Health Alert
DISCONTINUATION OF TRANSMISSION-BASED PRECAUTIONS / CRITERIA FOR HEALTHCARE PERSONNEL TO RETURN TO WORK

Summary

The Centers for Disease Control and Prevention (CDC) as of July 17, 2020 has updated its guidance for the discontinuation of transmission-based precautions and disposition of patients with COVID-19 in health care settings. The CDC has also updated its criteria for health care personnel to return to work after suspected or confirmed cases of COVID-19. These are interim guidances and are subject to change.

Background

Recent changes for the discontinuation of transmission-based precautions and disposition of patients with COVID-19 in healthcare settings:

•  Except for rare situations, a test-based strategy is no longer recommended to determine when to discontinue Transmission-Based Precautions.
•  For patients with severe to critical illness or who are severely immunocompromised¹, the recommended duration for Transmission-Based Precautions was extended to 20 days after symptom onset (or, for asymptomatic severely immunocompromised¹ patients, 20 days after their initial positive SARS-CoV-2 diagnostic test).
•  Other symptom-based criteria were modified as follows:
  •  Changed from “at least 72 hours” to “at least 24 hours” have passed since last fever without the use of fever-reducing medications.
  •  Changed from “improvement in respiratory symptoms” to “improvement in symptoms” to address expanding list of symptoms associated with COVID-19.
  •  A summary of current evidence and rationale for these changes is described in a decision memo.

The decision to discontinue Transmission-Based Precautions for patients with confirmed SARS-CoV-2 infection should be made using a symptom-based strategy as described below. The time period used depends on the patient’s severity of illness and if they are severely immunocompromised¹. Meeting criteria for discontinuation of Transmission-Based Precautions is not a prerequisite for discharge from a healthcare facility.

A test-based strategy is no longer recommended (except as noted below) because, in the majority of cases, it results in prolonged isolation of patients who continue to shed detectable SARS-CoV-2 RNA but are no longer infectious.

Patients with mild to moderate illness who are not severely immunocompromised:

•  At least 10 days have passed since symptoms first appeared and
•  At least 24 hours have passed since last fever without the use of fever-reducing medications and
•  Symptoms (e.g., cough, shortness of breath) have improved

Note: For patients who are not severely immunocompromised and who were asymptomatic throughout their infection, Transmission-Based Precautions may be discontinued when at least 10 days have passed since the date of their first positive viral diagnostic test.

Patients with severe to critical illness or who are severely immunocompromised¹.

•  At least 20 days have passed since symptoms first appeared and
•  At least 24 hours have passed since last fever without the use of fever-reducing medications and
•  Symptoms (e.g., cough, shortness of breath) have improved

Note:  For severely immunocompromised patients who were asymptomatic throughout their infection, Transmission-Based Precautions may be discontinued when at least 20 days have passed since the date of their first positive viral diagnostic test.

As described in the Decision Memo, an estimated 95% of severely or critically ill patients, including some with severe immunocompromise, no longer had replication-competent virus 15 days after onset of symptoms; no patients had replication-competent virus more than 20 days after onset of symptoms.  Because of the risks for transmission and the number of patients in health care settings at risk for severe illness if infected with SARS-CoV-2, a conservative approach was taken when assigning duration of Transmission-Based Precautions. However, because the majority of severely or critically ill patients no longer appear to be infectious 10 to 15 days after onset of symptoms, facilities operating under crisis standards of care might choose to discontinue Transmission-Based Precautions at 10 to 15 days, instead of 20 days, in order to maximize resources for those earlier in their clinical course who are at highest risk for being a source of transmission.

 

Test-Based Strategy for Discontinuing Transmission-Based Precautions

In some instances, a test-based strategy could be considered for discontinuing Transmission-based Precautions earlier  than if the symptom-based strategy were used. However, as described in the Decision Memo, many individuals will have prolonged viral shedding, limiting the utility of this approach. A test-based strategy could also be considered for some patients (e.g., those who are severely immunocompromised¹) in consultation with local infectious diseases experts  if concerns exist for the patient being infectious for more than 20 days.

The criteria for the test-based strategy are:

Patients who are symptomatic:

•  Resolution of fever without the use of fever-reducing medications and
•  Symptoms (e.g., cough, shortness of breath) have improved, and
•  Results are negative from at least two consecutive respiratory specimens collected ≥24 hours apart (total of two negative specimens) tested using an FDA-authorized molecular viral assay to detect SARS-CoV-2 RNA. See Interim Guidelines for Collecting, Handling, and Testing Clinical Specimens for 2019 Novel Coronavirus (2019-nCoV).

Patients who are not symptomatic:

•  Results are negative from at least two consecutive respiratory specimens collected ≥24 hours apart (total of two negative specimens) tested using an FDA-authorized molecular viral assay to detect SARS-CoV-2 RNA. See Interim Guidelines for Collecting, Handling, and Testing Clinical Specimens for 2019 Novel Coronavirus (2019-nCoV).

 

Criteria for Return to Work for Health Care Personnel (HCP) with Suspected or Confirmed COVID-19:

•  Except for rare situations, a test-based strategy is no longer recommended to determine when to allow HCP to return to work.
•  For HCP with severe to critical illness or who are severely immunocompromised1, the recommended duration for work exclusion was extended to 20 days after symptom onset (or, for asymptomatic severely immunocompromised¹ HCP, 20 days after their initial positive SARS-CoV-2 diagnostic test).
•  Other symptom-based criteria were modified as follows:
  •  Changed from “at least 72 hours” to “at least 24 hours” have passed since last fever without the use of fever-reducing medications
  •  Changed from “improvement in respiratory symptoms” to “improvement in symptoms” to address expanding list of symptoms associated with COVID-19
•  A summary of current evidence and rationale for these changes is described in a Decision Memo.​

 

Occupational health programs and public health officials making decisions about return to work for health care personnel (HCP) with confirmed SARS-CoV-2 infection, or who have suspected SARS-CoV-2 infection (e.g., developed symptoms of COVID-19) but were never tested for SARS-CoV-2.

HCP with symptoms of COVID-19 should be prioritized for viral testing with approved nucleic acid or antigen detection assays.  When a clinician decides that testing a person for SARS CoV-2 is indicated, negative results from at least one FDA Emergency Use Authorized COVID-19 molecular viral assay for detection of SARS-CoV-2 RNA indicates that the person most likely does not have an active SARS-CoV-2 infection at the time the sample was collected. A second test for SARS-CoV-2 RNA may be performed at the discretion of the evaluating health care provider, particularly when a higher level of clinical suspicion for SARS-CoV-2 infection exists.  For HCP who were suspected of having COVID-19 and had it ruled out, either with at least one negative test or a clinical decision that COVID-19 is not suspected and testing is not indicated, then return to work decisions should be based on their other suspected or confirmed diagnoses.

Decisions about return to work for HCP with SARS-CoV-2 infection should be made in the context of local circumstances. In general, a symptom-based strategy should be used as described below. The time period used depends on the HCP’s severity of illness and if they are severely immunocompromised.¹ 

Additional Information

• Delaware EmployeeTesting Guidance For Businesses: https://coronavirus.delaware.gov/wp-content/uploads/sites/177/2020/07/Business-Testing-Guidance-7.13.20.pdf
• Delaware Essential Services Screening Recommendations for COVID-19 Pandemic: https://coronavirus.delaware.gov/wp-content/uploads/sites/177/2020/07/7.21-Essential-Services-Screening-Policy_final.pdf
• Delaware Phase 2 General and Industry-Specific Reopening Guidance: https://business.delaware.gov/coronavirus/delawares-recovery-phase-2-guidance/

 

References

•  ¹The studies used to inform this guidance did not clearly define “severely immunocompromised.” For the purposes of this guidance, CDC used the following definition:
  •  Some conditions, such as being on chemotherapy for cancer, untreated HIV infection with CD4 T lymphocyte count < 200, combined primary immunodeficiency disorder, and receipt of prednisone >20mg/day for more than 14 days, may cause a higher degree of immunocompromise and inform decisions regarding the duration of Transmission-Based Precautions.
  •  Other factors, such as advanced age, diabetes mellitus, or end-stage renal disease, may pose a much lower degree of immunocompromise and not clearly affect decisions about duration of Transmission-Based Precautions.
  •  Ultimately, the degree of immunocompromise for the patient is determined by the treating provider, and preventive actions are tailored to each individual and situation.

Resources

• Discontinuation of Transmission-Based Precautions and Disposition of Patients with COVID-19 in Healthcare Settings (Interim Guidance): https://www.cdc.gov/coronavirus/2019-ncov/hcp/disposition-hospitalized-patients.html
• Criteria for Return to Work for Healthcare Personnel with SARS-CoV-2 Infection (Interim Guidance): https://www.cdc.gov/coronavirus/2019-ncov/hcp/return-to-work.ht

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