ACEP COVID-19 Field Guide

Guidance from the CDC on return to work criteria for HCP with confirmed or suspected COVID-19

Use one of the following strategies to determine when health care personnel (HCP) may return to work in health care settings (Figure 2.1).

Symptom-based strategy for determining when HCP can return to work:

• 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 (eg, cough, shortness of breath) have improved.
• Note: HCP who are not severely immunocompromised and were asymptomatic throughout their infection may return to work when 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 (eg, cough, shortness of breath) have improved.
• Note: HCP who are severely immunocompromised but who were asymptomatic throughout their infection may return to work when at least 20 days have passed since the date of their first positive viral diagnostic test.

The CDC is no longer recommending a test-based strategy to determine when to allow HCP to return to work. Additional information can be found on the CDC’s Guidance on Return to Work Criteria for Healthcare Workers. 

Figure 2.1 When can I return to work? Credit: Michael Macias, MD.

After returning to work, HCP should:

• Wear a face mask for source control at all times while in the health care facility until all symptoms are completely resolved or at baseline. A face mask instead of a cloth face covering should be used by these HCP for source control during this time period while in the facility. After this time period, these HCP should revert to their facility policy regarding universal source control during the pandemic.
• A face mask for source control does not replace the need to wear an N95 or higher-level respirator (or other recommended PPE) when indicated, including when caring for patients with suspected or confirmed COVID-19.
• Of note, N95 or other respirators with an exhaust valve might not provide source control.
• Self-monitor for symptoms, and seek re-evaluation from occupational health if respiratory symptoms recur or worsen.

For further information, review the CDC’s "Criteria for Return to Work for Healthcare Personnel With Confirmed or Suspected COVID-19 (Interim Guidance)."

Figure 2.2 Recommendations for monitoring and work restrictions based on risk category. Credit: Michael Macias, MD.

Public health recommendations for vaccinated persons

While mRNA COVID-19 vaccines have demonstrated high efficacy at preventing severe and symptomatic COVID-19, there is currently limited information on how much the vaccines might reduce transmission and how long protection lasts. In addition, the efficacy of the vaccines against emerging SARS-CoV-2 variants is not known. At this time, vaccinated persons should continue to follow current guidance to protect themselves and others, including wearing a mask, staying at least 6 feet away from others, avoiding crowds, avoiding poorly ventilated spaces, covering coughs and sneezes, washing hands often, following CDC travel guidance, and following any applicable workplace or school guidance, including guidance related to personal protective equipment use or SARS-CoV-2 testing.

However, vaccinated persons with an exposure to someone with suspected or confirmed COVID-19 are not required to quarantine if they meet all of the following criteria:

• Are fully vaccinated (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)
• Are within 3 months following receipt of the last dose in the series
• Have remained asymptomatic since the current COVID-19 exposure

Persons who do not meet all 3 of the above criteria should continue to follow current quarantine guidance after exposure to someone with suspected or confirmed COVID-19.

It is important to note that the CDC has not systematically evaluated the efficacy of COVID-19 vaccines from manufacturers that have not sought an EUA in the United States. For the purposes of these quarantine criteria, considerations for accepting a vaccination series that is not FDA-authorized include whether the vaccine product has received emergency approval from the World Health Organization or authorization from a national regulatory agency.

Although the risk of SARS-CoV-2 transmission from vaccinated persons to others is still uncertain, vaccination has been demonstrated to prevent symptomatic COVID-19; symptomatic and pre-symptomatic transmission is thought to have a greater role in transmission than purely asymptomatic transmission. Additionally, individual and societal benefits of avoiding unnecessary quarantine may outweigh the potential but unknown risk of transmission, and facilitate the direction of public health resources to persons at highest risk for transmitting SARS-CoV-2 to others. This recommendation to waive quarantine for people with vaccine-derived immunity aligns with quarantine recommendations for those with natural immunity, which eases implementation.

Fully vaccinated persons who do not quarantine should still watch for symptoms of COVID-19 for 14 days following an exposure. If they experience symptoms, they should be clinically evaluated for COVID-19, including SARS-CoV-2 testing, if indicated. In addition, vaccinated persons should continue to follow current guidance to protect themselves and others, including all other SARS-CoV-2 testing recommendations and requirements, and state, territorial, tribal, and local travel recommendations or requirements. For additional considerations regarding quarantine or work restrictions for fully vaccinated healthcare personnel, patients, or residents in healthcare settings, please see section below.

These quarantine recommendations for vaccinated persons, including the criteria for timing since receipt of the last dose in the vaccination series, will be updated when more data become available and additional COVID-19 vaccines are authorized.

Vaccinated healthcare personnel, patients, and residents in healthcare settings

These criteria could also be applied when considering work restrictions for fully vaccinated healthcare personnel with higher-risk exposures, as a strategy to alleviate staffing shortages. Of note, exposed healthcare personnel would not be required to quarantine outside of work.

As an exception to the above guidance no longer requiring quarantine for fully vaccinated persons, vaccinated inpatients and residents in healthcare settings should continue to quarantine following an exposure to someone with suspected or confirmed COVID-19; outpatients should be cared for using appropriate Transmission-Based Precautions. This exception is due to the unknown vaccine effectiveness in this population, the higher risk of severe disease and death, and challenges with social distancing in healthcare settings. Although not preferred, healthcare facilities could consider waiving quarantine for vaccinated patients and residents as a strategy to mitigate critical issues (e.g., lack of space, staff, or PPE to safely care for exposed patients or residents) when other options are unsuccessful or unavailable. These decisions could be made in consultation with public health officials and infection control experts.

CDC's healthcare infection control guidance contains additional considerations regarding the need to protect healthcare personnel, patients, and residents while also alleviating any staffing shortages.