04/07/2020
Background
Coronaviruses are a large family of viruses that are common in humans and in many different species of animals, including camels, cattle, cats, and bats. Rarely, animal coronaviruses can infect people and then spread between people such as with SARS-CoV, MERS-CoV, and now with SARS-CoV-2.
Published and early reports suggest spread from person-to-person most frequently happens during close exposure to a person infected with COVID-19. Person-to-person appears to occur similar to other respiratory viruses, mainly via respiratory droplets produced when an infected person coughs or sneezes. These droplets can land in the mouths, noses, or eyes of people who are nearby or possibly be inhaled into the lungs. Although not likely to be the predominant mode of transmission, it is not clear the extent to which touching a surface contaminated with the virus and then touching the mouth, nose, or eyes contributes to transmission.
Purpose
This interim guidance is intended to assist with assessment of risk, monitoring, and work restriction decisions for HCP with potential exposure to COVID-19. For guidance on assessment and management of exposure risk in non-healthcare settings, refer to the Interim US Guidance for Risk Assessment and Public Health Management of Persons with Potential Coronavirus Disease (COVID-19) Exposure in Travel-associated or Community Settings. The guidance for non-healthcare settings can also be used to identify the movement, public activity and travel restrictions that apply to the HCP included here.
Because of their often extensive and close contact with vulnerable individuals in healthcare settings, a conservative approach to HCP monitoring and restriction from work was taken to quickly identify early symptoms and prevent transmission from potentially contagious HCP to patients, HCP, and visitors. The signs and symptoms* described in this guidance are broader than those described when assessing exposures for individuals not working in healthcare. Healthcare facilities should have a low threshold for evaluating symptoms and testing symptomatic HCP, particularly those who fall into the high- and medium- risk categories described in this guidance.
This guidance is based on currently available data about COVID-19. Recommendations regarding which HCP are restricted from work may not anticipate every potential scenario and will change if indicated by new information.
Healthcare facilities, in consultation with public health authorities, should use clinical judgement as well as the principles outlined in this guidance to assign risk and determine need for work restrictions. CDC remains available for further consultation by calling the Emergency Operations Center at 770-488-7100. This cautious approach will be refined and updated as more information becomes available and as response needs change in the United States.
Other Resources
For guidance on risk assessment and public health management of persons not working in a U.S. healthcare setting refer to: Interim US Guidance for Risk Assessment and Public Health Management of Persons with Potential Coronavirus Disease (COVID-19) Exposure in Travel-associated or Community Settings.
For infection prevention and control guidance for healthcare settings caring for Persons with Known or Under Investigation (PUI) for Coronavirus Disease (COVID-19), refer to the Interim Infection Prevention and Control Recommendations for Patients with Known or Patients Under Investigation for Coronavirus Disease (COVID-19) in a Healthcare Setting.
I. Definitions Used in this Guidance
Self-monitoring means HCP should monitor themselves for fever by taking their temperature twice a day and remain alert for respiratory symptoms (e.g., cough, shortness of breath, sore throat)*. Anyone on self-monitoring should be provided a plan for whom to contact if they develop fever or respiratory symptoms during the self-monitoring period to determine whether medical evaluation is needed.
Active monitoring means that the state or local public health authority assumes responsibility for establishing regular communication with potentially exposed people to assess for the presence of fever or respiratory symptoms (e.g., cough, shortness of breath, sore throat)*. For HCP with high- or medium-risk exposures, CDC recommends this communication occurs at least once each day. The mode of communication can be determined by the state or local public health authority and may include telephone calls or any electronic or internet-based means of communication.
For HCP, active monitoring can be delegated by the health department to the HCP’s healthcare facility occupational health or infection control program, if both the health department and the facility are in agreement. Note, inter-jurisdictional coordination will be needed if HCP live in a different local health jurisdiction than where the healthcare facility is located.
Self-Monitoring with delegated supervision in a healthcare setting means HCP perform self-monitoring with oversight by their healthcare facility’s occupational health or infection control program in coordination with the health department of jurisdiction, if both the health department and the facility are in agreement. On days HCP are scheduled to work, healthcare facilities could consider measuring temperature and assessing symptoms prior to starting work. Alternatively, a facility may consider having HCP report temperature and absence of symptoms to occupational health prior to starting work. Modes of communication may include telephone calls or any electronic or internet-based means of communication.
Occupational health or infection control personnel should establish points of contact between the organization, the self-monitoring personnel, and the local or state health departments of authority in the location where self-monitoring personnel will be during the self-monitoring period. This communication should result in agreement on a plan for medical evaluation of personnel who develop fever or respiratory symptoms (e.g., cough, shortness of breath, sore throat)* during the self-monitoring period. The plan should include instructions for notifying occupational health and the local public health authority, and transportation arrangements to a designated hospital, if medically necessary, with advance notice if fever or respiratory symptoms occur. The supervising organization should remain in contact with HCP through the self-monitoring period to manage self-monitoring activities and provide timely and appropriate follow-up if symptoms occur in a HCP. Note, inter-jurisdictional coordination will be needed if HCP live in a different local health jurisdiction than where the healthcare facility is located.
Close contact for healthcare exposures is defined as follows: a) being within approximately 6 feet (2 meters), of a person with COVID-19 for a prolonged period of time (such as caring for or visiting the patient; or sitting within 6 feet of the patient in a healthcare waiting area or room); or b) having unprotected direct contact with infectious secretions or excretions of the patient (e.g., being coughed on, touching used tissues with a bare hand).
Data are limited for definitions of close contact. Factors for consideration include the duration of exposure (e.g., longer exposure time likely increases exposure risk), clinical symptoms of the patient (e.g., coughing likely increases exposure risk) and whether the patient was wearing a facemask (which can efficiently block respiratory secretions from contaminating others and the environment), PPE used by personnel, and whether aerosol-generating procedures were performed.
Data are insufficient to precisely define the duration of time that constitutes a prolonged exposure. However, until more is known about transmission risks, it is reasonable to consider an exposure greater than a few minutes as a prolonged exposure. Brief interactions are less likely to result in transmission; however, clinical symptoms of the patient and type of interaction (e.g., did the patient cough directly into the face of the HCP) remain important. Recommendations will be updated as more information becomes available.
Risk stratification can be made in consultation with public health authorities. Examples of brief interactions include: briefly entering the patient room without having direct contact with the patient or their secretions/excretions, brief conversation at a triage desk with a patient who was not wearing a facemask. See Table 1 for more detailed information.
Healthcare Personnel: For the purposes of this document HCP refers to all paid and unpaid persons serving in healthcare settings who have the potential for direct or indirect exposure to patients or infectious materials, including body substances; contaminated medical supplies, devices, and equipment; contaminated environmental surfaces; or contaminated air. For this document, HCP does not include clinical laboratory personnel.
II. Defining Exposure Risk Category
While body fluids other than respiratory secretions have not been clearly implicated in transmission of COVID-19, unprotected contact with other body fluids, including blood, stool, vomit, and urine, might put HCP at risk of COVID-19.
Table 1 describes possible scenarios that can be used to assist with risk assessment. These scenarios do not cover all potential exposure scenarios and should not replace an individual assessment of risk for the purpose of clinical decision making or individualized public health management. Any public health decisions that place restrictions on an individual’s or group’s movements or impose specific monitoring requirements should be based on an assessment of risk for the individual or group. Healthcare facilities, in consultation with public health authorities should use the concepts outlined in this guidance along with clinical judgement to assign risk and determine need for work restrictions.
For this guidance high-risk exposures refer to HCP who have had prolonged close contact with patients with COVID-19 who were not wearing a facemask while HCP nose and mouth were exposed to material potentially infectious with the virus causing COVID-19. Being present in the room for procedures that generate aerosols or during which respiratory secretions are likely to be poorly controlled (e.g., cardiopulmonary resuscitation, intubation, extubation, bronchoscopy, nebulizer therapy, sputum induction) on patients with COVID-19 when the healthcare providers’ eyes, nose, or mouth were not protected, is also considered high-risk.
Medium-risk exposures generally include HCP who had prolonged close contact with patients with COVID-19 who were wearing a facemask while HCP nose and mouth were exposed to material potentially infectious with the virus causing COVID-19. Some low-risk exposures are considered medium-risk depending on the type of care activity performed. For example, HCP who were wearing a gown, gloves, eye protection and a facemask (instead of a respirator) during an aerosol-generating procedure would be considered to have a medium-risk exposure. If an aerosol-generating procedure had not been performed, they would have been considered low-risk. See Table 1 for additional examples.
Low-risk exposures generally refer to brief interactions with patients with COVID-19 or prolonged close contact with patients who were wearing a facemask for source control while HCP were wearing a facemask or respirator. Use of eye protection, in addition to a facemask or respirator would further lower the risk of exposure.
Proper adherence to currently recommended infection control practices, including all recommended PPE, should protect HCP having prolonged close contact with patients infected with COVID-19. However, to account for any inconsistencies in use or adherence that could result in unrecognized exposures HCP should still perform self-monitoring with delegated supervision.
HCP with no direct patient contact and no entry into active patient management areas who adhere to routine safety precautions do not have a risk of exposure to COVID-19 (i.e., they have no identifiable risk.)
Currently, this guidance applies to HCP with potential exposure in a healthcare setting to patients with confirmed COVID-19. However, HCP exposures could involve a PUI who is awaiting testing. Implementation of monitoring and work restrictions described in this guidance could be applied to HCP exposed to a PUI if test results for the PUI are not expected to return within 48 to 72 hours. A record of HCP exposed to a PUI should be maintained and HCP should be encouraged to perform self-monitoring while awaiting test results. If the results will be delayed more than 72 hours or the patient is positive for COVID-19, then the monitoring and work restrictions described in this document should be followed.
Table 1: Epidemiologic Risk Classification1 for Asymptomatic Healthcare Personnel Following Exposure to Patients with Coronavirus Disease (COVID-19) or their Secretions/Excretions in a Healthcare Setting, and their Associated Monitoring and Work Restriction Recommendations
Both high- and medium-risk exposures place HCP at more than low-risk for developing infection; therefore, the recommendations for active monitoring and work restrictions are the same for these exposures. However, these risk categories were created to align with risk categories described in the Interim US Guidance for Risk Assessment and Public Health Management of Persons with Potential Coronavirus Disease (COVID-19) Exposure in Travel-associated or Community Settings, which outlines criteria for quarantine and travel restrictions specific to high-risk exposures. Use that Interim Guidance for information about the movement, public activity, and travel restrictions that apply to the HCP included here.
The highest risk exposure category that applies to each person should be used to guide monitoring and work restrictions.
Note: While respirators confer a higher level of protection than facemasks, and are recommended when caring for patients with COVID-19, facemasks still confer some level of protection to HCP, which was factored into our assessment of risk.
