On June 2, 2021, the Centers for Disease Control and Prevention (CDC) updated their criteria recommendations for healthcare personnel (HCP) returning to work with confirmed COVID-19 infection or having suspected COVID-19 infection. The updated criteria is a symptoms-based strategy and not a test-based strategy.
HCP with symptoms of COVID-19 should be prioritized for viral testing with approved nucleic acid or antigen detection assays. When a clinician decides that testing a person for COVID-19 is indicated, negative results from at least one FDA Emergency Use Authorized COVID-19 laboratory-based Nucleic Acid Amplification Test (NAAT) for detection of SARS-CoV-2 RNA indicates that the person most likely does not have an active SARS-CoV-2 infection at the time the sample was collected.
A second test for SARS-CoV-2 RNA may be performed at the discretion of the evaluating healthcare provider, particularly when a higher level of clinical suspicion for SARS-CoV-2 infection exists. If the second test is positive, consultation with an infectious disease expert should be considered to resolve the discrepant results.
For HCP who were suspected of having COVID-19 and had it ruled out, return to work decisions should be based on their other suspected or confirmed diagnoses.
Decisions about return to work for HCP with COVID-19 infection should be made in the context of local circumstances. In general, a symptom-based strategy should be used as described below. The time period used depends on the HCP’s severity of illness, and whether or not they are severely immunocompromised.
A test-based strategy is not recommended except in a few instances, because in the majority of cases, it results in exclusion from work for HCPs who continue to shed COVID-19 RNA but are no longer infectious.
The CDC symptom based strategy to return to work is as follows:
HCP with mild to moderate illness who are not 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
HCP who were asymptomatic throughout their infection and are not severely immunocompromised:
- At least 10 days have passed since the date of their first positive viral diagnostic test.
HCP with severe to critical illness or who are 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
- Consider consultation with infection control experts.
The following COVID-19 Illness Severity Criteria should be used to determine the severity of the HCP illness. The highest level of illness severity experienced by the HCP at any point in their clinical course should be used when determining when they may return to work.
The illness severity criteria is as follows:
- 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.
HCP who are 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. Consultation with infectious disease specialists is recommended. Use of a test-based strategy, in consultation with occupational health, for determining when these HCP may return to work could be considered.
A test-based strategy can be used in some instances, in consultation with occupational health, and could allow HCP to return to work earlier than if the symptom-based strategy were used. A test-based strategy could also be considered for some HCP (e.g., those who are severely immunocompromised) in consultation with local infectious diseases experts if concerns exist for the HCP being infectious for more than 20 days.
The criteria for the test-based strategy are as follows:
HCP who are symptomatic:
- Resolution of fever without the use of fever-reducing medications and
- Improvement in symptoms (e.g., cough, shortness of breath), and
- Results are negative from at least two consecutive respiratory specimens collected ≥24 hours apart (total of two negative specimens) tested using an FDA-authorized laboratory-based NAAT to detect SARS-CoV-2 RNA.
HCP 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 FDA-authorized laboratory-based NAAT to detect SARS-CoV-2 RNA.
After returning to work, HCP should self-monitor for symptoms, and seek reevaluation from occupational health if symptoms recur or worsen.
Maintaining appropriate staffing in healthcare facilities is essential to providing a safe work environment for HCP and safe patient care. Healthcare facilities must be prepared for potential staffing shortages and have plans and processes in place to mitigate them, including considerations for permitting HCP to return to work without meeting all return to work criteria stated above. Access the CDC’s document here.
CDC’s Interim U.S. Guidance for Risk Assessment and Work Restrictions for Healthcare Personnel with Potential Exposure to COVID-19 can be accessed here.
CDC’s Return to Work Criteria updated on June 2, 2021, can be accessed here.
Compliance Perspective
Issue
Nursing facilities must remain vigilant against the spread of COVID-19. A critical strategy that can be taken to help decrease the spread of COVID-19 is the COVID-19 vaccination, along with other CDC recommendations to help reduce transmission of the virus. As more is researched and learned about the COVID-19 virus, healthcare personnel must stay up-to-date on the important changes and train all staff on the available information.
Discussion Points
- Review your Infection Control Plan and your policy and procedure on the COVID-19 vaccination. Ensure that both include the most up-to-date information from the CDC. Develop a process for ensuring that all required education and vaccination data is accurately recorded and is reported timely per CMS requirements.
- Train all staff on your Infection Control Plan and your COVID-19 policies for vaccination and prevention of the spread of the virus. Provide education to residents, resident representatives, and staff prior to offering the COVID-19 vaccine. Train appropriate staff on the need to record and report vaccination status for residents and staff alike per CMS guidelines. Place training documentation in each employee’s education file.
- Periodically audit to ensure that all staff are following your Infection Control Plan, and that staff are aware of the benefits and risks associated with the COVID-19 vaccination. Audit vaccine education records, consent completion, and administration rates and provide additional education where needed. Monitor to ensure that vaccination reporting occurs each week as required beginning Sunday June 13, 2021.
