On July 17, 2020, CDC updated the guidance related to Discontinuation of Transmission-Based Precautions and Disposition of Patients with COVID-19 in Healthcare Settings (Interim Guidance) and the Criteria for Return to Work for Healthcare Personnel with SARS-CoV-2 Infection (Interim Guidance). Based on the updated guidance, a test-based strategy is no longer recommended to determine when to discontinue transmission-based precautions or when to allow staff to return to work because, in the majority of cases, it results in prolonged isolation of residents and excluding staff from work when they continue to shed detectable SARS-CoV-2 RNA but are no longer infectious. Instead, facilities should be using a symptom-based strategy to determine when to remove a resident from transmission-based precautions and when to allow staff to return to work following infection with COVID-19.
For residents and staff with mild to moderate illness, who are not severely immunocompromised, the following symptom-based strategy should be used for determining when transmission-based precautions can be discontinued and when staff can return to work:
- 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 have improved
- For those who tested positive and were asymptomatic throughout their infection, when at least 10 days have passed since the date of their first positive test
For residents and staff with severe to critical illness or who are severely immunocompromised:
- At least 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 have improved
- For severely immunocompromised patients who were asymptomatic throughout their infection, Transmission-Based Precautions may be discontinued when at least 20 days have passed since the date of their first positive viral diagnostic test.
When making decisions regarding discontinuing transmission-based precautions or allowing staff to return to work, the highest level of illness severity experienced at any point in their illness should be used. The criteria to determine severity of COVID-19 illness provided by the CDC includes:
- 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.
For the purpose of this guidance, CDC uses the following definition to define “severely immunocompromised”:
- Some conditions, such as being on chemotherapy for cancer, untreated HIV infection with CD4 T lymphocyte count < 200, combined primary immunodeficiency disorder, and receipt of prednisone >20mg/day for more than 14 days, may cause a higher degree of immunocompromise and inform decisions regarding the duration of Transmission-Based Precautions.
- Other factors, such as advanced age, diabetes mellitus, or end-stage renal disease, may pose a much lower degree of immunocompromise and not clearly affect decisions about duration of Transmission-Based Precautions.
- Ultimately, the degree of immunocompromise for the patient is determined by the treating provider, and preventive actions are tailored to each individual and situation.
Facilities should consult with their Medical Director and residents’ providers to assist in making determinations regarding severity of illness and if the resident or staff member is severely immunocompromised.
Based on this updated guidance, facilities should review and update their current policy and procedures related to discontinuing transmission-based precautions and excluding staff from work. It is also imperative to have good systems in place for evaluating and tracking symptoms for residents and staff to allow prompt removal from transmission-based precautions and allow staff to return to work when indicated.