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Updated: August 18, 2020

What guidance exists for asymptomatic COVID-19 testing in primary care settings?

Summary

The following is a summary of guidance for asymptomatic COVID-19 testing in primary care settings with relevance for Indigenous populations/communities including rural and remote communities and people with low socio-economic status. For additional information about each of the sources, see the Table below.

The guidance regarding asymptomatic testing is evolving, and the recommendations for routine testing for asymptomatic people or different risk groups varies across provinces in Canada. As Alberta Health Services (AHS) notes in its COVID-19 Priority Groups for Asymptomatic Testing Rapid Review, there is limited high quality evidence available regarding: 1) when to test asymptomatic individuals; 2) where (i.e., what site); and 3) how frequently to have effective, sustainable testing of asymptomatic people. An earlier rapid review conduced in April note did not recommend routine testing, yet the government has recently expanded testing programs to include anyone who would like to be tested, with or without symptoms [1]. In its guidance on COVID-19 Provincial Testing Guidance Update, the Ontario Ministry of Health states that it is not currently recommending routine testing for COVID-19 asymptomatic persons except for: 1) those recommended by a public health unit; 2) contacts who had ongoing exposure to a case or their contacts as part of an outbreak investigation; or 3) contacts who were only exposed to the case and who do not share acquisition exposures [4]. Guidance from Alberta Health Services and the Ontario College of Family Physicians, COVID-19: Tips for Family Doctors, recommend that asymptomatic testing be prioritized to: 1) residents and staff involved in an institutional outbreak; 2) an asymptomatic case who is concerned that they have been exposed to COVID-19; or 3) individuals at a higher risk for exposure through their employment [1,5]. Among this evolving policy context, in its Symptoms and Testing guidance document, the government of Alberta states that asymptomatic testing is available at local participating pharmacies, while symptomatic persons or persons with known exposure to COVID-19 must stay home and book a test with Alberta Health Services (AHS) [6]. The BC Center for Disease Control states that although testing for asymptomatic individuals is not currently recommended, private pay clinics are offering asymptomatic testing for reasons that fall outside of BC public health recommendations, such as travel or employment [7]
 
The Centre for Effective Practice, Ontario Ministry of Health and Ontario College of Family Physicians all state that testing can only be performed in a primary care office if the primary care provider is: 1) able to follow the Droplet and Contact Precautions; 2) has the appropriate tools and knowledge of how to test; 3) can ensure sample delivery to a COVID-19 testing laboratory; and 4) the patient wears a facemask, performs good hand hygiene and avoids contact with workers and other patients as much as possible [2,3,6]. If the primary care office is unable to adhere to these guidelines, they should refer the patient to an external assessment centre for testing [2,3,5]
 
AHS noted that among Indigenous communities, the risk of asymptomatic transmission and adverse COVID-19 related health outcomes may be increased due to greater rates of comorbidities and limited access to health care [1]. There are currently no guidelines found to prioritize asymptomatic testing in Indigenous communities, however other strategies are recommended: 1) self-isolation if returning to the community; 2) road access controls; 3) curfews; and 4) community lockdowns [1]. In its COVID-19 Provincial Testing Guidance Update, the Ontario Ministry of Health suggested that any person from a remote, isolated, rural or Indigenous community with COVID-19 symptoms be tested as soon as possible and if a COVID-19 case is confirmed, testing all contacts, including asymptomatic, should be considered in consultation with the local public health unit [4]. No current guidelines were found that prioritize low socio-economic status populations for asymptomatic testing.   

Evidence

What‘s Trending on Social Media and Media

After facing criticisms for its pandemic response, as of May 25th, 2020 Ontario’s provincial government has decided to expand its current testing criteria to include asymptomatic testing for individuals in high risk groups. The Globe and Mail article states that details regarding who fits into ‘high risk’ groups are not yet finalized. In addition, although infectious disease specialists are supportive of the plan, there has been criticism around the Province’s inconsistent messaging.
  
A COVID-19 pop-up testing site was set up on May 13th, 20th and 23rd in the Waterloo, Ontario region. This site was located at the KW Urban Native Wigwam Project and was open to everyone, but mainly targeted the nearby First Nations community. Roughly 60 people were tested including those that were asymptomatic or had mild symptoms.
  
The Southwest Ontario Aboriginal Health Access Centre (SOAHAC), opened a Chippewas of the Thames COVID-19 testing site southwest of London. Testing began on April 23 and is available for members of neighbouring communities including Munsee Delaware Nation, COTTFN and Oneida of the Thames, with the hopes of expanding to London, Windsor and Owen Sound. Testing at all four sites will be open to all First Nations, Métis and Inuit peoples. SOAHAC is also addressing mobility barriers by partnering with Emergency Medical Service (EMS) from Oneida to provide mobile testing. 

Organizational Scan

Precision Biomonitoring, a company from Guelph, Ontario created a novel coronavirus detection technology for rapid and portable testing for remote, Indigenous communities. The tool was created to ensure that all Canadians, especially individuals from vulnerable communities have access to rapid testing services. SARS-Cov-2 Go Strips can perform nine tests per hour with results being provided one hour following testing. The tool can also be used to screen individuals in locations such as airports, borders, and rural locations. Currently, Health Canada approval is pending before the device can be widely used [8].  
 
The Alliance of Healthier Communities, in conjunction with their partners, released an open letter to the Deputy Premier and Minister of Health of Ontario, highlighting the need for a health equity lens regarding new COVID-19 testing technologies and data tools. The letter highlights the Province’s Pandemic Threat Response (PANTHR) health data platform, and how data from Indigenous and other marginalized communities needs to be appropriately and equitably collected. The inclusion of expertise from Indigenous and marginalized community members was emphasized, to ensure they have a voice in providing recommendations regarding data collection and policies to overcome barriers while developing the PANTHR platform [9].

Review of Evidence

Resource Type/Source of Evidence Last Updated
COVID-19 Priority Groups for Asymptomatic Testing Rapid Review
— Alberta Health Services
Rapid Review

This review notes there is an absence of evidence on when to swab asymptomatic individuals, and the frequency of asymptomatic testing. It remains unknown how infectious SARS-CoV-2 is in asymptomatic cases and the accuracy of a negative test in asymptomatic cases to determine who is truly negative for COVID-19. Single testing is likely of limited benefit and an optimal protocol for sampling and resample is not yet defined.

AHS suggests testing these groups of asymptomatic people in the following order: 1) residents and staff in supportive living in an outbreak; 2) staff in high risk work conditions and their household contacts related to an outbreak; 3) residents and staff in homeless shelters and similar agencies in the context of an outbreak; and 4) routine testing of asymptomatic individuals in other populations is not prioritized at this time.

Among Indigenous communities, the impact of asymptomatic transmission may be greater than the general population. The risk of transmission and poor COVID-19 related health outcomes is greater due to overall poorer health and limited access to health care. Other strategies have been implemented by First Nations communities including self-isolation if returning to the community, road access controls, curfews and community lock downs.

Last Updated: April 28, 2020
COVID-19 Clinical and Practical Guidance for Primary Care Providers
— CEP: Centre for Effective Practice
Rapid Review

CEP advises that asymptomatic patients who suspect they have been exposed to COVID-19 are advised to self-isolate and to seek emergency medical attention if they have trouble breathing, paid or pressure in chest, new confusion or blue lips or face. 

CEP further advises that if a practice does not have the capacity to perform tests on site, to refer patients to an assessment centre for testing.

Last Updated: August 5, 2020
COVID-19 Guidance: Primary Care Providers in a Community Setting
— Ontario Ministry of Health
Provincial Guidance

This guidance notes that primary care providers who are able to provide testing should ensure the patient is given a facemask, performs good hand hygiene and avoids all contact with workers and other patients as much as possible.

The guidance recommends that testing in the primary care office should only be performed if the primary care provider is able to: 1) follow the Droplet and Contact Precautions; 2) has the appropriate tools and knowledge of how to test; and 3) can ensure coordination of sample delivery to a laboratory providing COVID-19 testing. Otherwise, the primary care provider should be familiar with local testing locations and their specific protocols.

Last Updated: May 21, 2020
COVID-19 Provincial Testing Guidance Update
— Ontario Ministry of Health
Provincial Guidance

This guidance states that routine testing of asymptomatic individuals in the absence of an exposure to a confirmed case should NOT be performed, unless otherwise directed by public health. Asymptomatic contacts of a confirmed case should be considered for testing within 14 days from their last exposure. Contacts who had ongoing exposure to the case or contacts part of an outbreak investigation should be tested as soon as possible. Contacts only exposed to the case and who do not share acquisition exposures should be tested 5-7 days after their exposure (median incubation period).  

This guidance reports that any person from a remote, isolated, rural or Indigenous community with any symptom compatible with COVID-19 be tested as soon as possible. If a COVID-19 case is confirmed, testing of all contacts (asymptomatic included) should be considered in consultation with the local public health unit.  

Last Updated: August 5, 2020
COVID-19: Tips for Family Doctors
— Ontario College of Family Physicians
Professional Organization

This report suggests that primary care providers should test or refer a patient for testing if the patient has at least one symptom, who is asymptomatic but concerned that they have been exposed to COVID-19 or are at risk for exposure through their employment. Since testing capacities vary by location, providers should be aware of local circumstances when providing referrals or testing.

Last Updated: May 25, 2020
Symptoms and Testing
— Government of Alberta
Provincial Guidance

The government of Alberta states that any person can be tested, even if they do not have symptoms. These individuals can book an appointment online, call the central number, or be tested at local participating pharmacies, however symptomatic persons or persons with known exposure to COVID-19 must stay home and book a test with Alberta Health Services (AHS) online or call 811.  

Last Updated: May 29, 2020
Viral Testing
— BC Centre for Disease Control
Provincial Guidance

This guidance does not recommend routine testing for asymptomatic individuals, although indicates that there are private pay clinics that offer asymptomatic testing for reasons that fall outside of BC public health recommendations, such as for travel or employment.  

Last Updated: August 6, 2020
Ontario must bring a health equity lens to new COVID-19 test technologies and data tools
— Alliance for Healthier Communities
Organizational Scan Last Updated: April 12, 2020
U of G Technology Behind Mobile COVID-19 Test for Rural, Indigenous, Remote Areas
— University of Guelph
Organizational Scan Last Updated: April 22, 2020
Disclaimer: The summaries provided are distillations of reviews that have synthesized many individual studies. As such, summarized information may not always be applicable to every context. Each piece of evidence is hyperlinked to the original source.

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