that all Queenslanders have a right to health services and human rights must be considered in all decision-making and action and only limit human rights in certain circumstances and after careful consideration.

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• All human life is equal, and all people should be able to access healthcare and live with dignity, regardless of their age, disability, expected longevity or where they live.

• Decisions made about prioritising testing, should the system reach capacity, must be based on a triage process that minimises possible bias.

• The rights of individuals must be balanced with consideration of the welfare and wellbeing of others, particularly at a time when there can be severe consequences to life if adequate infection control measures are unable to be fully realised.

• All testing is voluntary. Staff undertaking the testing must provide enough information to enable people to give properly informed consent and balance their responsibility to themselves, society and the healthcare teams.

4 HHS planning and logistics Operational Context COVID-19 testing programs provided by Hospital and Health Services (HHS) operate in response to the level of the pandemic, as determined by Health Directives of Queensland’s Chief Health Officer (CHO), as well as any epidemiological intelligence of the level of virus within local communities. Testing clinic availability and accessibility should be tailored to levels of community transmission and the population disease risk.

Each HHS with their Public Health Unit (PHU) develops strategies and plans to guide their COVID-19 testing programs. These plans should consider the needs of quarantine travellers and close contacts of confirmed cases, rural and remote populations, Aboriginal and Torres Strait Islander communities, people experiencing homelessness, culturally and linguistically diverse communities, healthcare and residential aged care settings, people with disability and congregate living/working settings. Each HHS with their PHU will develop strategies and plans to guide their COVID-19 testing programs. These plans will need to cover varying contexts:

• Small discrete townships and outstations

• Towns with Queensland Health Multi-Purpose Health Centres (MPHCs) and hospitals only

• Towns with Queensland Health facilities, GPs and private pathology collection centres

• Cities with COVID-19 Respiratory clinics

• Discrete Aboriginal and Torres Strait Islander communities

Testing facilities HHSs should ensure that there are sufficient options for testing to ensure accessibility to testing across the HHS, with options including:

• Private pathology providers via General Practitioner (GP) referral (outside of surge testing)

• Primary Healthcare Clinics, Aboriginal Community Controlled Health Services

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• Fever clinics

• COVID-19 respiratory clinics, supported by Primary Health Networks (PHNs)

• Pop up testing clinics implemented during surge testing periods

• Emergency Departments (EDs) for symptomatic people who are unwell or at high risk of severe disease

Surge or outbreak testing Surge testing as part of HHS Rapid Response Plans could encompass all of the above with extended hours for established clinics and the use of pop-up clinics. Surge testing will be of short duration and high intensity. HHSs should have plans in place for surge staffing to support testing in outbreaks in high-risk settings, when directed PHUs and the people with symptoms in the local community when directed by the CHO. Surge testing planning requirements are outlined in table 4 below.

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Table 4: HHS surge testing planning requirements

Domain Resources Comments

Planning Need • Number of people and predicted volume of tests required across a range of outbreak scenarios

• High risk populations or populations with specific needs including Aboriginal and Torres Strait Islander communities, residential aged care facilities, disability accommodation facilities, homeless population and homeless shelters, Culturally and Linguistically Diverse communities, places of detention (prisons, watch houses, youth detention centres, immigration detention facilities, community correctional centres), congregate living settings (boarding houses, student accommodation, women’s refuges, seasonal workers dormitories), high density housing, places of education and childcare centres, high density work sites (e.g. factories and processing facilities, abattoirs)

Testing and swab collection capacity

• Public and private testing capacity

• Swab collection capacity and ease of access may significantly impact the engagement of the public in testing – for sufficient PCR testing to facilitate monitoring for variants, access to PCR swab collection and testing facilities must continue to be simple. Challenges in access to PCR testing may result in delayed identification of new variants / sub-lineages in Queensland – where those new variants have a changed transmission and / severity, this presents a significant risk.

Environment Location • Consider consumer and staff safety, consumer convenience, and service efficiency

• Optimising accessibility of testing to residents throughout the geographic area of the HHS, across public and private pathology service providers

• Testing to occur outdoors, where possible – ensure attention to staff safety to prevent risks of dehydration or heat illness

Safety • Capacity to isolate people effectively in the setting

• Pre-existing and current capacity to implement preventative public health measures, including consideration of environmental, engineering, social and medical factors including vaccination rates of residents / clients and staff

Accessibility • Optimising accessibility of testing sites to persons with disability or frailty – see appendix 1 for details

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Staff Staffing considerations in setting-specific contexts

• Who collects the tests including their ability to comply with any related public health directions relevant to that setting (e.g. Aged Care Direction)

• Education, skill and capacity: Skill, knowledge and capacity of staff working in these settings

Testing staff • HHS staff and / or private pathology laboratory staff, GPs, Aboriginal Community Controlled Health Service staff or community-based clinicians

Triage staff • Nurses and Aboriginal Health Workers to:

• Triage patients based on:

o Essential versus enhanced testing

o Clinical risks and stability

• Assist in completion of enhanced data surveillance forms

Administrative staff • Administrative support for registration and generating HBCIS records (and / or episodes of care in relevant digital system depending on type of episode)

Outreach teams • Ability to provide outreach testing teams for instances where surge testing involves persons who experience difficulty in undertaking travel to hospital e.g. disability accommodation services

Consumables PPE • Ensure access to adequate supplies of PPE aligned to the relevant Queensland Health PPE guidance

Testing equipment • Ensure access to adequate supplies of testing consumables including point-of-care (POC) cartridges where relevant

Communication Patients • Mechanisms to advise patients of their results in a timely and effective manner – ensure accurate contact details collected at registration

• Consideration of communication of test results to those who have special communication needs

Transport

Transportation of tests to laboratories for testing

• Ensure transportation of swabs has clear arrangements across a range or geographic and setting scenarios.

Transport • Each laboratory option has differing turnaround times depending on their location and

transport times for swabs to the larger laboratories.

• Where patients are close contacts or live or work in high-risk environments, testing should occur via the closest laboratory with the shortest turn-around time to allow early identification of cases and early implementation of public health measures.

• Plans for transport of swabs with additional courier runs in the event of reduced flights need to be considered and for extended or surge testing.

5 Reporting and Evaluation Reporting and evaluation of testing will be multi-modal and occur at multiple levels. Queensland Health supports:

1. Daily reporting and review of:

a. Tests performed to detect SARS-CoV-2 infection: HHSs have testing targets for PCR testing. Data is regularly reported up from the COVID IMT Epidemiology team.

b. Positive case numbers, reported as number and rate per 100,000 population by HHS

c. Testing clinic demand at HHS and private provider level reported to SHECC / COVID.IMT.

d. Hospitalisation numbers by HHS, reported as number and proportion of cases by HHS

2. Evaluation of equity of access to testing.

3. Maintenance of a quality framework in accordance with the National Pathology Accreditation Advisory Council (NPAAC) Requirements for Medical Testing of Microbial Nucleic Acids to maintain high standards of quality control.

4. Laboratory monitoring of turn-around times for testing (from point of sample collection to communication of result to patient & public health units).

5. Evaluation of requirement for repeat testing.

Benchmarks* for testing include:

1. People whose symptoms meet the clinical criteria of the COVID-19 case definition are tested in a timely manner, with a testing turn-around time from specimen collection to return of result within 24 hours

2. Testing of all close contacts in congregate living settings (including homeless, residential aged care and disability accommodation services) once a single case of COVID-19 has been confirmed among any of staff, residents or frequent visitors, within 24 hours.

3. Minimum PCR testing target across the state to enable early detection of new variants (minimum suggested target of 5000 PCR tests per day, of which a subset will be sequenced);

Appendix 1 Strategies and considerations for ensuring access for people with disability to COVID-19 testing Service Level: The environment that the COVID-19 testing takes place in can improve the comfort and confidence of people with disability. The following strategies should be considered by Hospital and Health Services and private pathology providers to ensure that COVID-19 testing is accessible to persons with disability:

Domain Feature In-reach services In-reach testing is available for people with disability that are unable to access a testing site due to their complex care and support needs Interpreters People are encouraged to identify the need for interpreters on booking a test or as soon as possible after arrival to enable interpreter access

(including Auslan or spoken language)) Lay-out

Booking The layout of the testing site is described at the time of booking and request for any accessibility requirements are shared. Signage Ensure there is sufficient clear, simple and visible signage to direct people where to go – signage should be in large font, high contrast colours

and non-glare finish Parking Ensure at least one of every 25 parking spaces is accessible parking – spaces may be marked temporarily if needed. Ensure there are drop off

areas close to the entrance with under-cover seating. Entry Access: ensure there is a clear path to the entry with non-slip surfaces that minimises level changes and has handrails, resting places and shade

(if a long footpath). Ensure that the testing site is large enough so that people with accessibility challenges can still move freely when the space is crowded or busy. Where possible, automatic doors and wide doorways are preferred. Ensure that counter heights, lift buttons, door handles etc. are within reach.

Seating Provide sufficient seating that is not in direct sunlight for people to wait Lighting Maintain adequate lighting levels throughout premises Sensory Minimise stimulus or offer a quiet space for people with disability to wait Assistance animals

Assistance animals are allowed at testing sites and are provided drinking facilities

Information There are a range of accessible resources to assist people with disability to best understand the testing process and requirements Frontline staff Frontline staff are trained to appropriately engage with people with disability

A dedicated staff member is nominated to identify any accessibility issues at the test site each day and to provide assistance to people with accessibility challenges when they arrive for testing

*Source: COVID-19 Vaccination Clinics: Ensuring access for People with Disability. Available from: https://www.health.qld.gov.au/__data/assets/pdf_file/0009/1040004/covid19-disability-accessibility-guideline.pdf

Strategies and considerations for ensuring access for people with disability to COVID-19 testing (cont’d) Individual Level:

Domain Feature Communication Talk directly to the person in a manner that shows respect and express empathy

Take extra time to connect, explain the process and calm any anxieties the person may have Ask if there is anything that could be done to make the person feel more comfortable Ask the person first if they want assistance and if they answer yes, ask how you can best assist them. Do not assume they need assistance or that you know what they require Ask how they would like to communicate (e.g. interpreter, gestures, signs, sounds, symbols, pictures, social stories, devices etc) Provide an Auslan or spoken language interpreter Use appropriate language e.g. use the term “person with disability” rather than “disabled person” Respectfully check they have understood the information provided to them Ensure that you ask how the person would be able to receive results and ensure that processes are in place to document and enact the required method for sharing results e.g. text to carer or phone call to person with disability; ensure that the person and / or their carer understand the actions required prior to and on receipt of the test result.

Support network

Identify and acknowledge the carer or support person as a valuable resource The support person may be able to provide additional information on how the person with disability would best manage having the test performed

Sensory Provide active distraction. Engage with the person or ask them to do or focus on something. Use reassuring touch – be aware that some people with disability may react against this, so use touch thoughtfully and always ask beforehand. Clearly explain what you are about to do – particularly if people are blind or have significant vision impairment Do not move someone’s mobility device or personal belongings without asking

Appendix 2 Pathology Testing Capability across Queensland Health Table 1: Pathology Queensland public SARS-CoV-2 existing testing platform distribution and non-surge through-put capacity

HHS HHS population (2020)

Aboriginal & Torres Strait Islander population (2019)

Health service High-throughput PCR platform

High-throughput capacity (non-influenza season)

POC testing (capacity in tests/24 hrs)

PQ testing capacity per 1000 population where high through-put capacity exists – non-influenza season

Central West 10,171 826 Longreach - - PQ GeneXpert (40) Work referred to TW laboratory - population accounted for in testing capacity calculation for THHS

South West 23,907 3,121 Charleville hospital

PQ GeneXpert (40) Work referred to TW laboratory - population accounted for in testing capacity calculation for THHS

Roma hospital

PQ GeneXpert (40)

North West 27,494 8,529 Cloncurry hospital

Kirby GeneXpert Work referred to Infectious Diseases Laboratory (Brisbane) - population accounted for in testing capacity calculation for MNHHS

Doomadgee hospital

Kirby GeneXpert

Mornington Island hospital

Kirby GeneXpert

Mount Isa Base Hospital

PQ GeneXpert (250)

Normanton hospital

Kirby GeneXpert

Torres and Cape 28,427 19,356 Aurukun PHCC

Kirby GeneXpert Work referred to CN laboratory - population accounted for in testing capacity calculation for CHHHS

Badu Island PHCC

Kirby GeneXpert

Bamaga hospital

Kirby GeneXpert

Bolgu Island PHCC

Kirby GeneXpert

Coen - Spoke site of Lockhart River PHCC Kirby GeneXpert

Cooktown hospital

Kirby GeneXpert

Hope Vale - Spoke site of Cooktown Hospital Kirby GeneXpert

Kowanyama PHCC

Kirby GeneXpert

Lockhart River PHCC

Kirby GeneXpert

Mabulag - Spoke site of Badu Island Kirby GeneXpert

Mapoon - Spoke site of Weipa Hospital Kirby GeneXpert

Napranum - Spoke site of Weipa Hospital Kirby GeneXpert

Pormpuraaw PHCC

Kirby GeneXpert

Saibai Island PHCC

Kirby GeneXpert

St Pauls Kubin Kirby GeneXpert

Thursday Island Hospital

PQ GeneXpert (30)

Weipa hospital

Kirby GeneXpert

Wujal - Spoke site of Cooktown Hospital Kirby GeneXpert

Mackay 174,816 10,380 Mackay hospital Panther 700 PQ GeneXpert (80) 4.5

Wide Bay

221,687 10,974 Bundaberg Hospital Panther 700 PQ GeneXpert (50) 6.8

Hervey Bay Hospital Panther 700 PQ GeneXpert (50)

Maryborough Hospital

Central Queensland 220,891 15,375 Emerald hospital

PQ GeneXpert (40) 6.9

Gladstone hospital

PQ GeneXpert (40)

Rockhampton hospital Panther 1400 PQ GeneXpert (50)

Townsville

243,250 21,742 Palm Island PHCC

Kirby GeneXpert 6.5 (including population of Central West and South West = 5.5) Townsville hospital Panther 700 PQ GeneXpert (50)

Alinity 700

PQ IVD (QIAGEN)

100

Townsville Aboriginal and Islander Health Service Kirby GeneXpert

Cairns & Hinterland 261,394 31,087 Atherton hospital

PQ GeneXpert (30)

Cairns hospital Panther 700 PQ GeneXpert (60) 5.96 (including population of Torres and cape = 5.4)

COBAS 700

Wuchopperen AICCHS

Kirby GeneXpert

Innisfail hospital

PQ GeneXpert (30)

Gurriny Yealamucka

Kirby GeneXpert

Darling Downs 286,079 17,080 Cherbourg

Kirby GeneXpert 5.56

Dalby hospital

PQ GeneXpert (40)

Kingaroy hospital

PQ GeneXpert (40)

Toowoomba hospital Panther 700 PQ GeneXpert (50)

COBAS 700

Warwick hospital

PQ GeneXpert (40)

West Moreton 312,855 15,221 Ipswich Hospital

PQ GeneXpert (80) Work referred to PAH laboratory - population accounted for in testing capacity calculation for Metro South HHS

Sunshine Coast

445,889 13,099 Gympie hospital

PQ GeneXpert (35) 3.45

Nambour hospital

PQ GeneXpert (50)

Sunshine Coast University Hospital Panther 700 PQ GeneXpert (80)

Alinity 700

Gold Coast

650,996 12,722 Gold Coast University Hospital Panther 700 PQ GeneXpert (60) 2.31

Alinity 700

Robina Hospital

PQ GeneXpert (50)

Metro North

1,063,749 31,357 Caboolture hospital

PQ GeneXpert (50)

7.65 (including population of North West = 7.46)

Prince Charles Hospital Panther 700 PQ GeneXpert (60)

Central Laboratory Panther 700 PQ GeneXpert (80)

PQ IVD (QIAGEN)

100

Cobas 700

Infectious Diseases Laboratory Alinity 700

BGI 5,000

Redcliffe hospital

PQ GeneXpert (50)

Metro South

1,204,581 35,543 Redlands hospital

PQ GeneXpert (50) 2.0 (including population of WMHHS = 1.62)

Forensic and Scientific Services In-house assay

800

QEII hospital PQ GeneXpert (50)

Logan Hospital

PQ GeneXpert (80)

Princess Alexandra Hospital Cobas 700 PQ GeneXpert (80)

Panther 700

Children's Health Queensland

Queensland Children's Hospital Panther 700 PQ GeneXpert (40)

Totals 5,176,186 246,413

21,400 2,465 4.61

Selected References 1. Australian Commission on Safety and Quality in Healthcare. The Australian Charter of Healthcare Rights. 2019. https://www.safetyandquality.gov.au/consumers/working-your-healthcare-provider/australian-charter-healthcare-rights. accessed 1/10/2021. 2. Public Health Laboratory Network – Communicable Diseases Network of Australia Join Statement on SARS-CoV-2 Rapid Antigen Tests https://www.health.gov.au/resources/publications/phln-and-cdna- joint-statement-on-sars-cov-2-rapid-antigen-tests. 3. Muhi S, Tayler N, Hoang T, Ballard SA, Graham M, Rojek A, et al. Multi-site assessment of rapid, point-of-care antigen testing for the diagnosis of SARS-CoV-2 infection in a low-prevalence setting: A validation and implementation study. Lancet Reg Health West Pac. 2021;9:100115. 4. Masia M, Fernandez-Gonzalez M, Sanchez M, Carvajal M, Garcia JA, Gonzalo-Jimenez N, et al. Nasopharyngeal Panbio COVID-19 Antigen Performed at Point-of-Care Has a High Sensitivity in Symptomatic and Asymptomatic Patients With Higher Risk for Transmission and Older Age. Open Forum Infect Dis. 2021;8(3):ofab059. 5. Khandker SS, Nik Hashim NHH, Deris ZZ, Shueb RH, Islam MA. Diagnostic Accuracy of Rapid Antigen Test Kits for Detecting SARS-CoV-2: A Systematic Review and Meta-Analysis of 17,171 Suspected COVID-19 Patients. J Clin Med. 2021;10(16). 6. Public Health Laboratory Network. PHLN guidance on laboratory testing for SARS-CoV-2 (the virus that causes COVID-19). version 2.0. 7 June 2021. https://www.health.gov.au/sites/default/files/documents/2021/06/phln-guidance-on-laboratory-testing-for-sars-cov-2-the-virus-that-causes-covid-19.pdf accessed 1/11/2021. . 7. Czumbel LM, Kiss S, Farkas N, Mandel I, Hegyi A, Nagy A, et al. Saliva as a Candidate for COVID-19 Diagnostic Testing: A Meta-Analysis. Front Med (Lausanne). 2020;7:465. 8. Collaborative CO. Outcomes and Their State-level Variation in Patients Undergoing Surgery With Perioperative SARS-CoV-2 Infection in the USA: A Prospective Multicenter Study. Ann Surg. 2022;275(2):247-51. 9. Collaborative CO. Machine learning risk prediction of mortality for patients undergoing surgery with perioperative SARS-CoV-2: the COVIDSurg mortality score. Br J Surg. 2021;108(11):1274-92. 10. Collaborative CO. Mortality and pulmonary complications in patients undergoing surgery with perioperative SARS-CoV-2 infection: an international cohort study. Lancet. 2020;396(10243):27-38. 11. Thamboo A, Lea J, Sommer DD, Sowerby L, Abdalkhani A, Diamond C, et al. Clinical evidence based review and recommendations of aerosol generating medical procedures in otolaryngology - head and neck surgery during the COVID-19 pandemic. J Otolaryngol Head Neck Surg. 2020;49(1):28. 12. Jackson T, Deibert D, Wyatt G, Durand-Moreau Q, Adisesh A, Khunti K, et al. Classification of aerosol-generating procedures: a rapid systematic review. BMJ Open Respir Res. 2020;7(1). 13. BUPA. BUPA Schedule of Procedures. 2020. p. https://codes.bupa.co.uk/procedures.

14. Kanji JN, Zelyas N, MacDonald C, Pabbaraju K, Khan MN, Prasad A, et al. False negative rate of COVID-19 PCR testing: a discordant testing analysis. Virol J. 2021;18(1):13. 15. Dinnes J, Deeks JJ, Berhane S, Taylor M, Adriano A, Davenport C, et al. Rapid, point-of-care antigen and molecular-based tests for diagnosis of SARS-CoV-2 infection. Cochrane Database Syst Rev. 2021;3:CD013705. 16. Larremore DB, Wilder B, Lester E, Shehata S, Burke JM, Hay JA, et al. Test sensitivity is secondary to frequency and turnaround time for COVID-19 surveillance. medRxiv. 2020. 17. Mina MJ, Parker R, Larremore DB. Rethinking Covid-19 Test Sensitivity - A Strategy for Containment. N Engl J Med. 2020;383(22):e120. 18. Tan SY, Tey HL, Lim ETH, Toh ST, Chan YH, Tan PT, et al. The accuracy of healthcare worker versus self collected (2-in-1) Oropharyngeal and Bilateral Mid-Turbinate (OPMT) swabs and saliva samples for SARS-CoV-2. PLoS One. 2020;15(12):e0244417. 19. Klein JAF, Kruger LJ, Tobian F, Gaeddert M, Lainati F, Schnitzler P, et al. Head-to-head performance comparison of self-collected nasal versus professional-collected nasopharyngeal swab for a WHO-listed SARS-CoV-2 antigen-detecting rapid diagnostic test. Med Microbiol Immunol. 2021;210(4):181-6.

Document approval details

Document custodian COVID Testing Implementation & Improvement Working Group (TIIG)

Approval officer COVID System Leadership Forum Approval date 13 May 2022 Review date 1 April 2023

Version control

Version Comments v1.0 Initial draft combining Queensland Health COVID-19 Testing framework

implementation plans:

• Testing strategies for congregate living / work settings • Testing strategies for priority populations – people experiencing

homelessness v0.10 • Testing strategies for priority populations – people with disability v 2.0 • Testing strategies for priority populations – culturally and linguistically

diverse (CALD) communities • Testing strategies for residential aged care v • Testing strategies for rural and remote Queenslanders v1.0 • Testing strategies for Aboriginal and Islander Communities • Testing strategies for quarantine travellers and close contacts of

confirmed cases

v1.1 Updated based on feedback of owners of existing testing strategy documents v1.2 Updated based on feedback of:

• Testing Implementation & Improvement Working Group members

• Pathology Queensland • For Testing: clinical guidance section, clinical network chairs, Office of

Chief Psychiatrist, Office of Chief Dental Officer

V2.2 Updated based on:

• transition to a suppression phase and in anticipation of a living with COVID phase

• high levels of vaccination in population • changes to testing demand in an Omicron environment • changes to National definitions and AHPCC advice

V2.2.1 Updated to remove reference to repeating positive results using Kirby Institute GeneXpert.