What do you recommend in terms of office-based testing for SARS-CoV-2 in the occupational medicine ambulatory practice setting?

The Coronavirus Disease 2019 (COVID-19) caused by the new strain of coronavirus, SARS-CoV-2, has led to illness and death in unprecedented proportions in recent times, and the disease promises to continue to propagate.  Early detection of infected symptomatic and asymptomatic individuals1 with subsequent exhaustive contact tracing and quarantine are our current defenses, short of a vaccine. The ability to conduct office-based testing will help towards more efficient widespread testing. However, there are inherent hazards in this task, not only to the healthcare provider (HCP) conducting the test but also to others who share the office space. Given the hazards and the general lack of engineering controls in the office practice setting, the HCP may elect to send patients to a collection center with better engineering controls to prevent transmission during testing.

If the decision is made to conduct office-based testing, the CDC recommends the following collection methods for an upper respiratory specimen: “A nasopharyngeal (NP) specimen collected by a healthcare provider; or an oropharyngeal (OP) specimen collected by a healthcare provider; or a nasal mid-turbinate swab collected by a healthcare provider or by a supervised onsite self-collection (using a flocked tapered swab); or an anterior nares (nasal swab) specimen collected by a healthcare provider or by onsite or home self-collection (using a flocked or spun polyester swab); or nasopharyngeal wash/aspirate or nasal wash/aspirate (NW) specimen collected by a healthcare provider.”2. The nasal (anterior nasal) specimen collection is less invasive with resultant less patient discomfort compared to collection from the other upper respiratory tract sites. If the nasal swab is self-administered, the detection of coronavirus is similar to that using a nasopharyngeal swab. The nasal swab, technically less complex and less time consuming, can lead to reduced risk of infection spread to the HCP. The patient may also be allowed to perform self-collection under supervision.3

The HCP executing the collection must wear appropriate personal protective equipment (PPE) including a gown, nonsterile gloves, N95 respirator and a face shield4. A properly fit-tested N95 respirator is designed to achieve a close facial fit and efficient filtration of airborne particles of 0.3 microns or greater5. Pertinent respiratory and contact precautions specified by the CDC and one’s institution should be followed. Proper donning and doffing of PPE, hand washing or sanitization and collection procedures are essential4 to avoid poor specimen collection as well as injury to self or the patient. Depending on the mode of testing done, aerosol and/or droplets may be generated. Respiratory viruses are often transmitted through droplets exhaled during speech or coughing6, 7. According to McIntosh, “Direct person-to-person transmission is the primary means of transmission of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Whether SARS-CoV-2 can be transmitted through the airborne route (through particles smaller than droplets that remain in the air over time and distance) under natural conditions has been a controversial issue.8" Recognizing this uncertainty and the risk of transmission in a typical office setting without controls, it may be prudent to refer the patient to better controlled collection centers. The FDA has also recently authorized the First Test for Patient At-Home Sample Collection option as well.9


  1. Hanson K, Caliendo C, Arias C. et al. Infectious Diseases Society of America Guidelines on the Diagnosis of COVID-19. Published by IDSA, 5/6/2020. Accessed on July 1st 2020 at: https://www.idsociety.org/globalassets/idsa/practice-guidelines/covid-19/diagnostics/idsa-covid-19-guideline_dx_version-1.0.1.pdf
  2. Interim Guidelines for Collecting, Handling, and Testing Clinical Specimens for COVID-19. Updated May 22, 2020. Accessed on July 1st 2020 at: https://www.cdc.gov/coronavirus/2019-ncov/lab/guidelines-clinical-specimens.html
  3. Nasal (Anterior Nasal) Specimen Collection for SARS-CoV-2 Diagnostic Testing, Office of the Assistant Secretary of Health. SARS-CoV-2 (COVID-1 9 ) Fact Sheet. Accessed on July 1st 2020 at: https://www.cdc.gov/coronavirus/2019-ncov/downloads/OASH-nasal-specimen-collection-fact-sheet.pdf
  4. Marty F, Chen K, Verrill K. Videos in Medicine: How to Obtain a Nasopharyngeal Swab Specimen. NEJM. April 17, 2020. Accessed on July 1st 2020 at: https://www.nejm.org/doi/full/10.1056/NEJMvcm2010260.
  5. D’Allessandro M, Cichowicz K. Proper N95 Respirator Use for Respiratory Protection Preparedness. CDC/NIOSH. March 16, 2020. Accessed on July 1st 2020 at: https://blogs.cdc.gov/niosh-science-blog/2020/03/16/n95-preparedness/
  6. Bar-On Y, Flamholz A, Phillips R, Milo R. Science Forum SARS-CoV-2 (COVID-19) by the numbers. eLife. V.9; 2020. 2020; 9: e57309.Published online 2020 Apr 2. doi: 10.7554/eLife.57309. PMC7224694.
  7. Meselson M. NEJM. Correspondence. Droplets and Aerosols in the Transmission of SARS-CoV-2. N Engl J Med 2020; 382:2063. May 21, 2020. Accessed on July 1st 2020 at: https://www.nejm.org/doi/full/10.1056/NEJMc2009324
  8. McIntosh K. Coronavirus disease 2019 (COVID-19): Epidemiology, virology, and prevention, UpToDate, last updated: Jun 28, 2020. Accessed July 2nd, 2020
  9. https://www.fda.gov/news-events/press-announcements/coronavirus-covid-19-update-fda-authorizes-first-test-patient-home-sample-collection (assessed on July 8, 2020)

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The Forum does not necessarily represent an official ACOEM position. The Forum is intended for health professionals and is not intended to provide medical or legal advice, including illness prevention, diagnosis or treatment, or regulatory compliance. Such advice should be obtained directly from a physician and/or attorney. Questions are answered with the best available data or recommendations at the time.