Discontinuation of Transmission-Based Precautions and Disposition of Patients with COVID-19 in Healthcare Settings (Interim Guidance)
CDC guidance for COVID-19 may be adapted by state and local health departments to respond to rapidly changing local circumstances.
Who this is for: Healthcare personnel managing patients with coronavirus disease 2019 (COVID-19).
What this is for: To help prevent the spread of the virus that causes COVID-19 in healthcare facilities.
How to use: Reference to guide healthcare regarding discontinuing transmission-based precautions and discharging hospitalized patients with COVID-19.
Guidance as of March 23, 2020
- Clarified that patients with COVID-19 can be discharged from a healthcare facility whenever clinically indicated. Meeting criteria for discontinuation of Transmission-Based Precautions is not a prerequisite for discharge.
- Updated guidance for a test-based strategy: The recommendation to collect both NP and OP swabs at each sampling has been changed so that only one swab, preferably an NP, is necessary at each sampling.
- Added guidance for:
- Discontinuation of transmission-based precautions without testing.
- Discontinuation of empiric transmission-based precautions for patients suspected of having COVID-19.
- When using a testing-based strategy for discontinuation of transmission-based precautions is preferred.
This guidance is based on available information about COVID-19 and subject to change as additional information becomes available.
For discontinuation of home isolation for COVID-19, see (Interim Guidance for Discontinuation of In-Home Isolation for Patients with COVID-19).
For return-to-work criteria for healthcare personnel with COVID-19, see (Interim Guidance for Discontinuation of In-Home Isolation for Patients with COVID-19).
The decision to discontinue Transmission-Based Precautions should be made using a test-based strategy or a non-test-based strategy (i.e., time-since-illness-onset and time-since-recovery strategy). Meeting criteria for discontinuation of Transmission-Based Precautions is not a prerequisite for discharge.
- Test-based strategy.
- Resolution of fever without the use of fever-reducing medications and
- Improvement in respiratory symptoms (e.g., cough, shortness of breath), and
- Negative results of an FDA Emergency Use Authorized COVID-19 molecular assay for detection of SARS-CoV-2 RNA from at least two consecutive nasopharyngeal swab specimens collected ≥24 hours apart (total of two negative specimens) . See Interim Guidelines for Collecting, Handling, and Testing Clinical Specimens for 2019 Novel Coronavirus (2019-nCoV).
- Non-test-based strategy.
- At least 3 days (72 hours) have passed since recovery defined as resolution of fever without the use of fever-reducing medications and improvement in respiratory symptoms (e.g., cough, shortness of breath); and,
- At least 7 days have passed since symptoms first appeared
When a Testing-Based Strategy is Preferred
Hospitalized patients may have longer periods of SARS-CoV-2 RNA detection compared to patients with mild or moderate disease. Severely immunocompromised patients (e.g., medical treatment with immunosuppressive drugs, bone marrow or solid organ transplant recipients, inherited immunodeficiency, poorly controlled HIV) may also have longer periods of SARS-CoV-2 RNA detection and prolonged shedding of infectious recovery. These groups may be contagious for longer than others. In addition, placing a patient in a setting where they will have close contact with individuals at risk for severe disease warrants a conservative approach.
Hence, a test-based strategy is preferred for discontinuation of transmission-based precautions for patients who are
- Hospitalized or
- Severely immunocompromised or
- Being transferred to a long-term care or assisted living facility
If testing is not readily available, facilities should use the non-test-based strategy for discontinuation of Transmission-Based Precautions or extend the period of isolation beyond the non-test-based-strategy duration, on a case by case basis in consultation with local and state public health authorities.
The decision to discontinue empiric Transmission-Based Precautions by excluding the diagnosis of COVID-19 for a suspected COVID-19 patient can be made based upon having negative results from at least one FDA Emergency Use Authorized COVID-19 molecular assay for detection of SARS-CoV-2.
- If a higher level of clinical suspicion for COVID-19 exists, consider maintaining Transmission-Based Precautions and performing a second test for SARS-CoV-2.
- If a patient suspected of having COVID-19 is never tested, the decision to discontinue Transmission-Based Precautions can be made based upon using the non-test-based strategy described above.
Ultimately, clinical judgement and suspicion of SARS-CoV-2 infection determines whether to continue or discontinue empiric Transmission-Based Precautions.
Patients can be discharged from the healthcare facility whenever clinically indicated.
If discharged to home:
- Isolation should be maintained at home if the patient returns home before discontinuation of Transmission-Based Precautions. The decision to send the patient home should be made in consultation with the patient’s clinical care team and local or state public health departments. It should include considerations of the home’s suitability for and patient’s ability to adhere to home isolation recommendations. Guidance on implementing home care of persons who do not require hospitalization and the discontinuation of home isolation for persons with COVID-19 is available.
If discharged to a long-term care or assisted living facility, AND
- Transmission-Based Precautions are still required, they should go to a facility with an ability to adhere to infection prevention and control recommendations for the care of COVID-19 patients. Preferably, the patient would be placed in a location designated to care for COVID-19 residents.
- Transmission-Based Precautions have been discontinued, but the patient has persistent symptoms from COVID-19 (e.g., persistent cough), they should be placed in a single room, be restricted to their room, and wear a facemask during care activities until all symptoms are completely resolved or until 14 days after illness onset, whichever is longer.
- Transmission-Based Precautions have been discontinued and the patient’s symptoms have resolved, they do not require further restrictions, based upon their history of COVID-19.
- Al-Abdely HM, Midgley CM, Alkhamis AM, et al. Middle East respiratory syndrome coronavirus infection dynamics and antibody responses among clinically diverse patients, Saudi Arabia. Emerg Infect Dis. 2019 Apr;25(4):753–66.
- Al-Abdely HM, Midgley CM, Alkhamis AM, et al. Infectious MERS-CoV isolated from a mildly ill patient, Saudi Arabia. Open Forum Infect Dis. 2018 May 15;5(6):ofy111.
- Chan JF, Yuan S, Kok KH, et al. A familial cluster of pneumonia associated with the 2019 novel coronavirus indicating person-to-person transmission: a study of a family cluster. Lancet. 2020 Jan 24; 395(10223);514–23. doi: 10.1016/S0140-6736(20)30154-9.
- Chan KH, Poon LL, Cheng VC, et al. Detection of SARS coronavirus in patients with suspected SARS. Emerg Infect Dis. 2004 Feb;10(2):294–9.
- Cheng PK, Wong DA, Tong LK, et al. Viral shedding patterns of coronavirus in patients with probable severe acute respiratory syndrome. Lancet. 2004 May 22;363(9422):1699–700.
- Corman VM, Albarrak AM, Omrani AS, et al. Viral shedding and antibody response in 37 patients with Middle East respiratory syndrome coronavirus infection. Clin Infect Dis. 2016 Feb 15;62(4):477–83.
- Holshue ML, DeBolt C, Lindquist S, et al. First case of 2019 novel coronavirus in the United States. N Engl J Med. 2020 Jan 31. doi: 10.1056/NEJMoa2001191. [Epub ahead of print]
- Huang C, Wang Y, Li X, et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet. 2020 Jan 24;395(10223):497–506. doi: 10.1016/S0140-6736(20)30183-5
- Hung IF, Cheng VC, Wu AK, et al. Viral loads in clinical specimens and SARS manifestations. Emerg Infect Dis. 2004 Sep;10(9):1550–7.
- Liu W, Tang F, Fontanet A, et al. Long-term SARS coronavirus excretion from patient cohort, China. Emerg Infect Dis. 2004 Oct;10(10):1841–3.
- Memish ZA, Assiri AM, Al-Tawfiq JA. Middle East respiratory syndrome coronavirus (MERS-CoV) viral shedding in the respiratory tract: an observational analysis with infection control implications. Int J Infect Dis. 2014 Dec;29:307–8.
- Zhu N, Zhang D, Wang W, et al. A novel coronavirus from patients with pneumonia in China, 2019. N Engl J Med. 2020 Jan 24. doi: 10.1056/NEJMoa2001017 [Epub ahead of print]