Interim U.S. Guidance for Risk Assessment and Work Restrictions for Healthcare Personnel with Potential Exposure to SARS-CoV-2

Purpose

This interim guidance is intended to assist with assessment of risk and application of work restrictions for asymptomatic healthcare personnel (HCP) with potential exposure to patients, visitors, or other HCP with confirmed SARS-CoV-2 infection. Separate guidance is available for travel- and community-related exposures.  CDC has created frequently asked questions that can be used to inform risk assessment for patients and visitors exposed to SARS-CoV-2 in a healthcare setting. CDC has also released guidance about return to work criteria for HCP with COVID-19 and strategies for mitigating HCP staffing shortages.

Because of their often extensive and close contact with vulnerable individuals in healthcare settings, a conservative approach to HCP monitoring and applying work restrictions is recommended to prevent transmission from potentially contagious HCP to patients, other HCP, and visitors. Occupational health programs should have a low threshold for evaluating symptoms and testing HCP.

The feasibility and utility of performing contact tracing of exposed HCP and application of work restrictions depends upon the degree of community transmission of SARS-CoV-2 and the resources available for contact tracing. For areas with:

• Minimal to no community transmission of SARS-CoV-2, sufficient resources for contact tracing, and no staffing shortages, risk assessment of exposed HCP and application of work restrictions may be feasible and effective.
• Moderate to substantial community transmission of SARS-CoV-2, insufficient resources for contact tracing, or staffing shortages, risk assessment of exposed HCP and application of work restrictions may not be possible.

This guidance is based on currently available data about SARS-CoV-2. Recommendations regarding which HCP are restricted from work might not anticipate every potential scenario and will change if indicated by new information. Occupational health programs should use clinical judgement as well as the principles outlined in this guidance to assign risk and determine the need for work restrictions. This approach might be updated as more information becomes available and as response needs change in the United States.

Evolution of Currently Recommended HCP Assessment Guidance

CDC’s recommendations for the assessment of and response to HCP exposures to SARS-CoV-2-infected patients have evolved as the incidence of COVID-19 in the United States has changed. Before recognized widespread transmission in the United States, CDC recommended an aggressive approach to identifying exposed HCP and included recommendations for restricting some HCP from work who had higher risk exposures. As community spread of COVID-19 became apparent in many areas and as transmission from asymptomatic individuals was recognized, this approach became impractical and diverted resources away from other critical infection prevention and control functions. In response, CDC advised facilities to consider forgoing formal contact tracing and work restrictions for HCP with exposures in favor of universally applied symptom screening and source control strategies.

This updated guidance describes a process for resumption of contact tracing and application of work restrictions that can be considered in areas where spread in the community has decreased and when capacity exists to perform these activities without compromising other critical infection prevention and control functions. It has been simplified to focus on exposures that are believed to result in higher risk for HCP (e.g., prolonged exposure to patients with SARS-CoV-2 infection when HCP’s eyes, nose, or mouth are not covered). Other exposures not included as higher risk, including having body contact with the patient (e.g., rolling the patient) without gown or gloves, may impart some risk for transmission, particularly if hand hygiene is not performed and HCP then touch their eyes, nose, or mouth. The specific factors associated with these exposures should be evaluated on a case by case basis; interventions, including restriction from work, can be applied if the risk for transmission is deemed substantial.

The operational definition of “prolonged” refers to a cumulative time period of 15 or more minutes during a 24-hour period, which aligns with the time period used in the guidance for community exposures and contact tracing. Although this definition can be used to guide decisions about work restriction, appropriate follow-up, and contact tracing, the presence of extenuating factors (e.g., exposure in a confined space, performance of aerosol-generating procedure) could warrant more aggressive actions even if the cumulative duration is less than 15 minutes. For the purposes of this guidance, any duration should be considered prolonged if the exposure occurs during performance of an aerosol generating procedure.¹

Footnote 1

¹Data are insufficient to precisely define the duration of time that constitutes a prolonged exposure. Until more is known about transmission risks, it is reasonable to consider a cumulative exposure of 15 minutes or more during a 24-hour period as prolonged. This could refer to a single 15-minute exposure to one infected individual or several briefer exposures to one or more infected individuals adding up to at least 15 minutes during a 24-hour period. However, any duration should be considered prolonged if the exposure occurred during performance of an aerosol generating procedure.

Guidance for Asymptomatic HCP Who Were Exposed to Individuals with Confirmed SARS-CoV-2 Infection

Higher-risk exposures generally involve exposure of HCP’s eyes, nose, or mouth to material potentially containing SARS-CoV-2, particularly if these HCP were present in the room for an aerosol-generating procedure (See row 1 of the table).

Following a higher-risk exposure, work restriction of asymptomatic HCP who have recovered from SARS-CoV-2 infection in the prior 3 months and asymptomatic HCP who are fully vaccinated is not necessary.  Additional information about these scenarios, including possible exceptions, is available here and here.

HCP who have traveled should continue to follow CDC travel recommendations and requirements, including restriction from work, when recommended for any traveler.  HCP with community exposures should be restricted from work if they have a community exposure for which quarantine is recommended.

This guidance applies to HCP with potential exposure in a healthcare setting to patients, visitors, or other HCP with confirmed SARS-CoV-2 infection. Exposures can also occur after prolonged close contact with someone with suspected SARS-CoV-2 infection when testing has not yet occurred or if results are pending.  Work restrictions described in this guidance might be applied to HCP exposed to such an individual if test results for the individual are not expected to return within 48 to 72 hours. Therefore, a record of HCP exposed to individuals with suspected SARS-CoV-2 infection should be maintained. If test results will be delayed more than 72 hours or the patient is positive for SARS-CoV-2 infection, then the work restrictions described in this document should be applied.

HCP=healthcare personnel

1. Data are insufficient to precisely define the duration of time that constitutes a prolonged exposure. Until more is known about transmission risks, it is reasonable to consider an exposure of 15 minutes or more as prolonged. However, any duration should be considered prolonged if the exposure occurred during performance of an aerosol generating procedure.
2. Data are limited for the definition of close contact. For this guidance it is defined as: a) being within 6 feet of a person with confirmed SARS-CoV-2 infection or b) having unprotected direct contact with infectious secretions or excretions of the person with confirmed SARS-CoV-2 infection.
3. Determining the time period when the patient, visitor, or HCP with confirmed SARS-CoV-2 infection could have been infectious:
   1. For individuals with confirmed COVID-19 who developed symptoms, consider the exposure window to be 2 days before symptom onset through the time period when the individual meets criteria for discontinuation of Transmission-Based Precautions
   2. For individuals with confirmed SARS-CoV-2 infection who never developed symptoms, determining the infectious period can be challenging. In these situations, collecting information about when the asymptomatic individual with SARS-CoV-2 infection may have been exposed could help inform the period when they were infectious.
      1. In general, individuals with SARS-CoV-2 infection should be considered potentially infectious beginning 2 days after their exposure until they meet criteria for discontinuing Transmission-Based Precautions.
      2. If the date of exposure cannot be determined, although the infectious period could be longer, it is reasonable to use a starting point of 2 dayspdf icon prior to the positive test through the time period when the individual meets criteria for discontinuation of Transmission-Based Precautions for contact tracing.
4. While respirators confer a higher level of protection than facemasks and are recommended when caring for patients with SARS-CoV-2 infection, facemasks still confer some level of protection to HCP, which was factored into this risk assessment. Cloth face coverings are not considered PPE because their capability to protect HCP is unknown.
5. Work restriction of asymptomatic HCP who have recovered from SARS-CoV-2 infection in the prior 3 months and asymptomatic HCP who are fully vaccinated HCP is not necessary.  Additional information about these scenarios, including possible exceptions, is available here and here.
6. If staffing shortages occur, it might not be possible to exclude exposed HCP from work. For additional information and considerations refer to Strategies to Mitigating HCP Staffing Shortages.
7. Guidance addressing testing HCP, including asymptomatic HCP with known or suspected exposure to SARS-CoV-2, is available in the Interim Guidance on Testing Healthcare Personnel for SARS-CoV-2
8. For the purpose of this guidance, fever is defined as subjective fever (feeling feverish) or a measured temperature of 100.0^oF (37.8^oC) or higher. Note that fever may be intermittent or may not be present in some people, such as those who are elderly, immunocompromised, or taking certain fever-reducing medications (e.g., nonsteroidal anti-inflammatory drugs [NSAIDS]).