ACEP COVID-19 Field Guide

Due to concerns about transmissibility of the SARS-CoV-2 variants (including Omicron), the guidance from the CDC continues to be updated to enhance protection for healthcare personnel, patients, and visitors, and to address concerns about potential impacts on the healthcare system given a surge of SARS-CoV-2 infections. In general, asymptomatic HCP who have had a higher-risk exposure do not require work restriction if they have received all COVID-19 vaccine doses, including booster dose, as recommended by CDC and do not develop symptoms or test positive for SARS-CoV-2. 

This guidance is intended to assist with the following:

• Determining the duration of restriction from the workplace for HCP with SARS-CoV-2 infection.
• Assessment of risk and application of workplace restrictions for asymptomatic HCP with exposure to SARS-CoV-2.

Employers should be aware that other local, state, and federal requirements may apply, including those promulgated by OSHA.

Evaluating Healthcare Personnel with Symptoms of SARS-CoV-2 Infection

HCP with even mild symptoms of COVID-19 should be prioritized for viral testing with nucleic acid or antigen detection assays; ensure that SARS-CoV-2 testing is performed with a test that is capable of detecting SARS-CoV-2 even with currently circulating variants in the United States.

• When a clinician decides that testing a person for SARS-CoV-2 is indicated, negative results from at least one FDA EUA COVID-19 viral test 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 clinician, particularly when a higher level of clinical suspicion for SARS-CoV-2 infection exists.

Table. Work Restrictions for HCP with SARS-CoV-2 Infection and Exposures

Return to Work Criteria for HCP 

Testing overview:

• 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 symptomatic HCP and for asymptomatic HCP who have recovered from SARS-CoV-2 infection in the prior 90 days.

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

• At least 7 days if a negative antigen or NAAT is obtained within 48 hours prior to returning to work (or 10 days if testing is not performed or if a positive test at day 5-7) 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 moderately to severely immunocompromised:

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

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

• In general, when 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 HCP below can be used to inform the duration of isolation.

HCP 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 consultation with an infectious disease specialist or other expert and an occupational health specialist is recommended to determine when these HCP may return to work.

The criteria for the test-based strategy are:

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 antigen test or NAAT.

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 antigen test or NAAT.

Return to Work Criteria for HCP Who Were Exposed to Individuals with Confirmed SARS-CoV-2 Infection

For this guidance it is defined as: 

• being within 6 feet of a person with confirmed SARS-CoV-2 infection 
• Distances of more than 6 feet might also be of concern, particularly when exposures occur over long periods of time in indoor areas with poor ventilation. 
• having unprotected direct contact with infectious secretions or excretions of the person with confirmed SARS-CoV-2 infection. 

Table. Recommended Work Restrictions for HCP Based on Vaccination Status and Type of Exposure