Clinical Questions about COVID-19: Questions and Answers

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COVID-19 Risk

Among adults, the risk for severe illness from COVID-19 increases with age, with older adults at highest risk. Severe illness means that the person with COVID-19 may require hospitalization, intensive care, or a ventilator to help them breathe, or they may even die. People of any age with certain underlying medical conditions are at increased risk for severe illness from COVID-19. Based on what we know at this time, pregnant people might be at an increased risk for severe illness from COVID-19compared to non-pregnant people. Additionally, there may be an increased risk of adverse pregnancy outcomes, such as preterm birth, among pregnant people with COVID-19.

Please review CDC’s guidance on Public Health Recommendations for Community-Related Exposure. Some HCP may choose to implement extra measures when arriving home from providing healthcare, such as removing any clothing worn during delivery of healthcare, taking off shoes, washing clothing, and immediately showering. However, these are optional personal practices because there is insufficient evidence on whether they are effective. Person-to-person transmission is currently thought to be the main way the virus spreads, but we are still learning more about how this virus spreads.

Currently, those at greatest risk of infection are persons who have had prolonged, unprotected close contact with a patient with symptomatic, confirmed COVID-19 and those who live in or have recently been to areas with sustained transmission. For more information, see Risk Assessment.

COVID-19 is a new disease. and CDC is learning more about it and how it affects people every day. Among adults, the risk for severe illness from COVID-19 increases with age, with older adults at highest risk. Severe illness means that the person with COVID-19 may require hospitalization, intensive care, or a ventilator to help them breathe, or they may even die. People of any age with certain underlying medical conditions are at increased risk for severe illness from COVID-19.

Based on what we know at this time, pregnant people might be at an increased risk for severe illness from COVID-19 compared to non-pregnant people. Additionally, there may be an increased risk of adverse pregnancy outcomes, such as preterm birth, among pregnant people with COVID-19.

See also Interim Clinical Guidance for Management of Patients with Confirmed Coronavirus Disease 2019 (COVID-19) and Information for Healthcare Professionals: COVID-19 and Underlying Conditions.

Patients with Asthma
If I have patients with asthma, do I need to make any changes to their daily asthma preventive management regimens to reduce their risk of getting sick with COVID-19?

People with moderate to severe asthma might be at higher risk of getting very sick from COVID-19.

Based on what we currently know about COVID-19, the selection of therapeutic options through guideline-recommended treatment of asthma has not been affected.  are available. Continuation of inhaled corticosteroids is particularly important for patients already using these medications because there is no evidence of increased risk of COVID-19 morbidity with use of inhaled corticosteroids and an abundance of data showing reduced risk of asthma exacerbation with maintenance of asthma controller therapy.

Patients with asthma but without symptoms or a diagnosis of COVID-19 should continue any required nebulizer treatments.

Patients with Hypertension
Are patients with hypertension at higher risk for severe illness from COVID-19?

Hypertension is common in the United States. Hypertension is more frequent with advancing age and among men, non-Hispanic blacks, and people with other underlying medical conditions such as obesity, diabetes, and serious heart disease. Based on what we know at this time, people with pulmonary hypertension are at increased risk for severe illness. People with hypertension (high blood pressure) may have an increased risk of severe illness from COVID-19.

  • There is insufficient information on COVID-19 to determine the level of risk for each underlying medical condition. CDC is analyzing data continuously and provides updates as soon as new information is available.
  • You know your patient’s overall health and how well their conditions are managed. Use your clinical judgement to evaluate on a case by case basis. Patients frequently in congregate settings are at increased risk of infection. Patients with underlying medical conditions may be at increased risk of severe disease.
  • If possible, work with patients to manage their underlying condition to the best of their ability, including ensuring that patients have sufficient medication and supplies. Prescribing three-month supplies of medications may help ensure access to sufficient medications.
  • Explain to all patients which symptoms of their chronic conditions require emergency care or in-person visits. Stress the importance of obtaining emergency care if needed.
  • Reassure your patients who require emergency care that emergency departments have infection prevention plans to protect them from acquiring COVID-19
  • Tell patients with underlying medical conditions that increase their risk of severe illness or poorer outcomes from COVID-19:
    • To stay home as much as possible to reduce their risk of being exposed.
    • Closely follow their care plans for management of their chronic disease, including, for example, achieving better glycemic or blood pressure control.
    • Seek emergency care for acute exacerbations of their underlying medical conditions or any health condition that requires immediate attention.
  • Encourage all patients, regardless of risk, to:
    • Take steps to protect yourself.
    • Call your healthcare provider if you are sick with a fever, cough, or shortness of breath.
  • Follow CDC travel guidelines and the recommendations of your state and local health officials. Fear and anxiety about a disease can feel overwhelming, especially for those who might be at higher risk or are experiencing social isolation, and for healthcare providers that are treating patients at higher risk. Do what you can to take care of your mental health and encourage your patients to do the same.

Additional resources for healthcare providers

Pregnant healthcare personnel (HCP) should follow risk assessment and infection control guidelines for HCP exposed to patients with suspected or confirmed COVID-19. Adherence to recommended infection prevention and control practices is an important part of protecting all HCP in healthcare settings. Based on what we know at this time, pregnant people might be at an increased risk for severe illness from COVID-19 compared to non-pregnant people. Additionally, there may be an increased risk of adverse pregnancy outcomes, such as preterm birth, among pregnant people with COVID-19. Facilities may want to consider limiting exposure of pregnant HCP to patients with confirmed or suspected COVID-19, especially during higher risk procedures (e.g., aerosol-generating procedures) if feasible based on staffing availability.

CDC is investigating reports of multisystem inflammatory syndrome in children (MIS-C) associated with COVID-19. Patients with MIS-C have presented with a persistent fever and a variety of signs and symptoms including multiorgan (e.g., cardiac, gastrointestinal, renal, hematologic, dermatologic, neurologic) involvement and elevated inflammatory markers. CDC is collaborating with domestic and international partners to better understand this new syndrome, including how common it is and its risk factors, and to begin tracking cases. For more information, including a full case definition, visit MIS-C Information for Healthcare Providers.

Infection Control

Yes. To keep patients and healthcare personnel (HCP) healthy and safe, CDC’s infection prevention and control guidance applies to all settings where healthcare is delivered. However, as with any guidance, facilities can tailor certain recommendations to their setting. For example, inpatient psychiatric care includes communal experiences and group activities that may need to continue. If so, these activities might need to be adapted to align with social distancing recommendations. Other recommended infection control measures (for example, ensuring access to alcohol-based hand sanitizer, cohorting patients with COVID-19 and assigning dedicated staff, or implementing universal source control measures) might not be safe or appropriate to implement in all locations or for all patients due to security and behavioral concerns.

Challenges and potential solutions specific to behavioral health settings might include:

  • Cohorting
    • Challenge: To prevent transmission, it is generally recommended that patients with COVID-19 be transferred to a separate area of the facility where they can be cared for by dedicated HCP. Because of security concerns or specialized care needs, it might not be possible to cohort certain patients together or change HCP assigned to their care.
    • Potential Solutions: When cohorting is not possible, implement measures to maintain social distancing (at least 6 feet) between patients with COVID-19 and others on the unit. Ideally, this would include a separate bathroom for COVID-19 patients. Ensure HCP wear all recommended personal protective equipment (PPE) when caring for patients with suspected or confirmed COVID-19.
  • Group Therapy Sessions
    • Challenge: Group counseling, therapy, and discussion sessions are a critical component of psychiatric treatment and care plans, but the traditional set-up for these activities is not compatible with social distancing recommendations.
    • Potential Solutions: When possible, use virtual methods, or decrease group size so social distancing can be maintained. In the event that COVID-19 is transmitted in the facility, sessions should stop or move to a video discussion forum until additional infection prevention measures are in place to stop the spread.
  • Cloth Face Coverings
    • Challenge: For some patients, the use of cloth face coverings or facemasks might pose an additional danger or may cause distress. Some patients may be unable or unwilling to use them as intended. Elastic and cloth straps can be used for strangling oneself or others, and metal nasal bridges can be used for self-harm or as a weapon.
    • Potential Solutions: Consider allowing patients at low risk for misuse to wear cloth face coverings or facemasks, with a preference for those with short ear-loops rather than longer ties. Consider use of cloth face coverings or facemasks during supervised group activities. Ensure that HCP interacting with patients who cannot wear a cloth face covering or facemask are wearing eye protection and a facemask (or a respirator if the patient is suspected to have COVID-19 and respirators are available).
  • Alcohol-based Hand Sanitizer
    • Challenge: While alcohol-based hand sanitizer (ABHS) containing 60-95% alcohol is an important tool to increase adherence to hand hygiene recommendations, ABHS must be used carefully in psychiatric facilities to ensure it is not ingested by patients.
    • Potential Solutions: Consider not placing ABHS in patients’ rooms in psychiatric facilities, nor in locations where the patients have unsupervised access. Encourage frequent hand washing with soap and water for patients and HCP. Consider providing personal, pocket-sized ABHS dispensers for HCP.
  • Dining
    • Challenge: As part of social distancing, communal dining is generally not recommended. However, eating needs to remain supervised due to the potential for self-harm with eating utensils and because commonly used psychiatric medications may cause side effects (e.g., tardive dyskinesia, dysphagia, hypo- and hypersalivation) that increase choking risk for patients.
    • Potential Solutions: One option is to position staff in patients’ rooms to monitor their dining. Another option is to allow communal dining in shifts so that staff can monitor patients while ensuring they remain at least 6 feet apart. A third option is to have patients sit in appropriately spaced chairs in the hallway outside their rooms so they can be monitored while they eat.
  • Smoking
    • Challenge: A higher proportion of psychiatric patients smoke cigarettes compared to the general population. Patients might congregate in outdoor smoking spaces without practicing appropriate social distancing.
    • Potential Solutions: Limit the number of patients allowed to access smoking spaces at the same time, and position staff to observe and ensure patients are practicing appropriate physical distancing.

Facilities should follow the reporting requirements of their state or jurisdiction. Those regulated by the Centers for Medicare and Medicaid Services (CMS) (e.g., nursing homes) should also follow all CMS requirementspdf iconexternal icon, which are being updated to include new requirements for reporting to CDC and to residents and their representatives.

In addition, CDC recommends that health departments be promptly notified about:

  • Residents or healthcare personnel (HCP) with suspected or confirmed COVID-19,
  • Residents with severe respiratory infection resulting in hospitalization or death, and
  •  ≥ 3 residents or HCP with new-onset respiratory symptoms within 72 hours of each other.

These could signal an outbreak of COVID-19 or other respiratory disease in the facility. The health department can provide important guidance to assist with case finding and halting transmission.

The facility should also have a plan and mechanism to regularly communicate with residents, family members, and HCP, including if cases of COVID-19 are identified in the facility. Often, information in nursing homes is communicated through town hall meetings and staff meetings, along with letters or emails. However, during the COVID-19 pandemic, in-person gatherings should not occur. Instead, communication should occur through virtual meetings over phone or web platforms. These should be supplemented with written communications that provide contact information for a staff member who can respond to questions or concerns. Communications should include information describing the current situation, plans for limiting spread within the facility, and recommended actions they can take to protect themselves and others. Facilities should make this information available in a timely manner and offer periodic updates as the situation develops and more information becomes available.

No. For patients hospitalized with COVID-19, decisions about discharge from the hospital should be based on their clinical status and the ability of the accepting facility to meet their care needs and adhere to recommended infection prevention and control practices. Decisions about hospital discharge are distinct from decisions about discontinuation of Transmission-Based Precautions.

For patients with suspected or confirmed COVID-19, decisions about discontinuing Transmission-Based Precautions should be based on the strategies outlined here. The test-based strategy is NOT REQUIRED and might not be possible due to limitations on availability of testing.

If a patient with suspected or confirmed COVID-19 has not met criteria for discontinuing Transmission-Based Precautions, they should be transferred to a facility with the ability to adhere to infection prevention and control recommendations for the care of residents with COVID-19, including placement in a unit or area of the facility designated to care for residents with COVID-19 and provision of recommended personal protective equipment to healthcare personnel.

If the patient with suspected or confirmed COVID-19 has met the criteria for discontinuing Transmission-Based Precautions but has persistent symptoms (e.g., persistent cough), they should ideally 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. If the patient has met the criteria for discontinuing Transmission-Based Precautions and does not have persistent symptoms, they do not require additional restrictions.

A patient hospitalized for non-COVID-related illnesses whose COVID-19 status is not known can be transferred to a nursing home without testing. However, to ensure they are not infected, nursing homes should place them in Transmission-based Precautions in a separate observation area or in a single-person room until 14 days have elapsed since admission.

As part of universal source control measures, all residents (including those described in the scenarios above) should wear a cloth face covering or facemask (if tolerated) whenever they leave their room.

As part of routine practices, healthcare personnel (HCP) should be applying Standard Precautions. HCP should always deliberately assess potential risks of exposure to infectious material before engaging in activities and procedures in healthcare delivery. Based on their risk assessment, safe work practices, including engineering controls that reduce the release of infectious material, administrative controls, and use of personal protective equipment (PPE) should be implemented at the point of care according to CDC guidelines and standards of practice for the activity performed.

To reduce SARS-CoV-2 exposure during the COVID-19 pandemic, CDC recommends that facilities:

  • consider nonoperative approaches when feasible;
  • minimize the use of procedures or techniques that might produce infectious aerosols when feasible;
  • minimize the number of people in the operating or procedure room to reduce exposures;
  • use the extent of community transmission and an assessment of the likelihood for patient harm if care is delayed to make decisions about cancelling or postponing elective surgeries and procedures; and
  • implement universal source control measures, which includes having patients wear a cloth face covering (as tolerated) and having HCP wear a facemask at all times while they are in the healthcare facility.

If surgery or procedures cannot be postponed, HCP caring for patients with suspected or confirmed COVID-19 should adhere to all recommended infection prevention and control practices for COVID-19.  This includes:

  • Using all recommended PPE: an N95 or equivalent or higher-level respirator (or facemask if respirators are not available), eye protection, gloves, and a gown.
    • Respirators with exhalation valves should not be used during surgical procedures as unfiltered exhaled breath would compromise the sterile field.
    • If shortages exist, N95 or equivalent or higher-level respirators should be prioritized for procedures involving higher risk techniques (e.g., that generate potentially infectious aerosols) or that involve anatomic regions where viral loads might be higher (e.g., nose and throat, oropharynx, respiratory tract).
  • As part of routine practice, HCP should also be using additional engineering controls for source control, when applicable (e.g., smoke evacuation devices).

Because SARS-CoV-2 can be transmitted by individuals who are infected but do not have symptoms, some infected individuals will not be identified by screening for clinical signs and symptoms.  HCP providing surgical or procedural care to patients not suspected of having SARS-CoV-2 infection should use a tiered approach based on the level of community transmission to inform the need for universal eye protection and respirator use.  HCP should continue to use eye protection or an N95 or equivalent or higher-level respirator whenever recommended for patient care as a part of Standard or Transmission-Based Precautions.

In addition to the use of universal PPE and source control in healthcare settings, targeted SARS-CoV-2 testing of patients without signs or symptoms of COVID-19 might be used to identify those with asymptomatic or pre-symptomatic SARS-CoV-2 infection and further reduce risk for exposures in some healthcare settings. Depending on guidance from local and state health departments, testing availability, and how rapidly results are available, facilities can consider implementing pre-admission or pre-procedure diagnostic testing with authorized nucleic acid or antigen detection assays for SARS-CoV-2.
Testing results might inform decisions about rescheduling elective procedures or about the need for additional Transmission-Based Precautions when caring for the patient. Limitations of using this testing strategy include obtaining negative results in patients during their incubation period who later become infectious and false negative test results, depending on the test method used.

CDC’s guidance to use NIOSH-approved N95 disposable filtering facepiece or higher level respirators when providing care for patients with suspected or known COVID-19 is based on the current understanding of SARS-CoV-2 and related respiratory viruses.

Current data suggest that close-range aerosol transmission by droplet and inhalation, and contact followed by self-delivery to the eyes, nose, or mouth are likely routes of transmission. Long-range aerosol transmission, such as is seen with measles, has not been a feature of SARS-CoV-2.

Potential routes of close-range transmission include splashes and sprays of infectious material onto mucous membranes and inhalation of infectious virions exhaled by an infected person. The relative contribution of each of these is not known for SARS-Co-V-2.

Facemasks commonly used during surgical procedures will provide barrier protection against droplet sprays contacting mucous membranes of the nose and mouth, but they are not designed to protect wearers from inhaling small particles. N95 and higher level respirators, such as other disposable filtering facepiece respirators, powered air-purifying respirators (PAPRs), and elastomeric respirators, provide both barrier and respiratory protection because of their tight fit and filtration characteristics.

Respirators should be used as part of a respiratory protection program that provides staff with medical evaluations, training, and fit testing.

Although facemasks are routinely used for the care of patients with common viral respiratory infections, N95 or higher level respirators are routinely recommended for emerging pathogens like SARS CoV-2, which have the potential for transmission via small particles, the ability to cause severe infections, and no specific treatments or vaccines.

CDC recommendations acknowledge the current challenges with limited supplies of N95s and other respirators. Facilities that do not have sufficient supplies of N95s and other respirators for all patient care should prioritize their use for activities and procedures that pose high risks of generating infectious aerosols and use facemasks for care that does not involve those activities or procedures. Detailed strategies for optimizing the supply of N95 respirators are available on the CDC website. Once availability of supplies is reestablished, the guidance states that the use of N95 and higher level respirators should resume.

In general, transport and movement of a patient with suspected or confirmed SARS-CoV-2 infection outside of their room should be limited to medically essential purposes. If being transported outside of the room, such as to radiology, healthcare personnel (HCP) in the receiving area should be notified in advance of transporting the patient. For transport, the patient should wear a facemask or cloth face covering (if tolerated) to contain secretions and be covered with a clean sheet.

If transport personnel must prepare the patient for transport (e.g., transfer them to the wheelchair or gurney), transport personnel should wear all recommended PPE (gloves, a gown, respiratory protection that is at least as protective as a fit tested NIOSH-certified disposable N95 filtering facepiece respirator or facemask—if a respirator is not available—and eye protection [i.e., goggles or disposable face shield that covers the front and sides of the face]). This recommendation is needed because these interactions typically involve close, often face-to-face, contact with the patient in an enclosed space (e.g., patient room). Once the patient has been transferred to the wheelchair or gurney (and prior to exiting the room), transporters should remove their gown and gloves and perform hand hygiene.

The transporter should continue to wear a respirator or facemask.  The continued use of eye protection by the transporter is also recommended if there is potential that the patient might not be able to tolerate their facemask or cloth face covering for the duration of transport.   Additional PPE should not be required unless there is an anticipated need to provide medical assistance during transport (e.g., helping the patient replace a dislodged facemask).

After arrival at their destination, receiving personnel (e.g., in radiology) and the transporter (if assisting with transfer) should perform hand hygiene and wear all recommended PPE. If still wearing their original respirator or facemask and eye protection, the transporter should take care to avoid self-contamination when donning the remainder of the recommended PPE. This cautious approach will be refined and updated as more information becomes available and as response needs change in the United States.

Interim guidance for EMS personnel transporting patients with confirmed or suspected SARS-CoV-2 infection is available here. EMS personnel should wear all recommended PPE because they are providing direct medical care and in close contact with the patient for longer periods of time.

In general, only essential personnel should enter the room of patients with SARS-CoV-2 infection. Healthcare facilities should consider assigning daily cleaning and disinfection of high-touch surfaces to nursing personnel who will already be in the room providing care to the patient. If this responsibility is assigned to EVS personnel, they should wear all recommended PPE when in the room. PPE should be removed upon leaving the room, immediately followed by performance of hand hygiene.

After discharge, terminal cleaning can be performed by EVS personnel. They should delay entry into the room until time has elapsed for enough air changes to remove potentially infectious particles. After this time has elapsed, EVS personnel can enter the room and should wear a facemask (for source control) along with a gown and gloves when performing terminal cleaning. Eye protection should be added if splashes or sprays during cleaning and disinfection activities are anticipated or otherwise required based on the selected cleaning products. Shoe covers are not recommended at this time for personnel caring for patients with SARS-CoV-2 infection.

Some procedures performed on patients are more likely to generate higher concentrations of infectious respiratory aerosols than coughing, sneezing, talking, or breathing. These aerosol generating procedures (AGPs) potentially put healthcare personnel and others at an increased risk for pathogen exposure and infection.

Development of a comprehensive list of AGPs for healthcare settings has not been possible, due to limitations in available data on which procedures may generate potentially infectious aerosols and the challenges in determining if reported transmissions during AGPs are due to aerosols or other exposures.

There is neither expert consensus, nor sufficient supporting data, to create a definitive and comprehensive list of AGPs for healthcare settings.

Commonly performed medical procedures that are often considered AGPs, or that create uncontrolled respiratory secretions, include:

  • open suctioning of airways
  • sputum induction
  • cardiopulmonary resuscitation
  • endotracheal intubation and extubation
  • non-invasive ventilation (e.g., BiPAP, CPAP)
  • bronchoscopy
  • manual ventilation

Based on limited available data, it is uncertain whether aerosols generated from some procedures may be infectious, such as:

  • nebulizer administration*
  • high flow O2 delivery

*Aerosols generated by nebulizers are derived from medication in the nebulizer. It is uncertain whether potential associations between performing this common procedure and increased risk of infection might be due to aerosols generated by the procedure or due to increased contact between those administering the nebulized medication and infected patients.

References related to aerosol generating procedures:

Tran K, Cimon K, Severn M, Pessoa-Silva CL, Conly J (2012) Aerosol Generating Procedures and Risk of Transmission of Acute Respiratory Infections to Healthcare Workers: A Systematic Review. PLoS ONE 7(4); https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3338532/#!po=72.2222external iconexternal iconexternal icon).

Although spread of SARS-CoV-2 is believed to be primarily via respiratory droplets, the contribution of small respirable particles to close proximity transmission is currently uncertain. Airborne transmission from person-to-person over long distances is unlikely.

The amount of time that the air inside an examination room remains potentially infectious is not known and may depend on a number of factors including the size of the room, the number of air changes per hour, how long the patient was in the room, if the patient was coughing or sneezing, and if an aerosol-generating procedure was performed. Facilities will need to consider these factors when deciding when the vacated room can be entered by someone who is not wearing PPE.

For a patient who was not coughing or sneezing, did not undergo an aerosol-generating procedure, and occupied the room for a short period of time (e.g., a few minutes), any risk to HCP and subsequent patients likely dissipates over a matter of minutes. However, for a patient who was coughing and remained in the room for a longer period of time or underwent an aerosol-generating procedure, the risk period is likely longer.

For these higher risk scenarios, it is reasonable to apply a similar time period as that used for pathogens spread by the airborne route (e.g., measles, tuberculosis) and to restrict HCP and patients without PPE from entering the room until sufficient time has elapsed for enough air changes to remove potentially infectious particles.

General guidance on clearance rates under differing ventilation conditions is available.

In addition to ensuring sufficient time for enough air changes to remove potentially infectious particles, HCP should clean and disinfect environmental surfaces and shared equipment before the room is used for another patient.

CDC has released information about strategies to optimize the supply of isolation gowns. Healthcare facilities should refer to that guidance and implement the recommended strategies to optimize their current supply of gowns. This includes shifting toward the use of washable cloth gowns, if feasible.

The use of gowns as part of Contact Precautions in the context of MDROs has been implemented primarily to reduce the risk of transmission to other patients rather than to protect healthcare personnel (HCP). Facilities with shortages could consider suspending the use of gowns for the care of patients with endemic MDROs, such as MRSA, VRE, and ESBL-producing Gram-negative bacilli except as required for Standard Precautions. Facilities should assess their local epidemiology to determine which MDROs are considered endemic. Regardless of the use of gowns, HCP at facilities should continue to wear gloves for contact with these patients and their environment. Hand hygiene should continue to be emphasized. Facilities should also attempt to place patients colonized or infected with an MDRO in a private room, if available.

  • Caring for patients who have highly resistant Gram-negative organisms (e.g., carbapenem-resistant Enterobacteriacae) and other MDROs (e.g., Candida auris) that are not considered endemic:  Rather than gowns being donned for every room entry, they should be reserved for use as part of Standard Precautions and also prioritized for high-contact patient care activities that pose highest risk for transfer of pathogens from the patient to HCP. Examples of such high-contact care activities include dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator), and wound care. To further preserve gowns, HCP are recommended to bundle high-contact care activities as part of individual care encounters.  Regardless of the use of gowns, HCP at facilities should continue to wear gloves for contact with these patients and their environment. Hand hygiene should continue to be emphasized. Facilities should also attempt to place patients colonized or infected with an MDRO in a private room, if available.
  • Caring for patients with Clostridioides difficile infections (CDI):  Facilities should continue using Contact Precautions (putting on a gown and gloves upon entry into the patient’s room and placing the patient in a private room) for the care of symptomatic patients with CDI.  As part of a supplemental strategy to prevent transmission of CDI, some facilities have implemented Contact Precautions for the care of patients at high risk for CDI who have asymptomatic carriage of Clostridioides difficile. There are limited data about the role of asymptomatic carriage in transmission of CDI. In this setting of a critical national shortage of gowns, facilities should consider suspending this approach until the shortage is addressed. Gowns should still be used as part of Standard Precautions.

Anyone who had prolonged close contact (within 6 feet for at least 15 minutes) with the infected healthcare provider might have been exposed.

  • If the provider had COVID-19 symptoms, the provider is considered potentially infectious beginning 2 days before symptoms first appeared until the provider meets criteria to discontinue Transmission-Based Precautions or Home Isolation.
  • If the provider did not have symptoms, collecting information about when the provider may have been exposed could help inform the period when they were infectious.
    • If an exposure is identified. The provider should be considered potentially infectious beginning 2 days after the exposure until criteria to discontinue Transmission-Based Precautions or Home Isolation are met.
    • If the date of exposure cannot be determined. For the purposes of contact tracing, it is reasonable to use a cutoff of 2 days before the specimen testing positive for COVID-19 was collected as the starting point, continuing until the criteria to discontinue Transmission-Based Precautions or Home Isolation are met. Although the infectious period is generally accepted to be 10 days after onset of infection, eliciting contacts during the entire 10 days before obtaining the specimen that tested positive for COVID-19 is likely inefficient.  In most situations an exposed provider cannot recall all contacts over the preceding 10 days.  Also, because recent data suggest that asymptomatic persons may have a lower viral burden at diagnosis than symptomatic persons, the additional resources required may divert case investigation and contact tracing resources away from activities most likely to interrupt ongoing transmission.

Contact tracing is generally recommended for anyone who had prolonged close contact with the person with COVID-19 during these time periods.  While this question addresses exposure to a potentially infectious provider, the following actions are also recommended if the potentially infectious individual is a patient or visitor.

Recommended actions for HCP, patients, and visitors:

Healthcare facilities should have a process for notifying the health department about known or suspected cases of COVID-19, and should establish a plan, in consultation with local public health authorities, for how exposures in a healthcare facility will be investigated and how contact tracing will be performed.  The plan should address the following:

  • Who is responsible for identifying contacts and notifying potentially exposed individuals?
  • How will such notifications occur?
  • What actions and follow-up are recommended for those who were exposed?

Contact tracing should be carried out in a way that protects the confidentiality of affected individuals to the extent possible and is consistent with applicable laws and regulations.  HCP and patients who are currently admitted to the facility or were transferred to another healthcare facility should be prioritized for notification.  These groups, if infected, have the potential to expose a large number of individuals at higher risk for severe disease, or in the situation of admitted patients, be at higher risk for severe illness themselves.

Information for health departments about case investigation and contact tracing is available in the Health Departments:  Interim Guidance on Developing a COVID-19 Case Investigation and Contact Tracing Planpdf icon.  This guidance could also be helpful to healthcare facilities performing such activities.

Anyone who had prolonged close contact (within 6 feet for at least 15 minutes) should be considered potentially exposed.  The use of a facemask for source control and adherence to other recommended infection prevention and control (IPC) measures (e.g., hand hygiene) by the provider help to reduce the risk of transmission or severe illness. In areas with moderate to substantial community transmission, patients are already at risk for exposure to SARS-CoV-2 due to exposures outside their home and should be alert to the development of signs or symptoms consistent with COVID-19.

The following should be considered when determining which patients are at higher risk for transmission and might be prioritized for evaluation and testing:

  • Facemask use by the patient – Mirroring the risk assessment guidance for healthcare personnel, patients not wearing a facemask would likely be at higher risk for infection compared to those that were wearing a facemask.
  • Type of interaction that occurred between the patient and infected provider – An interaction involving manipulation or prolonged close contact with the patient’s eyes, nose, or mouth (e.g., dental cleaning) likely poses higher risk of transmission to the patient compared to other interactions (e.g., blood pressure check).
  • PPE used by infected HCP – HCP wearing a facemask (or respirator) and face shield that extends down below the chin might have had better source control than wearing only a facemask. Note that respirators with exhalation valves might not provide source control.
  • Current status of patient – Is the patient currently admitted to a hospital or long-term care facility?  These individuals, if infected, can be at higher risk for severe illness and have the potential to expose large numbers of individuals at risk for severe disease.

Transmission

The onset and duration of viral shedding and the period of infectiousness for COVID-19 are not yet known. It is possible that SARS-CoV-2 RNA may be detectable in the upper or lower respiratory tract for weeks after illness onset, similar to infections with MERS-CoV and SARS-CoV. However, detection of viral RNA does not necessarily mean that infectious virus is present. There are reports of asymptomatic infections (detection of virus with no development of symptoms) and pre-symptomatic infections (detection of virus prior to development of symptoms) with SARS-CoV-2, but their role in transmission is not yet known. Based on existing literature, the incubation period (the time from exposure to development of symptoms) of SARS-CoV-2 and other coronaviruses (e.g. MERS-CoV, SARS-CoV) ranges from 2–14 days.

SARS-CoV-2 RNA has been detected in upper and lower respiratory tract specimens, and SARS-CoV-2 virus has been isolated from upper respiratory tract specimens and bronchoalveolar lavage fluid. SARS-CoV-2 RNA has been detected in blood and stool specimens, and SARS-CoV-2 virus has been isolated in cell culture from the stool of some patients, including a patient with pneumonia 15 days after symptom onset. The duration of SARS-CoV-2 RNA detection in upper and lower respiratory tract specimens and in extrapulmonary specimens is not yet known but may be several weeks or longer. Duration of several week or longer has been observed in cases of MERS-CoV or SARS-CoV infection. While viable, infectious SARS-CoV has been isolated from respiratory, blood, urine, and stool specimens, viable, infectious MERS-CoV has only been isolated from respiratory tract specimens. It is not yet known whether other non-respiratory body fluids from an infected person including vomit, urine, breast milk, or semen can contain viable, infectious SARS-CoV-2.

The immune response, including duration of immunity, to SARS-CoV-2 infection is not yet understood. Patients with MERS-CoV are unlikely to be re-infected shortly after they recover, but it is not yet known whether similar immune protection will be observed for patients with COVID-19.

Testing, Diagnosis, and Notification

  • Clinicians are able to access laboratory testing through state and local public health laboratories, as well as commercial and clinical laboratories across the country. The Association of Public Health Laboratoriesexternal icon provides a list of states and territories with laboratories that are using COVID-19 viral tests. For more information, see Testing in U.S. Clinicians should direct testing questions to their state health departments. Commercial reference laboratories are also able to offer a larger volume of testing for SARS-CoV-2.
  • CDC has guidance for who should be tested, but decisions about testing are at the discretion of state and local health departments and/or individual clinicians.
  • Healthcare providers should report positive  results to their local/state health department CDC does not directly collect these data directly.
  • See recommendations for prioritization of testing, and instructions for specimen collection at Testing Overview for COVID-19.

Yes. There are commercially developed respiratory panels with multi-pathogen molecular assays that can detect respiratory pathogens, including SARS-CoV-2, influenza, and other human coronaviruses that can cause acute respiratory illness. The U.S. Food and Drug Administration (FDA) maintains a list of tests that includes viral tests with Emergency Use Authorizationexternal icon (EUA).

Patients can be infected with more than one virus at the same time. Coinfections with other respiratory viruses in people with COVID-19 have been reported. Therefore, identifying infection with one respiratory virus does not exclude SARS-CoV-2 virus infection.

Clinicians considering use of chest CT scans for diagnosis or management of COVID-19 patients should consider whether such imaging will change clinical management. The American College of Radiology (ACR) recommends that CT should not be used to screen for COVID-19, or as a first-line test to diagnose COVID-19, and that CT should be used sparingly and reserved for hospitalized, symptomatic patients with specific clinical indications for CT. Appropriate infection control procedures should be followed before scanning subsequent patients. For more information see, ACR Recommendations for the use of Chest Radiography and Computed Tomography (CT) for Suspected COVID-19 Infectionexternal iconexternal icon.

Healthcare providers should immediately notify infection control personnel at their facility if they suspect COVID-19 in a patient. If a patient tests positive, providers should report that positive result to their local/state health department.

Patients with MIS-C have presented with a persistent fever and a variety of signs and symptoms including multiorgan (e.g., cardiac, gastrointestinal, renal, hematologic, dermatologic, neurologic) involvement and elevated inflammatory markers. Not all children will have the same symptoms. For children who may have MIS-C, further evaluation for signs of this syndrome may include (but are not limited to) chest radiograph, echocardiography, and blood testing to evaluate for evidence of inflammation.

Healthcare providers who have cared or are caring for patients younger than 21 years of age meeting MIS-C criteria should report suspected cases to their local, state, or territorial health department. After hour phone numbers for health departments are available at the Council of State and Territorial Epidemiologists website.external icon  For additional reporting questions, please contact CDC’s 24-hour Emergency Operations Center at 770-488-7100. For more information, including a full case definition, please visit MIS-C Information for Healthcare Providers.

Testing in Nursing Homes

Whether residents or HCP who previously had COVID-19 confirmed by viral testing need to be re-tested depends on: 1) how much time has passed since their initial illness; 2) what strategy the facility is using to determine when residents can discontinue isolation and HCP can return to work; and 3) whether the individual has developed symptoms after initial recovery.

  • Most individuals who recently recovered from COVID-19 are likely no longer infectious even if they continue to have a positive viral test (e.g., persistently or recurrently detectable viral RNA). When an individual has a positive test result <6 weeks after they met criteria for discontinuation of Transmission-Based Precautions or Home Isolation, it can be difficult to determine if they have been re-infected or if they still have detectable viral RNA from their previous infection.
  • Residents and HCP who had a positive viral test in the past 6–8 weeks and are now asymptomatic may not need to be retested as part of facility-wide testing unless the facility is using a test-based strategy to determine if residents can discontinue isolation or HCP can return to work. Residents and HCP who had a positive viral test over 8 weeks ago should be retested as part of facility-wide testing, regardless of symptoms.
  • Residents and HCP who had a positive viral test at any time and become symptomatic after recovering from the initial illness should be re-tested and placed back on the appropriate Transmission-Based Precautions or excluded from work, respectively.

This guidance may be updated as we learn more information on viral persistence and risk for reinfection.

Yes. To determine if residents and HCP have a current infection, they should have a viral test (e.g., reverse-transcriptase polymerase chain reaction [RT-PCR]) regardless of their antibody test result. A positive antibody test result shows that an individual has antibodies from an infection with the virus that causes COVID-19, or possibly from infection with a related virus from the same family of viruses (called coronavirus), such as one that causes the common cold. We do not know yet if having antibodies to the virus that causes COVID-19 can protect someone from getting infected again or, if they do, how long this protection might last. Therefore, antibody tests should not be used to diagnose COVID-19 and should not be used to inform infection prevention actions.

Residents, or their medical powers of attorney, have the right to decline testing. Clinical discussions about testing may include alternative specimen collection sources that may be more acceptable to residents than nasopharyngeal swabs (e.g., anterior nares). Providing information about the method of testing and reason for pursuing testing may facilitate discussions with residents and their medical powers of attorney.

If a resident has symptoms consistent with COVID-19, but declines testing, they should remain on Transmission-Based Precautions until they meet the symptom-based criteria for discontinuation.

If a resident is asymptomatic and declines testing at the time of facility-wide testing, decisions on placing the resident on Transmission-Based Precautions for COVID-19 or providing usual care should be based on whether the facility has evidence suggesting SARS-CoV-2 transmission (i.e., confirmed infection in HCP or nursing-home onset infection in a resident).

Only residents who have a confirmed positive viral test should be moved to COVID-19-designated units or facilities.

If HCP with symptoms consistent with COVID-19 decline testing, they should be presumed to have COVID-19 and excluded from work. Return to work decisions should be based on COVID-19 return to work guidance at the discretion of the facility’s occupational health program.

If asymptomatic HCP decline testing, work restriction, if any, should be determined by the facility’s occupational health and local jurisdiction policies. All staff should be trained in proper use of personal protective equipment, including universal facemask policies, hand hygiene, and other measures needed to stop transmission of SARS-CoV-2.

No, HCP do not need to be tested at each facility. If documentation of the test result is provided to each facility, the results from one setting are adequate to meet the testing recommendations at any facility. Each facility should maintain appropriate documentation of test results and have a plan to evaluate and manage HCP. HCP should be encouraged to tell facilities if they have had exposures at other facilities with recognized COVID-19 cases.

Serial testing of HCP in nursing homes is indicated in two situations: when there is a COVID-19 outbreak in the facility and as part of the reopening process. If there is a COVID-19 outbreak in the facility, all previously negative residents and HCP should be serially tested until the testing identifies no new cases of COVID-19 among residents or HCP over at least 14 days since the most recent positive result.

As part of the reopening processexternal iconexternal icon, the decision to serially test HCP for SARS-CoV-2 should be made in the context of local incidence. Depending on the level of community transmission, HCP could continue to be at risk for acquiring infection in the community and introducing it to residents of nursing homes.

Health departments should have a plan on how to prioritize facilities when testing capacity is limited.

Priority facilities may include those with confirmed cases, those in counties with high incidence, those with the ability to cohort residents who are found to be positive, larger facilities, and facilities with more patients with recent healthcare exposures (e.g., recent hospitalization or outpatient dialysis).

If a facility identifies additional cases through facility-wide testing, then that facility should be prioritized for repeat testing of negative residents.

If HCP remain asymptomatic, they may continue working while awaiting test results, unless work restrictions have been implemented by the occupational health program because of an exposure warranting exclusion from work.

Treatment and Management

There is currently no FDA-approved post-exposure prophylaxis for people who may have been exposed to COVID-19. For information about registered clinical trials of investigational therapeutics for pre or post exposure prophylaxis of SARS-CoV-2 infection, visit ClinicalTrials.govexternal icon.

For more information on movement restrictions, monitoring for symptoms, and evaluation after possible exposure to COVID-19, see Interim US Guidance for Risk Assessment and Public Health Management of Persons with Potential Coronavirus Disease 2019 (COVID-19) Exposure in Travel-associated or Community Settings and Interim U.S Guidance for Risk Assessment and Public Health Management of Healthcare Personnel with Potential Exposure in a Healthcare Setting to Patients with Coronavirus Disease 2019 (COVID-19).

The National Institutes of Health recently published guidelines on prophylaxis use, testing, and management of COVID-19 patients. For more information, please visit: National Institutes of Health: Coronavirus Disease 2019 (COVID-19) Treatment Guidelinesexternal icon.

Not all patients with COVID-19 will require medical supportive care. Clinical management for hospitalized patients with COVID-19 is focused on supportive care for complications, including supplemental oxygen and advanced organ support for respiratory failure, septic shock, and multi-organ failure. Empiric testing and treatment for other viral or bacterial etiologies may be warranted.

Corticosteroids are not routinely recommended for treatment of viral pneumonia or ARDS, due to the potential for prolonging viral replication, as has been observed with MERS coronavirus and influenza. Corticosteroids should be avoided unless they are indicated for another reason (e.g., COPD exacerbation or refractory septic shock following the Surviving Sepsis Campaign Guidelinesexternal iconexternal icon).

For information on investigational therapies, see Therapeutic Options for Patients with COVID-19.

Not all patients with COVID-19 require hospital admission. Patients whose clinical presentation warrants in-patient clinical management for supportive medical care should be admitted to the hospital under appropriate isolation precautions.

Some patients with initial mild clinical presentation may worsen in the second week of illness. The decision to monitor these patients in the inpatient or outpatient setting should be made on a case-by-case basis. This decision will depend not only on the clinical presentation, but also on the patient’s ability to engage in self-monitoring, the feasibility of safe isolation at home, and the risk of transmission in the patient’s home environment. For more information, see Interim Infection Prevention and Control Recommendations for Patients with Suspected or Confirmed Coronavirus Disease 2019 (COVID-19) in a Healthcare Setting and Interim Guidance for Implementing Home Care of People Not Requiring Hospitalization for Coronavirus Disease 2019 (COVID-19).

Patients can be discharged from the healthcare facility whenever clinically indicated. Isolation should be maintained at home if the patient returns home before the time period recommended for discontinuation of hospital Transmission-Based Precautions.

Decisions to discontinue Transmission-Based Precautions or in-home isolation can be made on a case-by-case basis in consultation with clinicians, infection prevention and control specialists, and public health authorities based upon multiple factors, including disease severity, illness signs and symptoms, and results of laboratory testing for COVID-19 in respiratory specimens.

See Interim Considerations for Disposition of Hospitalized Patients with COVID-19. For non-hospitalized persons, see Interim Guidance for Implementing Home Care of People Not Requiring Hospitalization for COVID-19, and Discontinuation of In-Home Isolation for Immunocompromised Persons.

Patients with Persistent or Recurrent Positive Tests

Many recovered persons do not have detectable SARS-CoV-2 RNA in upper respiratory tract specimens.  In others, viral RNA can be persistently detected by RT-PCR in respiratory tract samples after clinical recovery.  In some persons, after testing negative by RT-PCR in two consecutive samples, later samples can test positive again. Whether persistent or recurrent, these repeated detections of viral RNA consistently are associated with higher cycle threshold (Ct) values (i.e., fewer RNA copies) than were found in earlier RT-PCR results in samples collected shortly or and during clinical illness. Studies that have looked at how long SARS-CoV-2 RNA can be detected in adults have demonstrated that in some persons it can detected for weeks.

Whether the presence of detectable but low concentrations of viral RNA after clinical recovery represents the presence of potentially infectious virus is unknown. Based on experience with other viruses, it is unlikely that such persons pose an infectious risk to others. However, whether this is true for SARS-CoV-2 infection has not been definitively established.

Typically, after the onset of illness, the detectable viral burden declines. After a week or more, anti-SARS-CoV-2 immunoglobulin becomes detectable and antibody titers rise. Some of these antibodies may prevent the virus from infecting cells in cell culture. The decline in viral burden is associated with decreased ability to isolate live virus. Efforts to isolate live virus from upper respiratory tract specimens have been unsuccessful when specimens are collected more than 10 days after illness onset.

Persons who have tested persistently or recurrently positive for SARS-CoV-2 RNA have shown stable or improving signs of illness. When viral isolation in tissue culture has been attempted in such persons in South Korea and the United States, live virus has not been isolated. In addition, there is no evidence that clinically recovered persons with persistent or recurrent detection of viral RNA have transmitted COVID-19 to others.

Despite encouraging observations to date, it’s not possible to conclude that persons with persistent or recurrent detection of SARS-CoV-2 RNA are no longer infectious. There is no firm evidence yet that the antibodies that develop in response to infection are protective. If these antibodies are protective, it’s not known what antibody titers are associated with protection from reinfection.

Based on these data and experience with other viral infections, most persons recovered from COVID-19 who test persistently or recurrently positive by RT-PCR are likely no longer infectious.  Additionally, the magnitude and persistence of the immune response following recovery may vary among individuals, with factors such as age potentially influencing protection.  Based on limited available data, determinations must be made on a case-by-case basis as to whether recovered persons with persistently detectable SARS-CoV-2 RNA are potentially infectious to others and should continue to be in home isolation and excluded from work, school, or other group settings. Such determinations are typically made in consultation with infectious diseases specialists and public health officials, after review of available information (e.g., medical history, time from initial positive test, RT-PCR Ct values, and presence of COVID-19 signs or symptoms).

No. Although attempts to culture virus from upper respiratory specimens have been largely unsuccessful when Ct values are in high but detectable ranges, Ct values are not a measure of viral burden, are not standardized  by RT-PCR platform, and have not been approved by FDA for use in clinical management. CDC does not endorse or recommend use of Ct values to assess when a person is no longer infectious; however, serial Ct values may be useful in the context of the entire body of information available when assessing recovery and resolution of infection.

Prospectively collecting serial respiratory samples and attempting to isolate live virus in tissue culture from multiple persons testing positive by RT-PCR following illness recovery is generally required. If repeated attempts to recover replication-competent virus in culture from such serial samples are unsuccessful that is considered sufficient evidence that infectious virus is absent, and that persons continuing to test positive do not pose an infectious risk to other people

Yes. However, viral culture is not widely performed for SARS-CoV-2. It must be conducted in Biosafety Level 3 (BSL-3) laboratories using BSL-3 practices by experienced virologists and results can take a week or more. Therefore, while persons whose specimens do not yield live virus are considered no longer infectious, the complexity of such testing and the time required to complete it mean that it is unlikely to be useful to guide management of infected persons.

The person should be managed as potentially infectious and isolated. When a positive test occurs less than about 6 weeks after the person met criteria for discontinuation of isolation, it can be difficult to determine if the positive test represents a new infection or a persistently positive test associated with the previous infection. If the positive test occurs more than 6-8 weeks after the person has completed their most recent isolation, clinicians and public health authorities should consider the possibility of reinfection. Ultimately, the determination of whether a patient with a subsequently positive test is contagious to others should be made on a case-by-case basis, in consultation with infectious diseases specialists and public health authorities, after review of available information (e.g., medical history, time from initial positive test, RT-PCR Ct values, and presence of COVID-19 signs or symptoms).  Persons who are determined to be potentially infectious should undergo evaluation and remain isolated until they again meet criteria for discontinuation of isolation or of transmission-based precautions, depending on their circumstances.

Yes, they should be isolated and retested. Persons who test positive for SARS-CoV-2 by RT-PCR come out of isolation after meeting criteria for the symptom-based or test-based strategy. We do not know the degree to which previous COVID-19 illness protects against a subsequent SARS-CoV-2 infection or for how long persons are protected. Currently, serologic testing cannot be used to determine if this person may be reinfected. A positive serologic test may be evidence of the prior infection, but it remains unknown to what degree persons with detectable anti-SARS-CoV-2 antibodies are immune to reinfection. Contact tracing for the second period of symptoms (new case investigation) may be warranted.

Yes, they should follow quarantine recommendations for contacts. We do not know to what degree or duration persons are protected against reinfection with SARS-CoV-2 following recovery from COVID illness.  A positive serologic test may be evidence of prior infection, but it remains unknown whether persons with detectable anti-SARS-CoV-2 antibodies are immune to reinfection.

No. The symptom-based strategy is intended to replace the need for repeated testing.

Yes. It is recommended that almost all persons wear cloth face coverings in public1. The primary purpose of cloth face coverings is to limit transmission of SARS-CoV-2 from infected persons who may be infectious but do not have clinical symptoms of illness or may have early or mild symptoms that they do not recognize. Fabric face coverings may also offer the wearer some protection against re-exposure to SARS-CoV-2, provide reassurance to others in public settings, and act as a reminder of the need to maintain social distancing. However, cloth face coverings are not personal protective equipment (PPE) and should not be used instead of a respirator or a facemask to protect a healthcare worker.

[1] Cloth face coverings should not be placed on young children under age 2, anyone who has trouble breathing, or is unconscious, incapacitated or otherwise unable to remove the mask without assistance.

Obstetrical Care

When available, respirators (or facemasks if a respirator is not available), eye protection, gloves, and gowns should be used for the care of patients with known or suspected COVID-19 infection, including women who are pregnant. For more information, please see Interim Infection Prevention and Control Recommendations for Patients with Suspected or Confirmed Coronavirus Disease 2019 (COVID-19) in Healthcare Settings.

During respirator shortages, care should be taken to ensure that N95 respirators are reserved for situations where respiratory protection is most important, such as performance of aerosol-generating procedures on patients with suspected or confirmed COVID-19 infection. In such shortage situations, facemasks might be used for other types of patient care.

Alternatives to N95 respirators might be considered where feasible. These include other classes of NIOSH-approved filtering facepiece respirators, half facepiece or full facepiece elastomeric respirators, and powered air-purifying respirators (PAPRs) where feasible. All of these alternatives will provide equivalent or higher protection than N95 respirators when properly worn. However, PAPRs and elastomeric respirators should not be used in surgical settings due to concerns that exhaled air may contaminate the sterile field. For more information please see: Strategies for Optimizing the Supply of N95 Respirators: Conventional Capacity Strategies.

When respirator supplies are restored, the facility can switch back to use of N95 respirators for all care of patients with known or suspected COVID-19 infection. For more information, please see Interim Infection Prevention and Control Recommendations for Patients with Suspected or Confirmed Coronavirus Disease 2019 (COVID-19) in Healthcare Settings.

Based on limited data, forceful exhalation during the second stage of labor would not be expected to generate aerosols to the same extent as procedures more commonly considered to be aerosol generating (such as bronchoscopy, intubation, and open suctioning. Forceful exhalation during the second stage of labor is not considered an aerosol-generating procedure for respirator prioritization during shortages over procedures more likely to generate higher concentrations of infectious respiratory aerosols.

When respirator supplies are restored, as with all clinical care activities for patients with known or suspected COVID-19, HCP should use respirators (or facemasks if a respirator is not available), eye protection, gloves, and gowns during the second stage of labor, in addition to other personal protective equipment that may be typically indicated for labor and delivery. For more information please see: Healthcare Infection Prevention and Control FAQs

Based on limited data, high-flow oxygen use is not considered an aerosol-generating procedure for respirator prioritization during shortages over procedures more likely to generate higher concentrations of infectious respiratory aerosols (such as bronchoscopy, intubation, and open suctioning). Patients with known or suspected COVID-19 should receive any interventions they would normally receive as standard of care. When respirator supplies are restored, as with all clinical care activities for patients with known or suspected COVID-19, respirators (or facemasks if a respirator is not available), eye protection, gloves, and gowns should be used by HCP for the care of pregnant patients with known or suspected COVID-19. For more information please see: Healthcare Infection Prevention and Control FAQs

Clinicians should use their judgment to determine if a patient has signs and symptoms compatible with COVID-19 and whether the patient should be tested. Fever is the most commonly reported sign; most patients with confirmed COVID-19 have developed fever and/or symptoms of acute respiratory illness (cough, difficulty breathing).

Data regarding COVID-19 in pregnancy are limited; according to current information, presenting signs and symptoms are expected to be similar to those for non-pregnant patients, including the presence of fever.

Other considerations that may guide testing are epidemiologic factors such as the occurrence of local community transmission of COVID-19 infections. As part of evaluation, clinicians are strongly encouraged to test for other causes of respiratory illness and peripartum fever. For more information please see: Testing Overview for Coronavirus Disease 2019 (COVID-19)

HCP in labor and delivery healthcare settings should follow the same infection prevention and control recommendations and personal protective equipment recommendations as all other HCP. If HCP are exposed to patients with COVID-19 infection, guidance is available for HCP and healthcare facilities on steps to take. For more information, please see: Interim U.S. Guidance for Risk Assessment and Public Health Management of Healthcare Personnel with Potential Exposure in a Healthcare Setting to Patients with Coronavirus Disease (COVID-19)

Drugs and Investigational Therapies

Several patients with COVID-19 have been reported to present with concurrent community-acquired bacterial pneumonia. Decisions to administer antibiotics to COVID-19 patients should be based on the likelihood of bacterial infection (community-acquired or hospital-acquired), illness severity, and antimicrobial stewardship issues. For more information, see Diagnosis and Treatment of Adults with Community-acquired Pneumonia: An Official Clinical Practice Guideline of the American Thoracic Society and Infectious Diseases Society of Americaexternal iconexternal icon.

There are currently no antiviral drugs approved by FDA to treat COVID-19. See Interim Clinical Guidance for Management of Patients with Confirmed Coronavirus Disease 2019 (COVID-19).

CDC is currently not aware of scientific evidence establishing a link between NSAIDs (e.g., ibuprofen, naproxen) and worsening of COVID‑19. FDAexternal iconexternal icon, the European Medicines Agencyexternal icon, the World Health Organization, and CDC are continuing to monitor the situation and will review new information on the effects of NSAIDs and COVID-19 disease as it becomes available. For those who wish to use treatment options other than NSAIDs, there are other over-the-counter and prescription medications approved for pain relief and fever reduction. Patients who rely on NSAIDs to treat chronic conditions and have additional questions should speak to their healthcare provider for individualized management. Patients should use NSAIDs, and all medications, according to the product labels and advice of their healthcare professional.

Patients with Asthma

People with moderate to severe asthma, particularly if not well controlled, might be at higher risk of getting very sick from COVID-19.

Based on what we currently know about COVID-19, the selection of therapeutic options through guideline-recommended treatment of asthma has not been affected. National asthma guidelinesexternal icon are available. Continuation of inhaled corticosteroids is particularly important for patients already using these medications because there is no evidence of increased risk of COVID-19 morbidity with use of inhaled corticosteroids and an abundance of data showing reduced risk of asthma exacerbation with maintenance of asthma controller therapy.

Patients with asthma but without symptoms or a diagnosis of COVID-19 should continue any required nebulizer treatments.

Selection of therapeutic options through guideline-recommended treatment of asthma exacerbations has not been affected by what we currently know about COVID-19.

Systemic corticosteroids should be used to treat an asthma exacerbation per national asthma guidelinesexternal icon and current standards of care, even if it is caused by COVID-19. Short-term use of systemic corticosteroids to treat asthma exacerbations should be continued. There is currently no evidence to suggest that short-term use of systemic corticosteroids to treat asthma exacerbations increases the risk of developing severe COVID-19, whereas there is an abundance of data to support use of systemic steroids for moderate or severe asthma exacerbations.

Patients with asthma but without symptoms or a diagnosis of COVID-19 should continue any required nebulizer for treatments, as recommended by national professional organizations, including the American Academy of Allergy, Asthma & Immunology (AAAAI) and the American College of Allergy, Asthma & Immunology (ACAAI). If healthcare providers need to be present during nebulizer use among patients who have either symptoms or a diagnosis of COVID-19, use CDC’s recommended precautions when performing aerosol-generating procedures (AGPs).

Clinicians may be concerned that an asthma exacerbation is related to an underlying infection with COVID-19. Clinicians can access laboratory testing for COVID-19 through a network of state and local public health laboratories across the country. Lists of states and territories with laboratories that are using COVID-19 viral tests are available. For more information, see Testing in U.S. Clinicians should direct testing questions to their state and localexternal icon health departments.

Patients can be referred to CDC’s recommendations for caring for themselves or someone else at home sick with COVID-19.

If nebulizer use at home is necessary for patients with asthma who have symptoms or a diagnosis of COVID-19, use of the nebulizer in a location that minimizes and preferably avoids exposure to any other members of the household, and preferably a location where air is not recirculated into the home (like a porch, patio, or garage) is recommended by national professional organizations, including the American College of Allergy, Asthma & Immunology (ACAAI) by the ACAAI and the Allergy & Asthma Network (AAN). Limiting the number of people in the room or location where the nebulizer is used is also recommended by the Asthma & Allergy Foundation of America (AAFA). Nebulizers should be used and cleaned according to the manufacturer’s instructions.

If nebulizer use in a healthcare setting is necessary for patients who have either symptoms or a diagnosis of COVID-19, use CDC’s recommended precautions when performing aerosol-generating procedures (AGPs).

Patients with Liver Disease

Yes, for your COVID-19 patients with risk factors for viral hepatitis and elevated hepatic enzymes, consider testing them for hepatitis A virus, hepatitis B virus, and hepatitis C virus infections. However, elevated alanine aminotransferase (ALT) or aspartate aminotransferase (AST) may also be associated with COVID-19 alone and indicate greater severity of illness. For more information, review CDC’s Interim Clinical Guidance for Management of Patients with Confirmed Coronavirus Disease (COVID-19)

Yes. People susceptible to hepatitis A virus (HAV) infection during the current hepatitis A outbreaks should receive the hepatitis A vaccine when possible. This includes:

  • people who use drugs (injection or non-injection)
  • people experiencing unstable housing or homelessness
  • men who have sex with men (MSM)
  • people who are or were recently incarcerated
  • people with chronic liver disease (including cirrhosis, hepatitis B, or hepatitis C) and living or working in areas where the hepatitis A outbreaks are ongoing

Vaccination in settings such as jails, other correctional facilities, and homeless shelters should continue if already previously planned and organized in a way that would adhere to infection control practices and where relevant social distancing standards can be maintained. However, efforts should be made to vaccinate people in non-congregate settings that allow for social distancing. Whenever possible, vaccination efforts in non-congregate settings should continue for people at highest risk of acquiring HAV infection or developing serious complications from HAV infection, if social distancing standards can be maintained.

Routine hepatitis A and hepatitis B vaccination of children should continue to the extent possible, according to the CDC immunization schedules.

Maintaining Childhood Immunizations During COVID-19 Pandemic

The COVID-19 pandemic is changing rapidly and continues to affect communities across the United States differently. Some of the strategies used to slow the spread of disease in communities include postponing or cancelling non-urgent elective procedures and using telemedicine instead of face-to-face encounters for routine medical visits.

Different strategies are needed to ensure the delivery of newborn care and well-child care, including childhood immunizations. Healthcare providers in communities affected by COVID-19 are using strategies to separate well visits from sick visitsexternal icon. Examples include:

  • Scheduling well visits in the morning and sick visits in the afternoon.
  • Separating patients spatially, such as by placing patients with sick visits in different areas of the clinic or another location from patients with well visits.
  • Collaborating with providers in the community to identify separate locations for holding well visits for children.

Because of personal, practice, or community circumstances related to COVID-19, some providers may not be able to provide well-child care, including immunizations, for all patients in their practice. If a practice can provide only limited well-child visits, healthcare providers are encouraged to prioritize newborn care and vaccination of infants and young children (through 24 months of age) when possible. CDC is monitoring the situation and will continue to provide guidance.

Yes. Hepatitis B vaccination of all infants, especially those exposed to hepatitis B virus, should occur according to the Advisory Committee on Immunization Practices (ACIP) recommendations.

Labor and Delivery Care

  • Identify HBsAg status of all women presenting for delivery.
  • If a woman’s HBsAg status is positive, HBIG and single antigen hepatitis B vaccine should be administered to her infant within 12 hours of birth.
  • If a woman’s HBsAg status is unknown, single antigen hepatitis B vaccine should be administered to her infant within 12 hours of birth. Administration of HBIG should be determined per ACIP recommendations (see https://www.cdc.gov/mmwr/volumes/67/rr/rr6701a1.htm). Infants weighing <2,000 grams should receive HBIG if the mother’s HBsAg status cannot be determined within 12 hours of birth.
  • Provide the birth dose of hepatitis B vaccine to all other newborns within 24 hours of birth to prevent horizontal hepatitis B virus transmission from household or other close contacts.

Yes. Management should continue to prevent mother-to-child transmission of hepatitis B.

Pediatric Care of HBV-exposed Infants

  • Make every effort to ensure HBV-exposed infants complete the hepatitis B vaccine series following the ACIP recommendations (see https://www.cdc.gov/mmwr/volumes/67/rr/rr6701a1.htm). Providers using single-component vaccine who are experiencing immunization service disruption should administer hepatitis B vaccine as close to the recommended intervals as possible, including series completion at 6 months, and follow ACIP recommendations for post-vaccination serologic testing.
  • If post-vaccination serologic testing is delayed beyond 6 months after the hepatitis B series is completed, consider administering a “booster” dose of single antigen hepatitis B vaccine and then ordering post-vaccination serologic testing (HBsAg & antibody to HBsAg [anti-HBs]) 1-2 months after the “booster” dose.

Yes. Continue to administer these vaccines if an in-person visit must be scheduled for some other purpose and the clinical preventive service can be delivered during that visit with no additional risk; or an individual patient and their clinician believe that there is a compelling need to receive the service based on an assessment that the potential benefit outweighs the risk of exposure to SARS-CoV-2 virus. For more information see Delivery of Adult Clinical Preventive Services, Including Immunizations.

Patients with Hypertension

Although many patients with severe illness from COVID-19 have underlying hypertension, it is unclear at this time if hypertension is an independent risk factor for severe illness from COVID-19. Hypertension is common in the United States. Hypertension is more frequent with advancing age and among men, non-Hispanic blacks, and people with other underlying medical conditions such as obesity, diabetes, and serious heart disease. At this time, people whose only underlying medical condition is hypertension are not considered to be at higher risk for severe illness from COVID-19.

No. The American Heart Association, the Heart Failure Society of America, and the American College of Cardiology recommendexternal icon continuing ACE-I or ARB medications for all patients already prescribed those medications for indications such as heart failure, hypertension, or ischemic heart disease. At this time, available evidence demonstrates no indication of COVID-specific harm from these agents. Several randomized controlled trials are under way to better answer this important clinical question. Cardiovascular disease patients diagnosed with COVID-19 should be fully evaluated by a healthcare professional before adding or removing any treatments, and any changes to their treatment should be based on the latest scientific evidence. Patients who rely on ACE-Is or ARBs to treat chronic conditions and have additional questions should speak to their healthcare provider for individualized management

Waste Management

Waste generated in the care of PUIs or patients with confirmed COVID-19 does not present additional considerations for wastewater disinfection in the United States. Coronaviruses are susceptible to the same disinfection conditions in community and healthcare settings as other viruses, so current disinfection conditions in wastewater treatment facilities are expected to be sufficient. This includes conditions for practices such as oxidation with hypochlorite (i.e., chlorine bleach) and peracetic acid, as well as inactivation using UV irradiation.

Wastewater workers should use standard practices including basic hygiene precautions and wear the recommended PPE as prescribed for their current work tasks when handling untreated waste. There is no evidence to suggest that employees of wastewater plants need any additional protections in relation to COVID-19.

Medical waste (trash) coming from healthcare facilities treating COVID-2019 patients is no different than waste coming from facilities without COVID-19 patients. CDC’s guidance states that management of laundry, food service utensils, and medical waste should be performed in accordance with routine procedures. There is no evidence to suggest that facility waste needs any additional disinfection.

More guidance about environmental infection control is available in section 7 of CDC’s Interim Infection Prevention and Control Recommendations for Patients with Confirmed COVID-19 or Persons Under Investigation for COVID-19 in Healthcare Settings.