Document One
Ministry of Health position statement
on pre-consultation testing of
unvaccinated individuals in healthcare
settings
19 NOVEMBER 2021
The Ministry of Health position statement is in three parts:
•
the principles on which the statement is based
•
a discussion of the risks of transmission occurring from unvaccinated individuals seeking healthcare
•
actions which can be taken and the rationale for these actions to mitigate those risks.
Purpose
The purpose of this statement is to address concerns from clinicians and providers regarding in person
consultations with unvaccinated patients, and in particular the issue of requiring a negative test for COVID-19
prior to a non-urgent consultation.
Principles of this statement
Health services need to provide services in accordance with the Health and Disability Commissioner (Code of
Health and Disability Services Consumers' Rights) Regulations 1996. Appropriate justification is needed if a
health service is proposing to refuse access to services or to not comply with rights under the Code.
The onus is on the provider to make that justification. Justification should be made based on a risk
under the Official Information Act 1982
assessment that considers both the provider and the patient, the other patients they see, the risk of attending
a premise where there are unvaccinated persons present, and the requirements outlined in Clause 3 of the
Code.
The Ministry is of the view that in in most cases, with vaccinated staff and other precautions in place, that the
risks are unlikely to be high enough to provide sufficient justification to not fol ow the Code.
Released
Consideration of a risk assessment should include the fol owing:
1. Access to health care is a fundamental right.
a. An individual seeking healthcare cannot be refused care because of their beliefs. In this case
an individual who believes that a vaccine is harmful cannot be refused care for that belief.
b. A practitioner’s personal beliefs should not influence that practitioner’s duty of care for any
individual. In this case a practitioner must not allow their opinion of an individual who refuses
to be vaccinated to influence the care that they offer that individual.
1
Document One
2. Health care workers have a right to be safe in their workplace in accordance with the Health and
Safety at Work Act 2015 (the Act).
a. All workers have a right to work within a safe environment. Healthcare settings are associated
with some intrinsic risks, for example the risk of contracting an infectious disease from a
member of the public seeking healthcare. Usually these risks are recognised, understood and
a set of recommended actions are in place to reduce this risk to an acceptable level. This
residual risk is not a zero risk.
b. The actions taken to mitigate any risks must be reasonable and proportionate to that risk.
c. Any actions taken to mitigate risk must be based, wherever possible on evidence.
3. Employers have a duty to ensure that their staff are able to work in a safe environment, in accordance
with the Act.
4. Employees have a responsibility to fol ow reasonable guidelines set by their employers to ensure
safety.
The introduction of vaccine certificates has provided some validity to the concept that unvaccinated
individuals should be managed differently to individuals who are vaccinated because of their public health
risk. It is important to note that vaccine certificates are dependent upon the prevalence of disease in the
community. The legislation wil be very clear that access to essential services, including healthcare services,
cannot be restricted based on vaccination status.
Summary
•
Individuals cannot be refused access to health care.
•
Restrictions to access to health care must be informed by a risk assessment, and the onus is upon the
provider to justify that the risks are sufficiently high to support those restrictions.
•
Total vaccination coverage and the prevalence of COVID-19 in the community are important factors in
the efficacy of any mitigations aimed to prevent transmission.
•
Vaccination status is one of many risk factors for infection and transmission. There is currently no
evidence that the application of an alternative pathway based solely on vaccination status, or the routine
incorporation of unvaccinated asymptomatic individuals into a high-risk pathway is justified.
•
Routine testing of asymptomatic individuals prior to consultation would identify some infectious
individuals and decrease the risk of transmission. However, the feasibility, cost and effectiveness of this
strategy has not been determined and must be assessed prior to diversion of scare testing resources
from urgent work.
under the Official Information Act 1982
•
Pathways exist for decreasing the risk of transmission from any asymptomatic individual. These pathways
must be utilised effectively prior to the introduction of additional interventions.
•
The management of unvaccinated individuals through an alternative pathway is highly likely to negatively
impact access to care which must be balanced by a demonstrable benefit.
•
Children form a large group of individuals who are unable to vaccinated and as such are likely to form a
majority the group managed through an alternative pathway. Specific consideration must be given to
Released
how this would impact on children’s clinical care.
The risks of transmission from unvaccinated individuals
There are concerns that the perceived increased risk from in person contact with unvaccinated patients
compared to vaccinated patients is sufficient to warrant actions to manage that risk.
There are two factors to consider:
•
the difference in risk between the two groups, and if this is clinically significant
•
the absolute magnitude of the risk.
2
Document One
The risk of infection is determined by a wide range of factors in addition to vaccination, including:
•
behavioural factors, such as spending time in at risk environments
•
medical factors, such as immunocompromise due to medical conditions, therapy, or age.
The absolute risk of transmission wil be highly dependent upon the prevalence of disease in the community.
When the rate of community spread is zero or very low, the risk of transmission from any consultation
will be very low, unless a person is known to be at higher risk because they are symptomatic or a close
contact of a confirmed case.
In addition, in this situation the difference in the risk of transmission between vaccinated and unvaccinated
people wil be negligible. When the prevalence of disease in the community is high, the risk of transmission
from any individual is not negligible and is likely to warrant application of mitigations for all consultations.
1982
When there is high COVID-19 vaccine coverage (i.e., above 80 percent of eligible people are fully
vaccinated), transmission is more likely to occur from a vaccinated than an unvaccinated individual.1
Act
Developing a separate pathway for vaccinated and unvaccinated individuals wil not prevent the risk of
inadvertently seeing an infectious person (regardless of vaccination status) without the health care worker
being aware, using appropriate personal protective equipment and/or being in an appropriate physical
environment.
Those under 12 years of age are not yet eligible for vaccination. In the event of different pathways being
Information
implemented to manage unvaccinated individuals, a decision wil need to be made on whether children wil
be included in this pathway, considering that the risk of transmission to adults from children appears to be
less than the risk of transmission between adults.
Official
Actions to mitigate the risk of transmission
the
Current mitigations
Health services have instituted a wide range of interventions aimed at reducing the risk of transmission. These
include but are not limited to: under
•
the identification of symptomatic patients
•
virtual consultations
•
routine use of medical masks
•
management of appointment times and spacing in waiting rooms
•
ventilation and air cleaning within indoor spaces.
Released
Testing prior to health care
Testing as a screening tool vs targeted testing
Testing of individuals for COVID-19 can provide a high degree of reassurance that an individual does not have
active infection.
Asymptomatic infection is the issue, not the vaccination status of the patient.
1 As our vaccination numbers increase, we will see fewer cases but more of those cases will be in fully
vaccinated people, meaning it is more likely transmission will occur from a vaccinated individual than an unvaccinated individual.
3
Document One
Testing may also provide additional benefit to the individual and their contacts through earlier diagnosis of
disease. Testing for this purpose prior to a consultation would be classified as opportunistic screening which
is, in general, a poor utilisation of resources and an ineffective method of identifying of cases.
Testing can be carried out for all individuals as a screening programme, or on groups or specific individuals
considered to be at higher risk. As symptomatic individuals or those who are a contact of a positive case are
considered high risk whether vaccinated or not, testing as a screening tool wil only apply to asymptomatic
low risk individuals. As indicated above, there is not sufficient evidence to classify all unvaccinated individuals
as being in a group of that should be tested prior to a consultation.
There may be situations in which a combination of risk factors, such as known immunosuppression, may result
in a medical justification for the testing of asymptomatic patients. Any such policy needs to apply to all
patients irrespective of vaccination status as asymptomatic infection is the issue, not the vaccination status of
the patient.
1982
Type of test
Act
There are a range of testing modalities which can be used to diagnose active cases of infection that are
situation dependent:
•
RT-PCR tests are very sensitive, identifying almost all cases with infection, however not al individuals
identified wil be infectious and the sample must be processed by a laboratory, meaning it can take up to
48 hours for a result to be received.
•
Point-of care RT-PCR tests provide a means to undertake testing immediately prior to a consultation,
however a result can take an hour to be received which wil have significant practical impacts on
Information
providing a service.
•
Rapid Antigen Tests are less sensitive than RT-PCR but have been shown to accurately identify most
infectious individuals.
Official
Testing capacity
It is important that testing capacity is used appro
the priately and efficiently. Priority must be given to
symptomatic individuals as these tests are required urgently and have a substantial impact on the
management of the individual and any related outbreak.
under
A screening policy based on RT-PCR is unfeasible due to capacity and the potential to cause delays in
treatment. The introduction of a screening policy using Rapid Antigen Testing is feasible.
Equity
Any approach that mandates unvaccinated patients are swabbed for COVID-19 prior to planned care risks
worsening access to health car
Released e for those already suffering health inequities:
•
Access to testing is not available 24/7 – shift workers or those working multiple jobs wil struggle to
access a testing service (unless Rapid Antigen Testing can be provided on a sufficient scale at the time of
a planned appointment)
•
Those without transport may not be able to obtain a test result in time to allow for their appointment to
proceed
•
If the testing system is overwhelmed by such testing, symptomatic test results may be delayed, further
risking spread and preventable exposure to COVID-19. The current outbreak is particularly affecting
disadvantaged areas of metro Auckland therefore any un-resourced expansion of testing may worsen
inequity caused by increased spread of COVID-19.
4
Document One
Protection of the health workforce
A range of guidance documents have been developed to minimise the risk of transmission of infection to the
healthcare workforce.2 The measures in these guidance documents have been largely effective. The rate of
infection within health care settings has been very low, despite being one of the most at risk environments.
It is recognised that the impact of health care workers being unavailable because of acute il ness can have a
significant impact in areas where healthcare resources are restricted.
Plans to manage workforce shortages are required irrespective of the management for unvaccinated
individuals, as healthcare provides are at risk of infection outside of their workplaces.
1982
Act
Information
Official
the
under
Released
2 https://www.health.govt.nz/our-work/diseases-and-conditions/covid-19-novel-coronavirus/covid-19-information-specific-
audiences/covid-19-personal-protective-equipment-central-supply/personal-protective-equipment-use-health-and-disability-care-
settings
5
