ACEP COVID-19 Field Guide

When to return to work after an exposure to or infection with a transmissible disease is a complex decision that must balance the risk to the worker with the risk to the public. These risks vary depending on host and public immunity, infection transmissibility and characteristics such as asymptomatic incubation and carrier states, the underlying health of the population, and so on. Recommendations for COVID-19 have changed as the pandemic has abated. The CDC has updated its recommendations on when health care workers should return to work in its “Interim Guidance for Managing Healthcare Personnel with SARS-CoV-2 Infection or Exposure to SARS-CoV-2.” These guidelines are reasonable for other workers as well.

In general, workers who do not test positive for COVID-19 and are asymptomatic do not require work restriction. Workers with mild symptoms consistent with COVID-19 should be tested. A single negative nucleic acid amplification test (NAAT) or two negative antigen tests are generally adequate for ruling out COVID-19, unless high suspicion for COVID-19 continues to exist. Infections other than COVID-19, however, may also warrant a delay in returning to work.

Return to work criteria for health care workers who had COVID-19

The following criteria can be used to determine when health care workers who are infected with COVID-19 can return to work. The criteria are influenced by symptom severity and the presence of immunocompromising conditions. After returning to work, health care workers should self-monitor for symptoms and seek re-evaluation from their occupational health department if symptoms recur or worsen. If symptoms recur (eg, rebound) and no alternative diagnosis is identified, these workers should be restricted from work and should follow the recommended practices to prevent transmission to others (eg, use of well-fitting source control) until they again meet the return-to-work criteria.

Workers who are not moderately to severely immunocompromised

Workers who were asymptomatic throughout their infection and are not moderately to severely immunocompromised can return to work after the following criteria have been met:

• At least 7 days have passed since the date of their first positive viral test if a negative viral test is obtained within 48 hours before returning to work (or 10 days if testing is not performed or if they have a positive test at day 5-7).

Workers with mild to moderate illness who are not moderately to severely immunocompromised can return to work after the following criteria have been met:

• At least 7 days have passed since symptoms first appeared and they have a negative viral test (either NAAT or antigen testing) within 48 hours before returning to work. If an antigen test is used, a negative test should be obtained on day 5 and then again 48 hours later; or
• If testing is not performed or they have a positive test at days 5 to 7, at least 10 days since symptom onset with at least 24 hours without fever (without using fever-reducing medications) should pass and symptoms should have improved before they return to work.

Workers with severe to critical illness who are not moderately to severely immunocompromised can return to work after the following criteria have been met:

• At least 10 days and up to 20 days have passed since symptoms first appeared;
• At least 24 hours have passed since their last fever without the use of fever-reducing medications; and
• Their symptoms have improved.

Workers who are moderately to severely immunocompromised

There are no exact criteria for determining which workers will shed replication-competent virus for longer periods. Disease severity factors and the presence of immunocompromising conditions should be considered when determining the appropriate duration for specific workers. For a summary of the literature, refer to “Ending Isolation and Precautions for People with COVID-19: Interim Guidance.”

Workers 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.

The test-based strategy for moderately to severely immunocompromised workers that is described below can be used to decide the duration of work restriction. Consultation with an infectious disease specialist or other expert and an occupational health specialist should also take place to determine when these workers can return.

The test-based strategy:

• Workers who are symptomatic can return to work after the following criteria are met:
  • Resolution of fever without the use of fever-reducing medications;
  • Improvement in symptoms; and
  • Negative test results (using an antigen test or NAAT) from at least two consecutive respiratory specimens collected 48 hours apart.
• Workers who are asymptomatic can return to work after the following criteria are met:
  • Negative test results from at least two consecutive respiratory specimens collected 48 hours apart.

Return to work criteria for workers who were exposed to individuals with confirmed COVID-19

COVID-19 exposures at work or in the community may require testing or restriction from work. Higher-risk exposures generally include exposure of the worker’s eyes, nose, or mouth to material potentially contaminated with the virus, especially if these workers were in a room during an aerosol-generating procedure.

Another potential, less risky exposure includes workers having body contact with patients (eg, rolling a patient) without wearing gowns or gloves and then touching their own mucous membranes without washing their hands first. When classifying potential exposures, specific factors associated with these exposures, like the quality of ventilation and use of personal protective equipment (PPE) and source control, should be evaluated on a case-by-case basis. Certain factors could raise or lower the risk of transmission. Interventions, including work restrictions, should be adjusted based on the estimated risk.

Higher-risk exposures are classified as prolonged, close contact with a patient, visitor, or other worker with confirmed COVID-19 and:

• The exposed worker was not wearing a respirator or, if wearing a face mask, the person with COVID-19 was not wearing a cloth mask or face mask;
• The exposed worker was not wearing eye protection and the person with COVID-19 was not wearing a cloth mask or face mask; or
• The exposed worker was not wearing all recommended PPE (ie, gown, gloves, eye protection, respirator) while present in a room during an aerosol-generating procedure.

An exposure for 15 minutes or more is considered prolonged contact, referring to both a single 15-minute exposure to one individual and several briefer exposures to multiple infected individuals that add up to at least 15 minutes during a 24-hour period. In certain situations, like exposure in a confined space or during an aerosol-generating procedure, exposures shorter than 15 minutes may be considered high risk. Exposures of any duration are considered prolonged if an aerosol-generating procedure took place.

Close contact is contact within 6 feet of a person with COVID-19 or unprotected direct contact with infectious secretions or excretions of a person with COVID-19.

After a higher-risk exposure, a health care worker should:

• Have a series of three COVID-19 tests. Testing is recommended the day after exposure. If results are negative, testing should be repeated 48 hours after the first negative test. If still negative, testing should occur again 48 hours after the second negative test. This will typically be at day 1 (the day after exposure), day 3, and day 5. Because of challenges with interpreting results, testing is generally not recommended for asymptomatic people who recovered from COVID-19 in the past 30 days but should be considered for those who recovered in the past 31 to 90 days; however, in these cases, antigen testing instead of NAAT is recommended because some people can remain NAAT positive even though they are not infectious during this period.
• Follow all recommended infection prevention and control practices, including wearing well-fitting source control, monitoring themselves for fever or symptoms consistent with COVID-19, and not reporting to work when ill or testing positive for COVID-19.
• Self-isolate if they develop fever or other symptoms consistent with COVID-19 and contact their occupational health point of contact to arrange for medical evaluation and testing.

Work restriction is unnecessary for most asymptomatic health care workers who had a higher-risk exposure, regardless of their vaccination status.  Examples of when work restriction may be considered include:

• The worker is unable to be tested or wear source control as recommended for the 10 days following their exposure;
• The worker is moderately to severely immunocompromised;
• The worker cares for or works on a unit with patients who are moderately to severely immunocompromised; or
• The worker works on a unit with a COVID-19 outbreak that is not controlled with initial interventions.

If work restriction is recommended, the health care worker could return to work after either of the following time periods:

• After day 7 following the exposure (day 0) if they do not develop symptoms and all viral testing as described for asymptomatic workers following a higher-risk exposure is negative; or
• If viral testing is not performed, after day 10 following the exposure (day 0) if they do not develop symptoms.

General recommendations

Health care workers should follow all recommended infection prevention and control practices, including wearing well-fitting source control in areas that pose a risk for infection, monitoring themselves for fever or symptoms consistent with COVID-19, and not reporting to work when ill or if testing positive for COVID-19. Any worker who develops fever or symptoms consistent with COVID-19 should immediately contact their established point of contact to arrange for medical evaluation and testing.

Workers with travel or community exposures should consult their occupational health program for guidance on the need for work restrictions. In general, workers who have had prolonged close contact with someone infected with COVID-19 in the community should be managed the same as workers who have had higher-risk occupational exposures.