Guidance on Quarantine for Health Care Personnel (HCP) Exposed to SARS-CoV-2

AFL 21-08.4 From the California Department of Public Health

September 9, 2021

TO: General Acute Care Hospitals (GACHs)
Acute Psychiatric Hospitals (APHs)
Skilled Nursing Facilities (SNFs)

SUBJECT: Guidance on Quarantine for Health Care Personnel (HCP) Exposed to SARS-CoV-2
(This AFL supersedes AFL 21-08.3)

All Facilities Letter (AFL) Summary

• The purpose of this AFL is to provide health care facilities with guidance on exposure risk assessment and the duration of quarantine for SARS-CoV-2 exposed HCP working in hospitals and SNFs, and SNF residents.
• This revision includes guidance on return to work for HCP diagnosed with COVID-19, including strategies to mitigate HCP staffing shortages.

The CDC and the California Department of Public Health (CDPH) continue to recommend a quarantine period of 14 days for unvaccinated or partially vaccinated individuals after SARS-CoV-2 exposure, based on estimates of the upper bounds of the COVID-19 incubation period. However, a 14-day quarantine for unvaccinated health care personnel may not be feasible in health care settings during critical staffing shortages when there are not enough staff to provide safe patient care. CDPH quarantine guidance for health care settings refers to CDC guidance on Strategies to Mitigate Healthcare Personnel Staffing Shortages, which include options to reduce quarantine for contacts of persons with SARS-CoV-2 infection, and quarantine and work exclusion guidance for HCP working in hospitals and SNFs, and quarantine guidance for SNF residents who have been fully vaccinated against SARS-CoV-2.

Quarantine for Exposed Hospital HCP

Hospitals should continue to use the CDC’s risk assessment framework to determine exposure risk for HCP with potential exposure to patients, visitors, and other HCP with confirmed COVID-19 in a health care setting. 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). The exposure period 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.

HCP who are not fully vaccinated against SARS-CoV-2, with higher risk exposure in a health care setting, or identified as close contacts in the community or while working in non-patient care areas, should generally be excluded from work during their quarantine period; however, hospitals may follow CDC staffing shortage mitigation strategies that provide options to reduce quarantine for asymptomatic unvaccinated HCP exposed at work or in the community, including the following CDPH-recommended options:

• Asymptomatic unvaccinated HCP may discontinue quarantine after Day 10 from the date of last exposure with or without testing.
• During critical staffing shortages, asymptomatic unvaccinated HCP are not prohibited from returning after Day 7 from the date of last exposure if they have received a negative PCR or other molecular test result from a specimen collected after Day 5.

Hospitals may also continue to use CDC guidance for staffing shortage mitigation strategies to determine when it could be appropriate to allow asymptomatic unvaccinated HCP with exposure but no known infection to continue to work onsite during their 14-day post-exposure period. Health care facilities should understand that shortening the duration of a work restriction might result in additional transmission risks.

Fully vaccinated HCP (i.e., ≥2 weeks following receipt of the second dose in a 2-dose series, or ≥2 weeks following receipt of one dose of a single-dose vaccine) with higher-risk exposures who are asymptomatic do not need to be restricted from work for 14 days following their exposure. Work restrictions for fully vaccinated HCP populations with higher-risk exposures should still be considered for HCP who have underlying immunocompromising conditions (e.g., organ transplantation, cancer treatment), which might impact level of protection provided by the COVID-19 vaccine.

General guidance on quarantine following travel applies to individuals who are hospital HCP. This guidance is that:

1. Testing before or after travel and self-quarantine after travel within the U.S. is no longer required for individuals who are fully vaccinated or COVID-19 recovered within 3 months as long as they are asymptomatic.
2. Self-quarantine after travel by air internationally and returning to the U.S. is no longer required for individuals who are fully vaccinated.

All HCP must continue wearing a surgical mask or respirator for source control within the facility. All HCP must also continue to report temperature and absence of symptoms each day.

Return to Work for Hospital HCP diagnosed with COVID-19

During critical staffing shortages that persist despite other mitigation strategies, as a last resort hospitals may consider allowing HCP with suspected or confirmed SARS-CoV-2 infection who are well enough and willing to work but have not met all Return to Work Criteria to work, following CDC Guidance on Mitigating Staffing Shortages.

Considerations for determining which HCP could be allowed to work include:

• The type of HCP shortages that need to be addressed.
• Where individual HCP are in the course of their illness (e.g., viral shedding appears to be higher earlier in the course of illness).
• The types of symptoms they are experiencing (e.g., persistent fever).
• Their degree of interaction with patients and other HCP in the facility. For example, are they working in telemedicine services, providing direct patient care, or working in a satellite unit reprocessing medical equipment?
• The type of patients they care for (e.g., immunocompromised patients or only patients with SARS-CoV-2 infection).

Positive HCP may not care for patients who have not tested COVID-19 positive until at least 10 days from the date of their positive test.

If hospital HCP are allowed to work before meeting all criteria, they should be restricted from contact with severely immunocompromised patients (e.g., transplant, hematology-oncology) and hospitals should consider prioritizing their duties in the following order:

• If not already done, allow HCP with suspected or confirmed SARS-CoV-2 infection to perform job duties where they do not interact with others (e.g., patients or other HCP), such as in telemedicine services.
• Allow HCP with confirmed SARS-CoV-2 infection to provide direct care only for patients with confirmed SARS-CoV-2 infection, preferably in a cohort setting.

Positive HCP 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.

Healthcare facilities (in collaboration with risk management) should inform patients and HCP when the facility is operating under critical staffing shortages, the changes in practice that should be expected, and actions that will be taken to protect them from exposure to SARS-CoV-2 if HCP with suspected or confirmed SARS-CoV-2 infection are allowed to work.

Quarantine for Exposed SNF HCP and Residents

SNFs should also generally use the CDC’s risk assessment framework to determine the risk of exposure for HCP with potential exposure to patients, visitors, or other HCP with confirmed COVID-19 in a health care setting. CDC guidance for assessing travel and community-related exposure should be applied to HCP with potential exposures outside of work (e.g., household) and exposures among HCP exposed to each other while working in non-patient care areas (e.g., administrative offices). 

SNF HCP who are not fully vaccinated against SARS-CoV-2, with higher risk exposure to SARS-CoV-2 or identified as close contacts in the community should be excluded from work for 14 days in the absence of staffing shortages. During critical staffing shortages, asymptomatic unvaccinated SNF HCP are not prohibited from returning to work after Day 7 from the date of last exposure if they have received a negative PCR or other molecular test result from a specimen collected after Day 5 after the date of last exposure.

Fully vaccinated SNF HCP (i.e., ≥2 weeks following receipt of the second dose in a 2-dose series, or ≥2 weeks following receipt of one dose of a single-dose vaccine) with higher-risk exposures who are asymptomatic do not need to be restricted from work for 14 days following their exposure. Work restrictions for fully vaccinated HCP populations with higher-risk exposures should still be considered for HCP who have underlying immunocompromising conditions (e.g., organ transplantation, cancer treatment), which might impact level of protection provided by the COVID-19 vaccine.

General guidance on quarantine following travel applies to individuals who are SNF HCP. This guidance is that:

1. Testing before or after travel and self-quarantine after travel within the U.S. is no longer required for individuals who are fully vaccinated or COVID-19 recovered within 3 months as long as they are asymptomatic.
2. Self-quarantine after travel by air internationally and returning to the U.S. is no longer required for individuals who are fully vaccinated.

In general, during an outbreak in a SNF, all HCP are considered potentially exposed and may continue working regardless of their vaccination status as long as they remain asymptomatic and are serially tested as part of facility-wide outbreak response testing. All HCP must continue wearing a surgical mask or respirator for source control within the facility, and report temperature and absence of symptoms each day.

CDPH guidance on quarantine recommends that SARS-CoV-2 exposed individuals who reside in a high-risk congregate living setting, such as SNF residents, quarantine for 14 days, regardless of their vaccination status. Quarantine is no longer required for residents who are being admitted to a post-acute care facility if they are fully vaccinated and have not had prolonged close contact with someone with SARS-CoV-2 infection in the prior 14 days; local health departments may continue to recommend quarantine for newly admitted residents from a hospital where there is known SARS-CoV-2 transmission. Fully vaccinated SNF residents who leave the facility for non-essential purposes (e.g., to go out to a restaurant or visit family in their home) do not need to quarantine upon return.

Return to Work for SNF HCP diagnosed with COVID-19

During critical staffing shortages that persist despite other mitigation strategies, as a last resort SNFs may consider allowing HCP with suspected or confirmed SARS-CoV-2 infection who are well enough and willing to work but have not met all Return to Work Criteria to work, following CDC Guidance on Mitigating Staffing Shortages.

SNF HCP who test positive and are well enough to work can continue to work following CDC Guidance on Mitigating Staffing Shortages, as long as they are only caring for residents with confirmed COVID-19, preferably in a cohort setting (i.e., in the Red zone). Positive HCP 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. Positive HCP may not care for residents who have not tested COVID-19 positive until at least 10 days from the date of their positive test.

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 fully vaccinated 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 HAIProgram@cdph.ca.gov or novelvirus@cdph.ca.gov.

Sincerely,

Original signed by Cassie Dunham

Cassie Dunham

Acting Deputy Director