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.

Summary of Changes to the Guidance

Below are changes to the guidance as of April 30, 2020:

  • Changed the name of the ‘non-test-based strategy’ to the ‘symptom-based strategy’ for those with symptoms and the ‘time-based strategy’ for those without symptoms, and updated these to extend the duration of Transmission-Based Precautions to at least 10 days since symptoms first appeared. This update was made based on evidence suggesting a longer duration of viral shedding and will be revised as additional evidence becomes available. This time period will capture a greater proportion of contagious patients; however, it will not capture everyone.
  • Added criteria for discontinuing Transmission-Based Precautions for patients who have laboratory-confirmed COVID-19, but have not had any symptoms of COVID-19.
  • Removed specifying use of nasopharyngeal swab collection for the Test-Based Strategy and linked to the Interim Guidelines for Collecting, Handling, and Testing Clinical Specimens for 2019 Novel Coronavirus (2019-nCoV), so that the most current specimen collection strategies are recommended.
Discontinuation of Transmission-Based Precautions for patients with COVID-19:

The decision to discontinue Transmission-Based Precautions for patients with confirmed COVID-19  should be made using either a test-based strategy or a symptom-based (i.e., time-since-illness-onset and time-since-recovery strategy) or time-based strategy as described below. Meeting criteria for discontinuation of Transmission-Based Precautions is not a prerequisite for discharge.

Symptomatic patients with COVID-19 should remain in Transmission-Based Precautions until either:

  • Symptom-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 10 days have passed since symptoms first appeared
  • 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 respiratory specimens collected ≥24 hours apart (total of two negative specimens) [1]. See Interim Guidelines for Collecting, Handling, and Testing Clinical Specimens for 2019 Novel Coronavirus (2019-nCoV). Of note, there have been reports of prolonged detection of RNA without direct correlation to viral culture.

Patients with laboratory-confirmed COVID-19 who have not had any symptoms should remain in Transmission-Based Precautions until either:

  • Time-based strategy
    • 10 days have passed since the date of their first positive COVID-19 diagnostic test, assuming they have not subsequently developed symptoms since their positive test. Note, because symptoms cannot be used to gauge where these individuals are in the course of their illness, it is possible that the duration of viral shedding could be longer or shorter than 10 days after their first positive test.
  • Test-based strategy
    • Negative results of an FDA Emergency Use Authorized COVID-19 molecular assay for detection of SARS-CoV-2 RNA from at least two consecutive respiratory specimens collected ≥24 hours apart (total of two negative specimens). Note, because of the absence of symptoms, it is not possible to gauge where these individuals are in the course of their illness. There have been reports of prolonged detection of RNA without direct correlation to viral culture.

Note that detecting viral RNA via PCR does not necessarily mean that infectious virus is present.

Consider consulting with local infectious disease experts when making decisions about discontinuing Transmission-Based Precautions for patients who might remain infectious longer than 10 days (e.g., severely immunocompromised).

Discontinuation of empiric Transmission-Based Precautions for patients suspected of having COVID-19:

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 RNA.

  • 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 RNA.
  • 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 symptom-based strategy described above.

Ultimately, clinical judgement and suspicion of SARS-CoV-2 infection determine whether to continue or discontinue empiric Transmission-Based Precautions.

Disposition of Patients with COVID-19:

Patients can be discharged from the healthcare facility whenever clinically indicated.

If discharged to home:

If discharged to a nursing home or other long-term care facility (e.g., 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 to the extent possible, and wear a facemask (if tolerated) during care activities until all symptoms are completely resolved or at baseline.
  • 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.