Important update: Healthcare facilities
CDC has updated select ways to operate healthcare systems effectively in response to COVID-19 vaccination. Learn more
UPDATE
Given new evidence on the B.1.617.2 (Delta) variant, CDC has updated the guidance for fully vaccinated people. CDC recommends universal indoor masking for all teachers, staff, students, and visitors to K-12 schools, regardless of vaccination status. Children should return to full-time in-person learning in the fall with layered prevention strategies in place.
UPDATE
The White House announced that vaccines will be required for international travelers coming into the United States, with an effective date of November 8, 2021. For purposes of entry into the United States, vaccines accepted will include FDA approved or authorized and WHO Emergency Use Listing vaccines. More information is available here.
UPDATE
Travel requirements to enter the United States are changing, starting November 8, 2021. More information is available here.

Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic

Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic
Updated May 27, 2022

CDC’s COVID-19 Community Levels recommendations do not apply in healthcare settings, such as hospitals and nursing homes. Instead, healthcare settings should continue to use community transmission rates and continue to follow CDC’s infection prevention and control recommendations for healthcare settings.

For healthcare personnel, see Isolation and work restriction guidance. For strategies to mitigate healthcare personnel staffing shortages, see Contingency and crisis management. For healthcare professionals advising people in non-healthcare settings about isolation for laboratory-confirmed COVID-19, see Ending Isolation and Precautions for People with COVID-19.

Summary of Recent Changes

  • Updated recommendations for screening everyone entering a healthcare facility for symptoms and exposures to SARS-CoV-2 to return to more typical processes (e.g., use of signs at entrances)
  • Vaccination status is no longer used to inform circumstances when source control might not be required for everyone in the facility
  • Clarified that screening testing of asymptomatic healthcare personnel, including those in nursing homes, is at the discretion of the healthcare facility
  • The Interim Infection Prevention and Control Recommendations to Prevent SARS-CoV-2 Spread in Nursing Homes was archived and special considerations for nursing homes not otherwise covered in Sections 1 and 2 were added to Section 3: Setting-specific considerations
    • Updated screening testing recommendations for nursing home admissions
    • Quarantine is generally not necessary for admissions unless the resident meets criteria for quarantine based on close contact with someone with SARS-CoV-2 infection
  • Clarified the types of long-term care settings for whom the healthcare infection prevention and control recommendations apply
Key Points
  • This guidance applies to all U.S. settings where healthcare is delivered, including nursing homes and home health.

Introduction

This interim guidance has been updated based on currently available information about COVID-19 and the current situation in the United States.

This guidance is applicable to all U.S. settings where healthcare is delivered (including nursing homes and home health). This guidance is not intended for non-healthcare settings (e.g., restaurants) and not for persons outside of healthcare settings. CDC’s main landing page for COVID-19 content will help readers navigate to information regarding modes of transmission, clinical management, laboratory settings, COVID-19 vaccines and CDC guidance on other COVID-19-related topics.

Employers should be aware that other local, territorial, tribal, state, and federal requirements may apply, including those promulgated by the Occupational Safety and Health Administration (OSHA).

Defining Community Transmission of SARS-CoV-2

Several of the IPC measures (e.g., use of source control, universal personal protective equipment) are influenced by levels of SARS-CoV-2 transmission in the community. Community Transmission is different than the COVID-19 Community Level metric used for non-healthcare settings. Community Transmission refers to measures of the presence and spread of SARS-CoV-2. COVID-19 Community Levels place an emphasis on measures of the impact of COVID-19 in terms of hospitalizations and healthcare system strain, while accounting for transmission in the community. Community transmission remains the metric used to guide select practices in healthcare settings to allow for earlier intervention, before there is strain on the healthcare system, and better protect the vulnerable individuals seeking care in these settings.

1. Recommended routine infection prevention and control (IPC) practices during the COVID-19 pandemic

Encourage everyone to remain up to date with all recommended COVID-19 vaccine doses.

Establish a Process to Identify and Manage Individuals with Suspected or Confirmed SARS-CoV-2 Infection

  • Ensure everyone is aware of recommended IPC practices in the facility.
    • Post visual alerts (e.g., signs, posters) at the entrance and in strategic places (e.g., waiting areas, elevators, cafeterias). These alerts should include instructions about current IPC recommendations (e.g., when to use source control and perform hand hygiene). Dating these alerts can let people know that they reflect current recommendations.
  • Instruct HCP, regardless of their vaccination status, to report any of the following criteria to occupational health or another point of contact designated by the facility so they can be properly managed:
    1. a positive viral test for SARS-CoV-2,
    2. symptoms of COVID-19, or
    3. a higher-risk exposure to someone with SARS-CoV-2 infection

The definition of higher-risk exposure and recommendations for evaluation and work restriction of these HCP are in the Interim Guidance for Managing Healthcare Personnel with SARS-CoV-2 Infection or Exposure to SARS-CoV-2.

  • Provide guidance (e.g., posted signs at entrances, instructions when scheduling appointments) about recommended actions for patients and visitors who have any of the following:
    1. a positive viral test for SARS-CoV-2,
    2. symptoms of COVID-19, or
    3. close contact with someone with SARS-CoV-2 infection

Patients meeting any of the 3 above criteria should be managed as described in Section 2.

Even if visitors have met community criteria to discontinue isolation or quarantine, it is safest to defer non-urgent in-person visitation if they have any of the 3 above criteria and have not met the same criteria used to discontinue isolation and quarantine for patients.

Additional information for outpatients and visitors is available in the FAQ: How should isolation and quarantine recommendations be applied to outpatients and visitors in healthcare settings?

Implement Universal Source Control Measures Based on SARS-CoV-2 Community Transmission Levels

Source control refers to use of respirators or well-fitting facemasks or cloth masks to cover a person’s mouth and nose to prevent spread of respiratory secretions when they are breathing, talking, sneezing, or coughing.

Any of these options can be used by patients and visitors in healthcare facilities; healthcare facilities should allow the use of a mask or respirator with higher-level protection that is not visibly soiled by patients and visitors who chose that option based on their individual preference.  Additional information is available in the FAQ: What should visitors use for source control (masks or respirators) when visiting healthcare facilities?

Source control options for HCP include:

  • A NIOSH-approved N95 or equivalent or higher-level respirator OR
  • A respirator approved under standards used in other countries that are similar to NIOSH-approved N95 filtering facepiece respirators (Note: These should not be used instead of a NIOSH-approved respirator when respiratory protection is indicated) OR
  • A well-fitting facemask.

When used solely for source control, any of the options listed above could be used for an entire shift unless they become soiled, damaged, or hard to breathe through. If they are used during the care of patient for which a NIOSH-approved respirator or facemask is indicated for personal protective equipment (PPE) (e.g., NIOSH-approved N95 or equivalent or higher-level respirator) during the care of a patient with SARS-CoV-2 infection, facemask during a surgical procedure or during care of a patient on Droplet Precautions, they should be removed and discarded after the patient care encounter and a new one should be donned.  Additional information is available in the FAQ: Can employees choose to wear respirators when not required by their employer?

When SARS-CoV-2 community transmission levels are substantial or high, source control is recommended for everyone in a healthcare setting.

When SARS-CoV-2 community transmission levels are moderate or low, healthcare facilities could choose not to require universal source control for:

  • HCP when they are in well-defined areas that are restricted from patient access (e.g., when in break rooms, conference rooms, kitchen);
  • Patients and their visitors when otherwise alone in their room or in a designated visitation area when they are physically distanced from others;
    • If a roommate is present, it is safest for the visitor to wear source control;
  • Residents in nursing homes; however, they should be encouraged to wear source control, if tolerated, during care activities involving extensive close contact with HCP (e.g., during morning and evening care sessions)

However, even for the excepted situations above, source control remains recommended for individuals in healthcare settings who:

  • Have suspected or confirmed SARS-CoV-2 infection or other respiratory infection (e.g., those with runny nose, cough, sneeze); or
  • Had close contact (patients and visitors) or a higher-risk exposure (HCP) with someone with SARS-CoV-2 infection, for 10 days after their exposure; or
  • Reside or work on a unit or area of the facility where healthcare-associated SARS-CoV-2 transmission is identified; universal use of source control could be discontinued as a mitigation measure once no new cases have been identified for 14 days
  • Have otherwise had source control recommended by public health authorities

Individuals might also choose to continue using source control based on personal preference, informed by personal level of risk (e.g., if they or someone in their household is immunocompromised or at increased risk for severe disease).

Implement Universal Use of Personal Protective Equipment for HCP

If SARS-CoV-2 infection is not suspected in a patient presenting for care (based on symptom and exposure history), HCP should follow Standard Precautions (and Transmission-Based Precautions if required based on the suspected diagnosis). Additionally, HCP working in facilities located in counties with substantial or high transmission should also use PPE as described below:

  • NIOSH-approved N95 or equivalent or higher-level respirators should be used for:
    • All aerosol-generating procedures (refer to Which procedures are considered aerosol generating procedures in healthcare settings?)
    • All surgical procedures that might pose higher risk for transmission if the patient has SARS-CoV-2 infection (e.g., that generate potentially infectious aerosols or involving anatomic regions where viral loads might be higher, such as the nose and throat, oropharynx, respiratory tract).
    • NIOSH-approved N95 or equivalent or higher-level respirators can also be used by HCP working in other situations where additional risk factors for transmission are present such as the patient is not up to date with all recommended COVID-19 vaccine doses, unable to use source control, and the area is poorly ventilated.  They may also be considered if healthcare-associated SARS-CoV-2 transmission is identified and universal respirator use by HCP working in affected areas is not already in place.
    • To simplify implementation, facilities in counties with substantial or high transmission may consider implementing universal use of NIOSH-approved N95 or equivalent or higher-level respirators for HCP during all patient care encounters or in specific units or areas of the facility at higher risk for SARS-CoV-2 transmission.
  • Eye protection (i.e., goggles or a face shield that covers the front and sides of the face) should be worn during all patient care encounters.

Optimize the Use of Engineering Controls and Indoor Air Quality

  • Optimize the use of engineering controls to reduce or eliminate exposures by shielding HCP and other patients from infected individuals (e.g., physical barriers at reception / triage locations and dedicated pathways to guide symptomatic patients through waiting rooms and triage areas).
  • Take measures to limit crowding in communal spaces, such as scheduling appointments to limit the number of patients in waiting rooms or treatment areas.
  • Explore options, in consultation with facility engineers, to improve ventilation delivery and indoor air quality in patient rooms and all shared spaces.

Perform SARS-CoV-2 Viral Testing

  • FDA evaluates test characteristics and facilities should be aware of how tests perform for circulating variants.
  • Anyone with even mild symptoms of COVID-19, regardless of vaccination status, should receive a viral test as soon as possible.
  • Asymptomatic patients with close contact with someone with SARS-CoV-2 infection, regardless of vaccination status, should have a series of two viral tests for SARS-CoV-2 infection. In these situations, testing is recommended immediately (but generally not earlier than 24 hours after the exposure) and, if negative, again 5–7 days after the exposure.  In general, testing is not necessary for asymptomatic people who have recovered from SARS-CoV-2 infection in the prior 90 days; however, it could be considered in some circumstances (e.g., patient is moderately to severely immunocompromised or is residing on a unit with others who are moderately to severely immunocompromised). If testing is performed on these individuals, an antigen test instead of a nucleic acid amplification test (NAAT) is recommended.  This is because some people may remain NAAT positive but not be infectious during this period.
  • Testing considerations for healthcare facilities with an outbreak of SARS-CoV-2 are described below.
  • The yield of screening testing for identifying asymptomatic infection is likely lower when performed on those in counties with lower levels of SARS-CoV-2 community transmission. However, these results might continue to be useful in some situations (e.g., when performing higher risk procedures or for HCP caring for patients who are moderately to severely immunocompromised) to inform the type of infection control precautions used (e.g., room assignment/cohorting, or PPE used) and prevent unprotected exposures.  If implementing a screening testing program, testing decisions should not be based on the vaccination status of the individual being screened.
    • In general, performance of pre-procedure or pre-admission testing is at the discretion of the facility.  However, for residents admitted to nursing homes in counties where community transmission is substantial or high, testing is recommended upon admission and, if negative, again 5-7 days after admission.
    • Performance of expanded screening testing of asymptomatic HCP without known exposures is at the discretion of the facility.

Create a Process to Respond to SARS-CoV-2 Exposures Among HCP and Others

Healthcare facilities should have a plan for how SARS-CoV-2 exposures in a healthcare facility will be investigated and managed and how contact tracing will be performed. Guidance on assessing the risk for exposed patients and HCP is available in the Healthcare Infection Prevention and Control FAQs for COVID-19.

If healthcare-associated transmission is suspected or identified, facilities might consider expanded testing of HCP and patients as determined by the distribution and number of cases throughout the facility and ability to identify close contacts.  For example, in an outpatient dialysis facility with an open treatment area, testing should ideally include all patients and HCP.  Depending on testing resources available or the likelihood of healthcare-associated transmission, facilities may elect to initially expand testing only to HCP and patients on the affected units or departments, or a particular treatment schedule or shift, as opposed to the entire facility. If an expanded testing approach is taken and testing identifies additional infections, testing should be expanded more broadly. If possible, testing should be repeated every 3-7 days until no new cases are identified for at least 14 days.

Guidance for outbreak response in nursing homes is described in setting-specific considerations below.

Healthcare facilities responding to SARS-CoV-2 transmission within the facility should always notify and follow the recommendations of public health authorities.

2. Recommended infection prevention and control (IPC) practices when caring for a patient with suspected or confirmed SARS-CoV-2 infection

The IPC recommendations described below also apply to patients with symptoms of COVID-19 (even before results of diagnostic testing) and asymptomatic patients who have met the criteria for empiric Transmission-Based Precautions (quarantine) based on close contact with someone with SARS-CoV-2 infection. However, these patients should NOT be cohorted with patients with confirmed SARS-CoV-2 infection unless they are confirmed to have SARS-CoV-2 infection through testing.

Patients placed in empiric Transmission-Based Precautions based on close contact with someone with SARS-CoV-2 infection should be maintained in Transmission-Based Precautions for the following time periods.

  • Patients can be removed from Transmission-Based Precautions after day 10 following the exposure (day 0) if they do not develop symptoms. Although the residual risk of infection is low, healthcare providers could consider testing for SARS-CoV-2 within 48 hours before the time of planned discontinuation of Transmission-Based Precautions
  • Patients can be removed from Transmission-Based Precautions after day 7 following the exposure (day 0) if a viral test is negative for SARS-CoV-2 and they do not develop symptoms.  The specimen should be collected and tested within 48 hours before the time of planned discontinuation of Transmission-Based Precautions.

Note: In general, asymptomatic patients who are up to date with all recommended COVID-19 vaccine doses or who have recovered from SARS-CoV-2 infection in the prior 90 days do not require empiric use of Transmission-Based Precautions (quarantine) for SARS-CoV-2 following close contact with someone with SARS-CoV-2 infection.  However, these patients should still wear source control and those who have not recovered from SARS-CoV-2 infection in the prior 90 days should be tested as described in the testing section.

However, there may be circumstances when Transmission-Based Precautions (quarantine) should be considered for these patients  (e.g., patient is moderately to severely immunocompromised or is residing on a unit with others who are moderately to severely immunocompromised or is unable be tested or wear source control as recommended). In the event of ongoing transmission within a facility that is not controlled with initial interventions, strong consideration should be given to use of quarantine for patients on affected units and work restriction of HCP with higher-risk exposures, even if they are up to date with all recommended COVID-19 vaccine doses. In addition, there might be other circumstances for which the jurisdiction’s public health authority recommends these and additional precautions.

Patient Placement

  • Place a patient with suspected or confirmed SARS-CoV-2 infection in a single-person room. The door should be kept closed (if safe to do so). The patient should have a dedicated bathroom.
    • If cohorting, only patients with the same respiratory pathogen should be housed in the same room.
  • Facilities could consider designating entire units within the facility, with dedicated HCP, to care for patients with SARS-CoV-2 infection. Dedicated means that HCP are assigned to care only for these patients during their shifts.
  • Limit transport and movement of the patient outside of the room for medically essential purposes.
  • Communicate information about patients with suspected or confirmed SARS-CoV-2 infection to appropriate personnel before transferring them to other departments in the facility (e.g., radiology) and to other healthcare facilities.

Personal Protective Equipment

  • HCP who enter the room of a patient with suspected or confirmed SARS-CoV-2 infection should adhere to Standard Precautions and use a NIOSH-approved N95 or equivalent or higher-level respirator, gown, gloves, and eye protection (i.e., goggles or a face shield that covers the front and sides of the face).
    • Respirators should be used in the context of a comprehensive respiratory protection program, which includes medical evaluations, fit testing and training in accordance with the Occupational Safety and Health Administration’s (OSHA) Respiratory Protection standard (29 CFR 1910.134)
  • Additional information about using PPE is available in Protecting Healthcare Personnel

Aerosol Generating Procedures (AGPs)

  • Procedures that could generate infectious aerosols should be performed cautiously and avoided if appropriate alternatives exist.
  • AGPs should take place in an airborne infection isolation room (AIIR), if possible.
  • The number of HCP present during the procedure should be limited to only those essential for patient care and procedure support. Visitors should not be present for the procedure.

Visitation

  • For the safety of the visitor, in general, patients should be encouraged to limit in-person visitation while they are infectious. However, facilities should adhere to local, territorial, tribal, state, and federal regulations related to visitation. Additional information about visitation from the Centers for Medicare and Medicaid Services (CMS) is available at Policy & Memos to States and Regions | CMS
    • Counsel patients and their visitor(s) about the risks of an in-person visit.
    • Encourage use of alternative mechanisms for patient and visitor interactions such as video-call applications on cell phones or tablets, when appropriate.
  • Facilities should provide instruction, before visitors enter the patient’s room, on hand hygiene, limiting surfaces touched, and use of PPE according to current facility policy.
  • Visitors should be instructed to only visit the patient room. They should minimize their time spent in other locations in the facility.

Duration of Transmission-Based Precautions

The following are criteria to determine when Transmission-Based Precautions could be discontinued for patients with SARS-CoV-2 infection (isolation). These patients should self-monitor and seek re-evaluation if symptoms recur or worsen.  In general, patients who are hospitalized for SARS-CoV-2 infection should be maintained in Transmission-Based Precautions for the time period described for patients with severe to critical illness.

Information about antigen tests and NAAT is available in Testing | CDC.  Some people may be beyond the period of expected infectiousness but remain NAAT positive for an extended period. Antigen tests typically have a more rapid turnaround time but are often less sensitive than NAAT.

In general, patients should continue to wear source control until symptoms resolve or, for those who never developed symptoms, until they meet the criteria to end isolation below.  Then they should revert to usual facility source control policies for patients.

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

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

Patients who were asymptomatic throughout their infection and are not moderately to severely immunocompromised:

  • At least 10 days have passed since the date of their first positive viral test.

Patients with severe to critical illness and who are not moderately to severely immunocompromised:

  • At least 10 days and up to 20 days have passed since symptoms first appeared and
  • At least 24 hours have passed since last fever without the use of fever-reducing medications and
  • Symptoms (e.g., cough, shortness of breath) have improved
  • The test-based strategy as described for moderately to severely immunocompromised patients below can be used to inform the duration of isolation.

The exact criteria that determine which patients will shed replication-competent virus for longer periods are not known. Disease severity factors and the presence of immunocompromising conditions should be considered when determining the appropriate duration for specific patients. For a summary of the literature, refer to Ending Isolation and Precautions for People with COVID-19: Interim Guidance

Patients who are moderately to severely immunocompromised:  may produce replication-competent virus beyond 20 days after symptom onset or, for those who were asymptomatic throughout their infection, the date of their first positive viral test.

  • Use of a test-based strategy and (if available) consultation with an infectious disease specialist is recommended to determine when Transmission-Based Precautions could be discontinued for these patients.

The criteria for the test-based strategy are:

Patients who are symptomatic:

  • Resolution of fever without the use of fever-reducing medications and
  • Symptoms (e.g., cough, shortness of breath) have improved, and
  • Results are negative from at least two consecutive respiratory specimens collected ≥24 hours apart (total of two negative specimens) tested using an antigen test or NAAT (see Testing).

Patients who are not symptomatic:

  • Results are negative from at least two consecutive respiratory specimens collected ≥24 hours apart (total of two negative specimens) tested using an antigen test or NAAT (see Testing).

The decision to discontinue empiric Transmission-Based Precautions by excluding the diagnosis of current SARS-CoV-2 infection for a patient with suspected SARS-CoV-2 infection can be made based upon having negative results from at least one respiratory specimen tested using an FDA-authorized COVID-19 viral test.

  • If a higher level of clinical suspicion for SARS-CoV-2 infection exists, consider maintaining Transmission-Based Precautions and performing a second test for SARS-CoV-2 RNA.
  • If a patient suspected of having SARS-CoV-2 infection is never tested, the decision to discontinue Transmission-Based Precautions can be made based on time from symptom onset as described above.

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

Environmental Infection Control

  • Dedicated medical equipment should be used when caring for a patient with suspected or confirmed SARS-CoV-2 infection.
    • All non-dedicated, non-disposable medical equipment used for that patient should be cleaned and disinfected according to manufacturer’s instructions and facility policies before use on another patient.
  • Routine cleaning and disinfection procedures (e.g., using cleaners and water to pre-clean surfaces prior to applying an EPA-registered, hospital-grade disinfectant to frequently touched surfaces or objects for appropriate contact times as indicated on the product’s label) are appropriate for SARS-CoV-2 in healthcare settings, including those patient-care areas in which AGPs are performed.
    • Refer to List Non the EPA website for EPA-registered disinfectants that kill SARS-CoV-2; the disinfectant selected should also be appropriate for other pathogens of concern at the facility (e.g., a difficile sporicidal agent is recommended to disinfect the rooms of patients with C. difficile infection).
  • Management of laundry, food service utensils, and medical waste should be performed in accordance with routine procedures.
  • Once the patient has been discharged or transferred, HCP, including environmental services personnel, should refrain from entering the vacated room until sufficient time has elapsed for enough air changes to remove potentially infectious particles [more information (to include important footnotes on its application) on clearance rates under differing ventilation conditions is available]. After this time has elapsed, the room should undergo appropriate cleaning and surface disinfection before it is returned to routine use.

3. Setting-specific considerations

In addition to the recommendations described in the guidance above, here are additional considerations for the settings listed below.

Dialysis Facilities

Considerations for Patient Placement

  • Patients on dialysis with suspected or confirmed SARS-CoV-2 infection or who have reported close contact should be dialyzed in a separate room with the door closed.
    • Hepatitis B isolation rooms can be used if: 1) the patient is hepatitis B surface antigen positive or 2) the facility has no patients on the census with hepatitis B infection who would require treatment in the isolation room.
  • If a separate room is not available, patients with confirmed SARS-CoV-2 infection should be cohorted to a specific well-ventilated unit or shift (e.g., consider the last shift of the day). Only patients with confirmed SARS-CoV-2 infection should be cohorted together:
    • In the context of an outbreak or an increase in the number of confirmed SARS-CoV-2 infections at the facility, if a separate shift or unit is not initially available, efforts should be made to create specific shifts or units for patients with confirmed SARS-CoV-2 infection to separate them from patients without SARS-CoV-2 infection.

Additional Guidance for Use of Isolation Gowns

  • When caring for patients with suspected or confirmed SARS-CoV-2 infection, gowns should be worn over or instead of the cover gown (e.g., laboratory coat, gown, or apron with incorporate sleeves) that is normally worn by hemodialysis personnel.

Cleaning and Disinfecting Dialysis Stations

Emergency Medical Services

Considerations for vehicle configuration when transporting a patient with suspected or confirmed SARS-CoV-2 infection

  • Isolate the ambulance driver from the patient compartment and keep pass-through doors and windows tightly shut.
  • When possible, use vehicles that have isolated driver and patient compartments that can provide separate ventilation to each area.
    • Before entering the isolated driver’s compartment, the driver (if they were involved in direct patient care) should remove and dispose of PPE and perform hand hygiene to avoid soiling the compartment.
    • Close the door/window between these compartments before bringing the patient on board.
    • During transport, vehicle ventilation in both compartments should be on non-recirculated mode to maximize air changes that reduce potentially infectious particles in the vehicle.
    • If the vehicle has a rear exhaust fan, use it to draw air away from the cab, toward the patient-care area, and out the back end of the vehicle.
    • Some vehicles are equipped with a supplemental recirculating ventilation unit that passes air through high-efficiency particulate air (HEPA) filters before returning it to the vehicle. Such a unit can be used to increase the number of air changes per hour (ACH) Health Hazard Evaluation Report 95–0031–2601 pdf icon[1.52 MB, 10 Pages].
    • After patient unloading, allowing a few minutes with ambulance module doors open will rapidly dilute airborne viral particles.
  • If a vehicle without an isolated driver compartment must be used, open the outside air vents in the driver area and turn on the rear exhaust ventilation fans to the highest setting to create a pressure gradient toward the patient area.
    • Before entering the driver’s compartment, the driver (if they were involved in direct patient care) should remove their gown, gloves and eye protection and perform hand hygiene to avoid soiling the compartment. They should continue to wear their NIOSH-approved N95 or equivalent or higher-level respirator.

Additional considerations when performing AGPs on patients with suspected or confirms SARS-CoV-2 infection:

  • If possible, consult with medical control before performing AGPs for specific guidance.
  • Bag valve masks (BVMs) and other ventilatory equipment should be equipped with HEPA filtration to filter expired air.
  • EMS systems should consult their ventilator equipment manufacturer to confirm appropriate filtration capability and the effect of filtration on positive-pressure ventilation.
  • If possible, the rear doors of the stationary transport vehicle should be opened and the HVAC system should be activated during AGPs. This should be done away from pedestrian traffic.
  • If possible, discontinue AGPs prior to entering the destination facility or communicate with receiving personnel that AGPs are being implemented.

Dental Facilities

  • Dental healthcare personnel (DHCP) should regularly consult their state dental boards and state or local health departments for current information and recommendations and requirements specific to their jurisdictions, which might change based on SARS-CoV-2 transmission levels in the county where their healthcare facility is located.
  • Postpone all non-urgent dental treatment for: 1) patients with suspected or confirmed SARS-CoV-2 infection until they meet criteria to discontinue Transmission-Based Precautions and 2) patients who meet criteria for quarantine until they complete quarantine as described for healthcare settings above.
    • Dental care for these patients should only be provided if medically necessary. Follow all recommendations for care and placement for patients with suspected or confirmed SARS-CoV-2 infection. Extra attention may be required to ensure HVAC ventilation to the dental treatment area does not reduce or deactivate during occupancy based on temperature demands.
    • If a patient has a fever strongly associated with a dental diagnosis (e.g., pulpal and periapical dental pain and intraoral swelling are present) but no other symptoms consistent with COVID-19 are present, dental care can be provided following the practices recommended for routine health care during the pandemic.
  • When performing aerosol generating procedures on patients who are not suspected or confirmed to have SARS-CoV-2 infection, ensure that DHCP correctly wear the recommended PPE (including a NIOSH-approved N95 or equivalent or higher-level respirator in counties with substantial or high levels of transmission) and use mitigation methods such as four-handed dentistry, high evacuation suction, and dental dams to minimize droplet spatter and aerosols.
    • Commonly used dental equipment known to create aerosols and airborne contamination include ultrasonic scaler, high-speed dental handpiece, air/water syringe, air polishing, and air abrasion.
  • Dental treatment should be provided in individual patient rooms whenever possible with the HVAC in constant ventilation mode.
  • For dental facilities with open floor plans, strategies to prevent the spread of pathogens include:
    • At least 6 feet of space between patient chairs.
    • Adjunct use of portable HEPA air filtration systems to enhance air cleaning
    • Physical barriers between patient chairs. Easy-to-clean floor-to-ceiling barriers will enhance effectiveness of portable HEPA air filtration systems (check to make sure that extending barriers to the ceiling will not interfere with fire sprinkler systems).
    • Operatories oriented parallel to the direction of airflow when possible.
    • Where feasible, consider patient orientation carefully, placing the patient’s head near the return air vents, away from pedestrian corridors, and toward the rear wall when using vestibule-type office layouts.
    • Ensure to account for the time required to clean and disinfect operatories between patients when calculating your daily patient volume.

Nursing Homes

  • Assign one or more individuals with training in infection prevention and control (IPC) to provide on-site management of the IPC program
    • This should be a full-time role for at least one person in facilities that have more than 100 residents or that provide on-site ventilator or hemodialysis services. Smaller facilities should consider staffing the IPC program based on the resident population and facility service needs identified in the IPC risk assessment.
  • Stay connected with the healthcare-associated infection program in your state health department, as well as your local health department, and their notification requirements. Report SARS-CoV-2 infection data to National Healthcare Safety Network (NHSN) Long-term Care Facility (LTCF) COVID-19 Module. See Centers for Medicare and Medicaid Services (CMS) COVID-19 reporting requirements.
  • Managing admissions and residents who leave the facility:
    • In general, admissions in counties where community transmission is substantial or high should be tested upon admission and, if negative, again 5-7 days after admission; they should also be advised to wear source control for the 10 days following their admission.  Residents who leave the facility for 24 hours or longer should generally be managed as an admission
      • Quarantine is generally not necessary unless the resident meets criteria for quarantine based on close contact with someone with SARS-CoV-2 infection. However, it could be considered during higher levels of community transmission.
    • In most circumstances, quarantine is not recommended for residents who leave the facility for less than 24 hours (e.g., for medical appointments, community outings with family or friends) and do not have close contact with someone with SARS-CoV-2 infection, even in counties where transmission levels are high.
      • Quarantining residents who regularly leave the facility for medical appointments (e.g., dialysis, chemotherapy) would result in indefinite isolation of the resident that likely outweighs any potential benefits of quarantine.
    • Responding to a newly identified SARS-CoV-2-infected HCP or resident
      • When performing an outbreak response to a known case, facilities should always defer to the recommendations of the jurisdiction’s public health authority.
      • A single new case of SARS-CoV-2 infection in any HCP or resident should be evaluated to determine if others in the facility could have been exposed.
        • The approach to an outbreak investigation could involve contact tracing or a broad-based approach and should take into consideration whether the facility has the experience and resources to perform individual contact tracing, whether there are other individuals with suspected or confirmed SARS-CoV-2 infection identified at the same time as the initial case, and the extent of potential exposures identified during the evaluation of the initial case.
        • Consider increasing clinical evaluation of all residents from daily to every shift, to more rapidly detect those with new symptoms.
      • Perform contact tracing to identify any HCP with higher-risk exposure or residents with close contact with the individual with SARS-CoV-2 infection:
        • HCP with higher-risk exposures should be managed as described in the Interim U.S. Guidance for Managing Healthcare Personnel with SARS-CoV-2 infection or Exposure to SARS-CoV-2.
        • Residents identified as close contacts (e.g., roommates) should be tested and managed as described in Sections 1 and 2
        • If testing reveals additional HCP or residents with SARS-CoV-2 infection, contact tracing should be continued or a broad-based approach can be used, as described in the broad-based approach section below.
          • A facility-wide or group-level (e.g., unit, floor, or other specific area(s) of the facility) approach is preferred if all potential contacts cannot be identified or managed with contact tracing or if contact tracing fails to halt transmission.
        • Broad-based approach:
          • If contact tracing is not feasible, the facility should instead investigate the outbreak at a facility-level or group-level (e.g., unit, floor, or other specific area(s) of the facility).
            • Broader approaches might also be required if the facility is directed to do so by the jurisdiction’s public health authority, or in situations where all potential contacts are unable to be identified, are too numerous to manage, or when contact tracing fails to halt transmission.
          • Perform testing for all residents and HCP on the affected unit(s), regardless of vaccination status, immediately (but generally not earlier than 24 hours after the exposure, if known) and, if negative, again 5-7 days later.
          • Residents who are not up to date with all recommended COVID-19 vaccine doses should generally be placed in quarantine, even if testing is negative.
          • Residents who are up to date with all recommended COVID-19 vaccine doses should wear source control and be tested as described in the testing section; they do not need to be restricted to their rooms or cared for by HCP using the full PPE recommended for the care of a resident with SARS-CoV-2 infection unless they develop symptoms of COVID-19, are diagnosed with SARS-CoV-2 infection, or the facility is directed to do so by the jurisdiction’s public health authority.
            • In the event of ongoing transmission within a facility that is not controlled with initial interventions, strong consideration should be given to use of quarantine for residents and work restriction of HCP with higher-risk exposures, even if they are up to date with all recommended COVID-19 vaccine doses. In addition, there might be other circumstances for which the jurisdiction’s public authority recommends these and additional precautions.
          • If no additional cases are identified during the broad-based testing, no further testing is indicated. Quarantine for residents who are not up to date with all recommended COVID-19 vaccine doses can be discontinued as described in Section 2 for residents who were known to be close contacts; A similar approach can be taken for residents whose contact status was unknown (e.g., quarantine can be discontinued after the last round of testing).
          • If additional cases are identified, testing should continue on affected unit(s) or facility-wide every 3-7 days in addition to quarantine of residents who are not up to date with all recommended COVID-19 vaccine doses, regardless of their close contact status, until there are no new cases for 14 days.
            • If antigen testing is used, more frequent testing (every 3 days), should be considered.
          • Indoor visitation during an outbreak response:
            • Facilities should follow guidance from CMS about visitation.
            • Visitors should be counseled about their potential to be exposed to SARS-CoV-2 in the facility.
            • When residents who are up to date with all recommended COVID-19 vaccine doses are known to be close contacts or are identified as a part of a broad-based outbreak response but not known to be close contacts, indoor visitation should ideally occur in the resident’s room. The resident and their visitors should wear well-fitting source control (if tolerated) and physically distance (if possible) during the visit.
            • Source control and physical distancing recommendations should also be followed for residents who are up to date with all recommended COVID-19 vaccine doses.
            • Outdoor visitation could be allowed, but residents should wear well-fitting source control (if tolerated), maintain physical distancing from others, and not linger in common spaces when moving from their rooms to the outdoors.

Assisted living communities, group homes and other residential care settings (excluding nursing homes)

In general, long-term care settings (excluding nursing homes) whose staff only provide non-skilled personal care* similar to that provided by family members in the home (e.g., many assisted living communities, group homes), should follow community prevention strategies based on COVID-19 Community Levels, similar to independent living, retirement communities or other non-healthcare congregate settings. Residents should also be counseled about strategies to protect themselves and others, including recommendations for source control if they are immunocompromised or at high risk for severe disease. CDC has information and resources for older adults and for people with disabilities.

Healthcare personnel who enter the setting to provide skilled care to one or more residents (e.g., physical therapy, wound care, intravenous injections, or catheter care provided by home health agency nurses) should follow the healthcare IPC recommendations in this guidance. In addition, if staff in a residential care setting are providing in-person services for a resident with SARS-CoV-2 infection, they should be familiar with recommended IPC practices to protect themselves and others from potential exposures including the hand hygiene, personal protective equipment and cleaning and disinfection practices outlined in this guidance.

*Non-skilled personal care consists of any non-medical care that can reasonably and safely be provided by non-licensed caregivers, such as help with daily activities like bathing and dressing; it may also include the kind of health-related care that most people do themselves, like taking oral medications. In some cases where care is received at home or a residential setting, care can also include help with household duties such as cooking and laundry.

Definitions:

Healthcare Personnel (HCP): HCP refers to all paid and unpaid persons serving in healthcare settings who have the potential for direct or indirect exposure to patients or infectious materials, including body substances (e.g., blood, tissue, and specific body fluids); contaminated medical supplies, devices, and equipment; contaminated environmental surfaces; or contaminated air. HCP include, but are not limited to, emergency medical service personnel, nurses, nursing assistants, home healthcare personnel, physicians, technicians, therapists, phlebotomists, pharmacists, dental healthcare personnel, students and trainees, contractual staff not employed by the healthcare facility, and persons not directly involved in patient care, but who could be exposed to infectious agents that can be transmitted in the healthcare setting (e.g., clerical, dietary, environmental services, laundry, security, engineering and facilities management, administrative, billing, and volunteer personnel).

Healthcare settings refers to places where healthcare is delivered and includes, but is not limited to, acute care facilities, long-term acute-care facilities, inpatient rehabilitation facilities, nursing homes, home healthcare, vehicles where healthcare is delivered (e.g., mobile clinics), and outpatient facilities, such as dialysis centers, physician offices, dental offices, and others.

Source control: Use of respirators, well-fitting facemasks, or well-fitting cloth masks to cover a person’s mouth and nose to prevent spread of respiratory secretions when they are breathing, talking, sneezing, or coughing. Source control devices should not be placed on children under age 2, anyone who cannot wear one safely, such as someone who has a disability or an underlying medical condition that precludes wearing one safely, or anyone who is unconscious, incapacitated, or otherwise unable to remove their source control device without assistance. Face shields alone are not recommended for source control. At a minimum, source control devices should be changed if they become visibly soiled, damaged, or hard to breathe through.

Cloth mask: Textile (cloth) covers that are intended primarily for source control in the community. They are not personal protective equipment (PPE) appropriate for use by healthcare personnel. Guidance on design, use, and maintenance of cloth masks is available.

Facemask: OSHA defines facemasks as “a surgical, medical procedure, dental, or isolation mask that is FDA-cleared, authorized by an FDA EUA, or offered or distributed as described in an FDA enforcement policy. Facemasks may also be referred to as ‘medical procedure masks.”  Facemasks should be used according to product labeling and local, state, and federal requirements. FDA-cleared surgical masks are designed to protect against splashes and sprays and are prioritized for use when such exposures are anticipated, including surgical procedures. Other facemasks, such as some procedure masks, which are typically used for isolation purposes, may not provide protection against splashes and sprays.

Respirator: A respirator is a personal protective device that is worn on the face, covers at least the nose and mouth, and is used to reduce the wearer’s risk of inhaling hazardous airborne particles (including dust particles and infectious agents), gases, or vapors. Respirators are certified by CDC/NIOSH, including those intended for use in healthcare.

Airborne Infection Isolation Rooms (AIIRs):

  • AIIRs are single-patient rooms at negative pressure relative to the surrounding areas, and with a minimum of 12 ACH (6 ACH are allowed for AIIRs last renovated or constructed prior to 1997).
  • Air from these rooms should be exhausted directly to the outside or be filtered through a HEPA filter directly before recirculation.
  • Room doors should be kept closed except when entering or leaving the room, and entry and exit should be minimized.
  • Facilities should monitor and document the proper negative-pressure function of these rooms.

Immunocompromised:  For the purposes of this guidance, moderate to severely immunocompromising conditions include, but might not be limited to, those defined in the Interim Clinical Considerations for Use of COVID-19 Vaccines

  • Other factors, such as end-stage renal disease, may pose a lower degree of immunocompromise. However, people in this category should still consider continuing to practice physical distancing and use of source control while in a healthcare facility, even if they are up to date with all recommended COVID-19 vaccine doses.
  • Ultimately, the degree of immunocompromise for the patient is determined by the treating provider, and preventive actions are tailored to each individual and situation.

Close contact:  Being within 6 feet for a cumulative total of 15 minutes or more over a 24-hour period with someone with SARS-CoV-2 infection.

SARS-CoV-2 Illness Severity Criteria (adapted from the NIH COVID-19 Treatment Guidelines)

The studies used to inform this guidance did not clearly define “severe” or “critical” illness. This guidance has taken a conservative approach to define these categories. Although not developed to inform decisions about duration of Transmission-Based Precautions, the definitions in the National Institutes of Health (NIH) COVID-19 Treatment Guideline are one option for defining severity of illness categories. The highest level of illness severity experienced by the patient at any point in their clinical course should be used when determining the duration of Transmission-Based Precautions. Clinical judgement regarding the contribution of SARS-CoV-2 to clinical severity might also be necessary when applying these criteria to inform infection control decisions.

Mild Illness: Individuals who have any of the various signs and symptoms of COVID-19 (e.g., fever, cough, sore throat, malaise, headache, muscle pain) without shortness of breath, dyspnea, or abnormal chest imaging.

Moderate Illness: Individuals who have evidence of lower respiratory disease by clinical assessment or imaging, and a saturation of oxygen (SpO2) ≥94% on room air at sea level.

Severe Illness: Individuals who have respiratory frequency >30 breaths per minute, SpO2 <94% on room air at sea level (or, for patients with chronic hypoxemia, a decrease from baseline of >3%), ratio of arterial partial pressure of oxygen to fraction of inspired oxygen (PaO2/FiO2) <300 mmHg, or lung infiltrates >50%.

Critical Illness: Individuals who have respiratory failure, septic shock, and/or multiple organ dysfunction.

In pediatric patients, radiographic abnormalities are common and, for the most part, should not be used as the sole criteria to define COVID-19 illness category. Normal values for respiratory rate also vary with age in children, thus hypoxia should be the primary criterion to define severe illness, especially in younger children.