While new discoveries continue to be made about COVID-19, early reports indicate that person-to-person transmission most often occurs during close contact with an individual infected with COVID-19. Healthcare workers (HCWs) are not only at higher risk of infection but can also amplify outbreaks within healthcare facilities if they become ill. Identifying and managing HCWs who have been exposed to a patient with COVID-19 is of great importance in preventing healthcare transmission and protecting staff and vulnerable patients in healthcare settings.
2. Target Audience
These operational considerations are intended to be used by healthcare facilities and public health authorities in non-US healthcare settings, particularly focusing on low- and middle-income countries, assisting with the management of HCWs exposed to a person with confirmed or suspected COVID-19.
This includes but is not limited to:
- Healthcare facility leadership
- Infection prevention and control (IPC)
- Occupational health and worker safety
- Public health staff at the national and sub-national level
The goal of HCW risk assessment, work restriction, and monitoring is to:
- Allow for early identification of HCWs at high risk of exposure to COVID-19
- Reinforce the need for HCWs to self-monitor for fever and other symptoms and avoid work when ill
- Limit introduction of COVID-19 and spread within healthcare facilities by healthcare personnel
This document is only intended to advise on the management of HCWs regarding their work within healthcare facilities. Guidance on management of exposed HCWs outside of healthcare facilities (e.g., quarantine, travel-restriction) is beyond the scope of this document. Recommendations are made based on currently available data and subject to change based on newly available information.
Healthcare worker – all paid and unpaid persons serving in healthcare settings who have the potential for direct or indirect exposure to patients or their infectious secretions and materials (e.g., doctors, nurses, laboratory workers, facility or maintenance workers, clinical trainees, volunteers).
High risk exposure –
- Close contact with a person with COVID-19 in the community1; OR
- Providing direct patient care for a patient with COVID-19 (e.g., physical exam, nursing care, performing aerosol-generating procedures, specimen collection, radiologic testing), without using proper personal protective equipment (PPE)2 or not performing appropriate hand hygiene after these interactions; OR
- Having contact with the infectious secretions from a patient with COVID-19 or contaminated patient care environment, without using proper personal protective equipment (PPE) or not performing appropriate hand hygiene
Low risk exposure – contact with a person with COVID-19 having not met criteria for high-risk exposure.
Active monitoring – healthcare facility or public health authority establishes a minimum of daily communication with exposed HCWs to assess for the presence of fever or symptoms consistent with COVID-193. Monitoring could involve in-person temperature and symptom checks before starting a shift, or remote contact (e.g., telephone or electronic-based communication).
Self-monitoring – HCWs monitor themselves for fever by taking their temperature twice a day and remaining alert for respiratory and other symptoms that may be compatible with COVID-19. HCWs should be provided a plan for whom to contact if they develop fever or even mild symptoms during the self-monitoring period to determine whether medical evaluation and testing is needed.
5. Considerations when Managing HCWs Exposed to Individuals with COVID-19
Healthcare facilities may choose to manage exposed HCWs in a variety of ways and may consider multiple factors when deciding on a management strategy for exposed HCWs, including:
- Epidemiology of COVID-19 in the surrounding community
- Ability to maintain staffing levels to provide adequate care to all patients in the facility
- Availability of IPC, employee/occupational health, or other chosen personnel to carry out HCW risk assessment and monitoring activities
- Access to resources that can limit the burden of HCW active monitoring (e.g., electronic tools)
All healthcare facilities should have an established communication plan for notifying appropriate public health authorities of any HCW who requires testing for COVID-19 during the monitoring period. Staff should be aware of the established procedures for HCWs who have been exposed to a person with COVID-19 and facilities should develop paid sick leave policies and contract extensions that support the ability for staff to avoid work when ill.
Risk Assessment, Work Restriction, and Monitoring
The accompanying flowchart [see Figure] describes possible scenarios for risk assessment of exposed HCWs. Any HCW exposed to a person with COVID-19 in a healthcare facility or in the community should be quickly identified and assessed for fever or symptoms of COVID-19. If found to be symptomatic, they should be immediately restricted from work until a medical evaluation can be completed and testing for COVID-19 considered. If the exposed worker is not symptomatic, an assessment can be done to determine the risk category of exposure, necessary work restriction, and monitoring for 14 days [see Appendix 1].
Ideally, HCWs who had a high-risk exposure should be restricted from work and remain quarantined with active monitoring for COVID-19 symptoms for 14 days after the date of last exposure. If at any time the worker develops fever or symptoms, they should undergo medical evaluation and COVID-19 testing, if indicated. Those who test negative should continue to be restricted from work, actively monitored and may return to work at the end of the monitoring period if symptoms are resolved. Those HCWs who remain asymptomatic over the monitoring period may likewise return to work after 14 days. See below Considerations When Resources are Limited for alternative strategies if staffing shortages prevent the ability to restrict HCWs from work.
HCWs who had a low-risk exposure and are considered essential staff may continue to work during the 14 days after their last exposure to a COVID-19 patient. These HCWs should preferably be assigned to COVID-19 patient care and should perform self-monitoring twice a day. If the worker is scheduled for a shift, they should take their temperature and self-evaluate for symptoms before reporting to work. Healthcare facilities can consider establishing protocols in which HCWs under self-monitoring report their temperature and symptom status to IPC staff, employee/occupational health, or a designated supervisor prior to beginning a shift. If the HCW develops fever or symptoms, they should:
- Not report to work (or should immediately stop patient care if symptoms begin during a work shift)
- Alert their designated point of contact (POC)
- Be restricted from work until medical evaluation and COVID-19 testing can be performed
If testing is negative and symptoms are resolved, they may return to work while observing standard precautions and continuing to self-monitor for the remainder of the 14 days. Some facilities have instructed any exposed staff that continue working during the 14 days post-exposure (e.g., asymptomatic low-risk exposure or staff who had symptoms, tested negative and return to work within the exposure period) to wear a medical mask at all times in the facility to reduce the risk of asymptomatic or pre-symptomatic transmission.
Any HCW who tests positive for COVID-19, either in the course of monitoring after an exposure or otherwise, should be immediately restricted from work and public health notified for further case management.
There may be situations in which healthcare facilities are unable to perform contact tracing of all HCWs exposed to a known patient with COVID-19 or unable to carry out an individual risk assessment for all exposed HCWs. Some of these scenarios include:
- Inability to perform contact tracing
Healthcare delivery and traffic flow in a healthcare facility can be dynamic, and documentation of staffing assignments may not be routine practice. This has made it challenging for some healthcare facilities to identify all HCWs who had contact with a case. In situations where identifying all exposed HCWs is not possible, facilities have sent a general communication to all facility staff informing them of:
- Exposure risk
- Associated facility location(s)
- Date(s) and time(s) for potential exposure
- Instructions for staff to self-identify any known exposures to a POC so that risk assessment and public health recommendations can be made
- Instructions for staff to self-monitor for fever or respiratory symptoms for a chosen period of time and notify the POC if they become ill
- Inability to perform individual HCW risk assessments
If many HCWs were exposed to a case or there are limited IPC, employee/occupational health, or public health staff available to assist with public health management, some facilities have found it impractical or impossible to perform individual risk assessments on all exposed HCWs. Efforts have instead focused on identifying staff at highest risk of exposure to COVID-19, including those who were exposed in the setting of an aerosol-generating procedure without the use of appropriate PPE, since this would pose the highest risk of transmission to the HCW. These staff have been designated as potential high-risk exposures, with the remaining exposed staff as potentially exposed. Facilities and public health authorities then determined whether they will manage these staff as low-risk or high-risk while weighing the risks and benefits of each strategy (e.g., available resources, ability to work restrict HCWs, etc.).
Limited Testing Availability
When overall testing capacity has been limited and must be rationed, facilities and public health authorities have prioritized symptomatic HCWs for testing over low-risk groups in the community (e.g., young healthy individuals). If no testing is available, for the purposes of returning to work, these HCWs have been managed as if potentially infected with COVID-19 and can return to work based on the non-test-based strategy described below.
6. Management Considerations of HCWs Infected with COVID-19
Return to work
HCWs infected with COVID-19 may return to work after applying one of the two below strategies:
- Test-based strategy. Exclude from work until:
- Resolution of fever without the use of fever-reducing medications, and
- Improvement in respiratory symptoms (e.g., cough, shortness of breath), and
- Negative results of COVID-19 testing from at least two consecutive swab specimens collected ≥24 hours apart.5
- Non-test-based strategy. Exclude from work until:
- All symptoms have resolved, OR
- 14 days have passed since onset of symptoms
After returning to work, HCWs should continue to adhere to hand hygiene, respiratory hygiene, and cough etiquette at all times, and continue to self-monitor for symptoms, seeking medical evaluation if fever or respiratory symptoms recur.
If testing was completed and positive on an asymptomatic HCW, facilities have allowed staff to return to work when repeat testing is negative or, alternatively, no earlier than ten days after the last known positive test, assuming no symptoms develop over that period of time. HCWs who were a suspect COVID-19 case but could not be tested or declined testing should be managed according to the non-test-based-strategy.
Considerations for the Return to Work Strategy
Facilities have considered local testing availability and the facility’s ability to maintain staffing levels when deciding on which testing strategy to apply, and those factors may change over time.
If testing is limited or must be rationed, facilities have used the non-test based strategy to determine return to work, in order to conserve testing for diagnosis of persons suspected of having COVID-19, but it can be considered for HCWs who have prolonged symptoms or have underlying medical conditions that could prolong viral shedding.
While not recommended, in situations of critical staffing shortages some facilities have conferred with the local public health authorities and allowed COVID-19 infected HCWs to return to work earlier than indicated in the above strategies . This has been determined on a case-by-case basis, and facilities have considered duty restrictions, such as only permitting infected HCWs to care for COVID-19 patients or limiting them to non-patient care activities.