Many technicians at Labcorp and Quest Diagnostics, two of the largest commercial labs in the US, have been refusing to draw blood from patients who might have monkeypox, CNN has learned.
Labcorp and Quest don't dispute that in many cases, their phlebotomists are not taking blood from possible monkeypox patients. What remains unclear, after company statements and follow-ups from CNN, is whether the phlebotomists are refusing on their own to take blood or if it is the company policy that prevents them. The two testing giants say they're reviewing their safety policies and procedures for their employees.
Infectious disease experts who treat monkeypox patients say that the refusals are based on stigma and slow efforts to identify and isolate patients with monkeypox at a time when the nation's health officials are coming under criticism for struggling to get the outbreak under control. As of Tuesday, there were 6,326 reported cases of monkeypox, an 81% increase from a week before, according to data from the US Centers for Disease Control and Prevention.
"This is absolutely inexcusable. It's a grave dereliction of duty," said David Harvey, executive director of the National Coalition of STD Directors, which represents 1,600 sexual health clinics in the US, some of which have phlebotomists from commercial labs including Labcorp and Quest in their offices. The commercial labs employ tens of thousands of phlebotomists -- health care professionals who draw blood -- in various types of clinics and doctors' offices across the country, as well as in their own patient service centers.
Although monkeypox is diagnosed by swabbing lesions, blood tests are necessary to differentiate the virus from other types of infections, infectious disease experts say. Harvey said doctors at sexual health clinics have had to find workarounds when phlebotomists have refused to take blood from suspected monkeypox patients.
"We can't afford a delay in diagnostic testing because commercial labs aren't doing the right thing," he said.
Harvey added that it feels like the refusals are "a modern-day example of discrimination" -- a viewpoint shared by others.
"This reminds me of the olden days when people didn't want to care for HIV patients," said Arthur Caplan, a bioethicist at New York University.
Monkeypox cases in the US have been mainly among men who have sex with men, and when a technician does not draw blood, it "perpetuates more stigma and fear and anxiety" for a virus that's already stigmatized, added Dr. Peter Chin-Hong, a member of the California Department of Public Health's Monkeypox Virus Scientific Advisory Committee who is caring for monkeypox patients.
Chin-Hong, an infectious disease specialist at UCSF Health, said men are avoiding getting tested for the virus for fear of being stigmatized.
"The fact that phlebotomists are afraid of taking specimens makes it even more unappealing for someone to ask for a monkeypox test," he said. "So this is going to make it even worse."
Phlebotomists take blood from people with many kinds of infections on a regular basis, and monkeypox is not new: The US has seen cases before, including two last year and dozens in 2003. The amount of pox virus in blood is "low," according to the CDC, which instructs health care workers to use standard precautions to prevent transmission when handling specimens from suspected or confirmed monkeypox patients.
'Some of our phlebotomists have been scared'
Blood tests are necessary not only to differentiate between monkeypox and other infections but to test for other sexually transmitted infections, such as syphilis, since people with monkeypox sometimes have STIs.
If suspected monkeypox patients don't have their blood drawn, "the standard of care is not being followed," said Harvey, the director of the sexual health clinics association.
In an email to CNN on Monday morning, a Quest spokeswoman wrote that "we follow CDC guidelines that state that patients with confirmed or suspected monkeypox infection should be isolated. Once an individual is out of isolation, we will provide service for them."
The spokeswoman, Kim Gorode, sent a link to these CDC guidelines to back up Quest's policy. However, those guidelines don't say that health care services should be delayed until after an isolation period. In fact, the CDC says its isolation recommendations "do not apply in healthcare settings."
CDC spokeswoman Kristen Nordlund said that "CDC's monkeypox isolation guidance specifically states that people should remain isolated, except to get medical care. Obtaining a sample for testing is medical care that could lead to diagnosis or treatment if warranted."
Since the first US case was identified in May, the CDC has given monkeypox infection control guidelines to health-care providers. That page offers detailed instructions on how to treat these patients safely and notes that transmission in health-care settings has been "rarely" reported.
Later Monday, Gorode wrote in an email to CNN that "we are now evaluating our guidance in light of updates posted on the CDC site today." She did not specify what those updates were. CDC spokesman Jason McDonald said the only update Monday was that the sentence about the isolation guidelines not applying to health-care settings was moved higher on the page.
Gorode added that "we want to ensure every patient has access to the testing they need while also fostering a safe environment for our employees and all of our patients."
Labcorp executive Dr. Brian Caveney told CNN last week that "up until now, we have typically not been doing" blood draws from suspected monkeypox patients but that the company was reviewing its policies, and this was "likely to change."
Caveney, the company's president of diagnostics, said Labcorp was "trying to make sure that our work force is safe but also to ensure that we take care of our customers while we were figuring out the appropriate occupational safety regulations and policies."
"(Monkeypox) is new -- nobody knew what it was -- some nurses and doctors are scared of it. Some of our phlebotomists have been scared -- appropriately -- of it," he said.
But the head of a phlebotomists' group said they shouldn't be scared, as long as they take standard precautions.
Diane Crawford, CEO of the National Phlebotomy Association, said she is "disappointed" that labs are allowing phlebotomists to refuse to draw blood from suspected or confirmed monkeypox patients.
"It is a problem. It's just like a doctor refusing to take care of a patient," she said.
Calls for CDC to do more education
Caplan, the bioethicist, questioned why Quest and Labcorp are working on guidelines now for their phlebotomists when the first monkeypox case appeared in the US more than two months ago.
"This should have been done already," he said.
Caplan said the CDC needed to do more to educate phlebotomists beyond the pages on its website.
"They need an educational rollout (for phlebotomists) and not just issue guidance. That's very, very important," he said.
He said education about standard safety precautions should help phlebotomists feel comfortable taking specimens from these patients.
"I don't want you sicking out or leaving or taking a new job, which would harm the availability of these services," he said. "And we have the obligation to make their work as safe and risk-free as we can, and that goes beyond just information on websites."
But Caplan added that at the end of the day, phlebotomists do need to take blood from people who have, or might have, monkeypox.
"We want you to do it, it's important to help control the outbreaks, and this is the kind of risk factor you signed up for," he said.
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