AFL 21-08.8 From the California Department of Public Health
March 7, 2022
TO: General Acute Care Hospitals (GACHs)
Acute Psychiatric Hospitals (APHs)
Skilled Nursing Facilities (SNFs)
SUBJECT: Guidance on Quarantine and Isolation for Health Care Personnel (HCP) Exposed to SARS-CoV-2 and Return to Work for HCP with COVID-19
(This AFL supersedes AFL 21-08.7)
AUTHORITY: Proclamation of Emergency (PDF)
All Facilities Letter (AFL) Summary
- The purpose of this AFL is to provide hospitals and SNF with updated guidance on:
- Exposure risk assessment and work restriction for asymptomatic HCP with SARS-CoV-2 exposures (quarantine)
- Work restrictions for HCP diagnosed with SARS-CoV-2 infection (isolation)
- This revision incorporates updated Centers for Disease Control and Prevention (CDC) guidance on Interim Guidance for Managing Healthcare Personnel with SARS-CoV-2 Infection or Exposure to SARS-CoV-2 and Strategies to Mitigate Healthcare Personnel Staffing Shortages.
- Pursuant to Welfare and Institutions Code section 14126.033 a SNF’s receipt of the annual increase in the weighted average Medi-Cal reimbursement rate may be conditioned on the facility’s good faith compliance with CDPH AFLs related to the COVID-19 Public Health Emergency, as a result the recommendations included in this AFL are requirements for SNFs.
- This AFL update supersedes and removes the temporarily adjusted return-to-work criteria in place from January 8, 2022 – February 1, 2022, which was not renewed. Hospitals should and SNFs must now resume using the table, below, to guide work restrictions for HCP with SARS-CoV-2 infection and for asymptomatic HCP with exposures based upon HCP vaccination status and facility staffing level.
With the increasing number of COVID-19 cases from the Omicron variant and in preparation for an anticipated surge in patients, in December 2021, CDC updated their guidance for HCP isolation and quarantine to reflect what is currently known about infection and exposure in the context of vaccination and booster doses. Additionally, CDC updated their guidance for contingency and crisis management to mitigate the effects of staff shortages caused by COVID-19 on patient care.
In AFL 21-08.6, CDPH aligned with CDC’s shortened duration of isolation and testing considerations for SARS-CoV-2 infected HCP and consolidated the CDC’s conventional, contingency and crisis framework into “routine” and “critical staffing shortage” scenarios as outlined in the table, below. In AFL 21-08.7, due to statewide critical staffing shortages, CDPH temporarily waived these considerations from January 8, 2022 – February 1, 2022. Now that this waiver period has ended, hospitals should and SNFs must now resume using the table, below, to guide work restrictions for HCP with SARS-CoV-2 infection and for asymptomatic HCP with exposures based upon HCP vaccination status and facility staffing level.
All healthcare facilities should continue anticipating and contingency planning for staffing shortages by adjusting staff schedules, hiring additional HCP, rotating HCP to positions that support patient care activities, identifying roles that can be cross-covered by those not specifically assigned to a role, and developing regional plans to identify designated healthcare facilities or alternate care sites with adequate staffing to care for patients with SARS-CoV-2 infection. The duration of work restrictions and negative test criteria in the table below reflect CDPH recommendations; facilities and LHDs always have the option to implement more protective procedures and follow prior guidance for a longer (10-day) isolation period for infected or a longer (10-day) quarantine for exposed HCP.
Exposure Risk Assessment for HCP
Hospitals should and SNFs must use the CDC’s updated risk assessment framework to determine exposure risk for HCP with potential exposure to patients, residents, visitors, and other HCP with confirmed COVID-19 in a health care setting. CDC’s updated definition of higher-risk exposure includes use of a facemask by HCP (instead of a respirator) while caring for an infected patient who is not also wearing a facemask or cloth mask. CDC guidance for assessing travel and community-related exposures should continue to be applied to HCP with potential exposures outside of work (e.g., household,) and among HCP exposed to each other while working in non-patient care areas (e.g., administrative offices). For the purpose of contact tracing to identify exposed HCP, the exposure period for the source case begins from two days before the onset of symptoms or, if asymptomatic, two days before test specimen collection for the individual with confirmed COVID-19.
Isolation, Quarantine and Work Restriction for HCP
Hospitals should and SNFs must use the table, below, to guide work restrictions for HCP with SARS-CoV-2 infection and for asymptomatic HCP with exposures based upon HCP vaccination status and facility staffing level.
Work Restrictions for HCP with SARS-CoV-2 Infection (Isolation)
| Vaccination Status | Routine | Critical Staffing Shortage |
|---|---|---|
| Boosted, ORVaccinated but not booster-eligible | 5 days* with negative diagnostic test† same day or within 24 hours prior to return OR 10 days without a viral test | <5 days with most recent diagnostic test† result to prioritize staff placement‡ |
| Unvaccinated, ORThose that are vaccinated and booster-eligible but have not yet received their booster dose | 7 days* with negative diagnostic test† same day or within 24 hours prior to return OR10 days without a viral test | 5 days with most recent diagnostic test† result to prioritize staff placement‡ |
Work Restrictions for Asymptomatic HCP with Exposures (Quarantine)
| Vaccination Status | Routine | Critical Staffing Shortage |
|---|---|---|
| Boosted, ORVaccinated but not booster-eligible | No work restriction with negative diagnostic test† upon identification and at 5-7 days | No work restriction with diagnostic test† upon identification and at 5-7 days |
| Unvaccinated§, ORThose that are vaccinated and booster-eligible but have not yet received their booster dose§ | 7 days with diagnostic test† upon identification and negative diagnostic test† within 48 hours prior to return | No work restriction with diagnostic test† upon identification and at 5-7 days |
*Asymptomatic or mildly symptomatic with improving symptoms, and meeting negative test criteria; facilities should refer to CDC guidance for HCP with severe to critical illness or moderately to severely immunocompromised.
† Either an antigen test or nucleic acid amplification test (NAAT) can be used. 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. Antigen testing is preferred for discontinuation of isolation and return-to-work for SARS-CoV-2 infected HCP and for HCP who have recovered from SARS-CoV-2 infection in the prior 90 days; NAAT is also acceptable if done and negative within 48 hours of return.
‡ If most recent test is positive, then HCP should provide direct care only for patients/residents with confirmed SARS-CoV-2 infection, preferably in a cohort setting. This may not apply for staff types or in settings where practically infeasible (e.g., Emergency Departments where patient COVID status is unknown) or where doing so would disrupt safe nurse to patient ratios, and for staff who do not have direct patient/resident care roles.
§ In general, asymptomatic HCP who have recovered from SARS-CoV-2 infection in the prior 90 days do not require work restriction following a higher-risk exposure.
HCP whose most recent test is positive and are working before meeting routine return-to-work criteria must maintain separation from other HCP as much as possible (for example, use a separate breakroom and restroom) and wear a N95 respirator for source control at all times while in the facility. Similarly, exposed unvaccinated and vaccinated HCP who are booster-eligible but have not yet received their booster dose who are working during their quarantine period should also wear a N95 respirator for source control at all times while in the facility until they meet routine return-to-work criteria. In addition, healthcare facilities should make N95 respirators available to any HCP who wishes to wear one when not otherwise required for the care of patients or residents with suspected or confirmed COVID-19.
These recommendations will be updated as additional information becomes available, including regarding the ability of currently authorized vaccines to protect against infection with novel variants and the effectiveness of additional authorized vaccines. This could result in additional circumstances when work restrictions for HCP are recommended.
If you have any questions regarding this AFL, quarantine guidance, or work restrictions, please contact CDPH Healthcare-Associated Infections Program via email at CovHAI@cdph.ca.gov.
If you have any questions about this AFL, please contact your local district office.
Sincerely,
Original signed by Cassie Dunham
Cassie Dunham
Acting Deputy Director