Screening Approaches to Use in Non-Healthcare Settings to Identify People Who May Have COVID-19 and Need To Take Appropriate Action

Last Updated: May 15, 2020

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Purpose

This note provides a summary of scientific evidence and Canadian/international experiences on what
screening approaches can be used in non-healthcare settings (e.g., universities, stores, and office settings) to identify people who may have COVID-19 and need to take appropriate action.

*The full version of the Briefing Note including the Appendix can be accessed in the PDF file at the top of the page*

Key Findings

Analysis for Ontario

Supporting Evidence

This section below summarizes scientific evidence and lessons learned from international and Canadian experiences with screening for COVID-19 in non-healthcare settings. The findings are structured around two broad considerations:

  • What screening approach to use:
    • Symptoms, such as fever, cough, shortness of breath / difficulty breathing, headache, runny nose, sore throat, and sudden loss of taste (ageusia) and/or smell (anosmia);
    • Signs, specifically temperature; and
    • Recent tests, specifically a positive antibody test.
  • How to screen and support screening:
    • How to do the symptom screening, such as self screening prompted by (passive) signage, self screening using a questionnaire, and screening using a questionnaire administered by another person;
    • How to do temperature checking;
    • Digital approaches for screening or supporting screening (e.g., an app that prompts the user to complete a symptom check list, enter or provide consent to add their temperature, and provide consent to add a recent antibody text, and then an overall assessment about whether an individual should or should not take appropriate actions).

Scientific Evidence

  • Most of the findings from highly relevant evidence documents focus on symptom lists and temperature taking as screening approaches, as well as how to do symptom screening and take temperatures. Only one highly relevant primary study and one protocol for a systematic review focus on positive antibody tests. None of the highly relevant evidence documents focused on digital approaches for screening or supporting screening.
  • For symptoms, research points to a wide array of symptoms for COVID-19 that could be used in screening. Two of these documents provide particularly helpful insights:
    • A recent study published in the journal Nature that analyzed potential symptoms reported on a smartphone app from 2.6 million people. It found that loss of smell (anosmia), skipped meals, and fatigue are the three best predictors of COVID-19 and that, while cough is important, it is also common in those who do not have COVID-19. Moreover, among these three top predictors, anosmia was most strongly associated with COVID-19.
    • An up-to-date tracker that provides signs and symptoms for severe and non-severe COVID-19 provided by the Centre for Evidence-Based Medicine lists fever, cough, fatigue, dyspnea, sputum production, shortness of breath, myalgia, chill, dizziness, and headache as the top 10 symptoms.
    • Moreover, a recent but low-quality systematic review highlighted that a combination of the most frequent symptoms (which it highlights as anosmia, fever, fatigue, persistent cough, diarrhoea, abdominal pain, and loss of appetite) have a reasonable specificity for COVID-19 diagnosis. However, the review notes that the symptoms can have rapid cessation or late onset and some people will also be asymptomatic
  • For signs to use in screening, McMaster Health Forum’s rapid evidence profile about temperature taking as a screening tool (at borders or in general) highlights that most guidelines and the included rapid reviews do not recommend temperature screening based on the available evidence.
  • Only one highly relevant primary study and a protocol for a systematic review focus on positive antibody tests, with the study indicating that antibody-based rapid tests should not be relied on for screening in community settings.
  • In addition to findings from identified guidelines, one guideline from the American College Health Association emphasizes that U.S. universities should screen healthservice patients and staff regularly using symptom and temperature screening, and two guidelines for the food industry (one WHO technical guidance and one from WHO and Agriculture Organization of the United Nations) focus on the need for employees in the food sector to be aware of and recognize the symptoms of COVID-19.
  • Two single studies provide insight about additional approaches:
  • Given the emergent nature of these findings about the use of symptom lists and temperature tracking (and the lack of evidence about using a recent antibody test result), there’s a clear need for a ‘living review’ on this topic

International Scan

  • The most common forms of symptom screening is through a self-administered questionnaire that is typically completed online through government websites or mobile apps as a self-assessment tool. No lessons could be gleaned from the jurisdictional scan about the relative effectiveness of the different types of screening.
  • Australia, New Zealand, and the U.K. have all established self-assessments, which are then followed up with directives to self-isolate or seek a diagnostic test.
  • China has widely implemented temperature screening using hand-held thermometers and calibrated non-contact thermometers in a range of transit hubs (e.g., buses and train terminals), workplaces, and institutions (e.g., childcare facilities, colleges and universities, social housing, among others). In addition, China has established a QR code system based on an online assessment that serves as a regional traffic permit as well as permission to enter public spaces or take public transportation.
  • Sweden is relying on self-screening by signage.

Canadian Scan

  • Many Canadian provinces and territories, including British Columbia, Alberta, Saskatchewan, Ontario, New Brunswick, Nova Scotia, Newfoundland and Labrador, Yukon, Northwest Territories, and Nunavut, have established online self-assessments for COVID-19, however, the symptoms included in the assessments vary.
  • Alberta, Saskatchewan, and the Northwest Territories have implemented temperature screening for particular high-risk groups.
  • Quebec has established checkpoints to limit travel into and out of select regions whereby access is prohibited for those with symptoms of COVID-19 (as determined through administered questions).
  • As provinces and territories begin to resume normal activities, many of their plans for ‘re-opening’ rely on self-screening for symptoms through signage, questions administered by employers, and in select cases temperature screening (e.g., British Columbia universities and Saskatchewan personal care homes and personal services).

Ontario Scan

  • Ontario is using different tools to screen for COVID-19 symptoms:
    • The provincial government has created a self-assessment tool which lists varying COVID-19 symptoms.
    • The Ministry of Labour, Training and Skills Development has developed sector specific guidance and signage, which recommends that employees use the COVID-19 screening checklist and that any worker with symptoms related to cold, flu, or COVID-19 be sent home.
    • The Infrastructure Health and Safety Association has developed a COVID-19 screening checklist indicating that any workers or visitors accessing a work site should complete.

Methods

The COVID-19 Evidence Synthesis Network is comprised of groups specializing in evidence synthesis and knowledge translation. The group has committed to provide their expertise to provide high-quality, relevant, and timely synthesized research evidence about COVID-19 to inform decision makers as the pandemic continues. The following members of the Network provided evidence synthesis products that were used to develop this Evidence Synthesis Briefing Note: