Coronavirus Disease 2019

• Emergency Medical Services (EMS) provider agencies are responsible for developing and executing an agency plan to decrease risk of COVID-19 exposure from potentially infectious EMS personnel.
• All EMS personnel should self-monitor for symptoms.
• EMS personnel should wear a medical-grade surgical/procedure mask or respirator for universal source control at all times while they are in a healthcare facility, work, and in the field .
• Unless they are fully vaccinated, EMS personnel who are a close contact to a confirmed COVID-19 case in the community or who have a high-risk occupational COVID-19 exposure should be excluded from work for 10 days from last exposure with certain exceptions for staffing shortages.

EMS personnel may be exposed to COVID-19 in the community or at home and increase the risk of transmission to patients or other co-workers. Exposures encountered by non-fully vaccinated EMS personnel at work are unlike those that might occur in the community because EMS agencies follow infection control prevention and control procedures and EMS personnel use personal protective equipment (PPE) per strict standards. Due to their often extensive and close contact with vulnerable individuals, EMS personnel with symptoms of possible COVID-19 illness and those with community or high-risk occupational exposures should be managed more conservatively.

These guidelines have evolved as a result of greater experience, the availability of published data on COVID-19, continued evidence of community transmission of COVID-19 including asymptomatic and pre-symptomatic transmission, established infection control principles, and the availability of effective COVID-19 vaccines.

In addition to following these monitoring guidelines, EMS provider agencies are expected to protect their staff and patients by following CDC and Cal/OSHA COVID-19 infection prevention guidance including universal use of PPE for patient care, use of N95 respirators for the care of suspect or confirmed COVID-19 cases, and routine respirator fit testing. For more information see:

• CDC Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html
• Cal/OSHA Interim Guidance on COVID-19 for Health Care Facilities (8-6-20) https://dir.ca.gov/dosh/coronavirus/Cal-OSHA-Guidance-for-respirator-shortages.pdf

The following healthcare exposures to a confirmed infectious COVID-19 case* are considered high-risk if the personnel are not fully vaccinated:

1. EMS personnel who performed or were present in the room during a high-risk respiratory aerosol-generating procedure (AGP) (i.e., intubation [King or direct laryngoscopy], bag mask ventilation, chest compressions, suctioning, CPAP, or nebulized treatments) where the confirmed case patient was not masked and where the EMS personnel was missing some element of PPE (either eye protection or a respirator). This includes EMS personnel that wore all other recommended PPE but who wore a facemask instead of a respirator during an AGP.
2. EMS personnel who had prolonged close contact (i.e. they were within 6 feet for a cumulative total of 15 minutes or more in a 24-hour period and/or they had direct unprotected contact with infectious secretions/excretions) with a confirmed case:
   • while not wearing a respirator or facemask.
   • while not wearing eye protection if the case was not wearing a facemask or cloth face covering.

*COVID-19 cases are considered to be infectious beginning 2 days prior to symptom onset (or initial positive viral test if case is asymptomatic) until the time they meet criteria for discontinuing transmission based-precautions.

Regardless of vaccination status, EMS personnel with any signs or symptoms of COVID-19 should be prioritized for SARS-CoV-2 diagnostic testing (and other respiratory viral testing, such as influenza as indicated), even if the symptoms are mild. Positive viral tests (molecular or antigen tests) in vaccinated personnel should not be attributed to the COVID-19 vaccine as vaccination does not affect the results of these tests.

Currently, the CDC does not generally recommend testing asymptomatic HCP who had occupational exposures (see CDC Interim Guidance on Testing Healthcare Personnel for SARS-CoV-2). The CDC does recommend testing exposed non-fully vaccinated close contacts if quarantine is to be discontinued early, see Facilities Experiencing Staffing Shortages below. Re-testing for return to work clearance is not recommended, see EMS Personnel with Confirmed COVID-19 Return-To-Work Protocol below.

EMS Provider Agencies should have a plan to evaluate EMS personnel with symptoms of possible COVID-19 illness. It is recommended that symptomatic personnel be evaluated by a clinician. SARS-CoV-2 diagnostic viral testing is recommended for personnel with even mild symptoms of possible COVID-19 infection. Symptomatic personnel with compatible symptoms and no clear alternate diagnosis should be told to isolate at home pending clinical evaluation and testing.

• A single negative SARS-CoV-2 RT-PCR result is adequate to exclude COVID-19 in symptomatic staff with lower epidemiologic risk and/or lower clinical suspicion. A negative test result from a lower sensitivity assay (e.g. antigen tests and some molecular tests), however, should be considered presumptive and confirmation with RT-PCR is recommended.
• Two negative RT-PCR tests at least 24 hours apart are recommended to exclude COVID-19 in EMS personnel with higher clinical suspicion and/or higher epidemiologic risk.

For EMS personnel who had symptoms of possible COVID-19 and had it ruled out, either with negative PCR test(s) and/or with a clinical assessment that COVID-19 is not suspected (e.g. clear alternate diagnosis), then return to work decisions should be based on their other suspected or confirmed diagnoses.

See CDC Return to Work: https://www.cdc.gov/coronavirus/2019-ncov/hcp/return-to-work.html

EMS personnel with mild to moderate illness who are not severely immunocompromised can return to work:

• At least 10 days after symptom onset AND
• At least 24 hours since last fever without fever-reducing medication AND
• Improvement in symptoms.

Asymptomatic EMS personnel who are not severely immunocompromised should be excluded from work until 10 days have passed since the date of their first positive COVID-19 diagnostic test, assuming they have not subsequently developed symptoms. If they develop symptoms, follow above guidance.

Symptomatic EMS personnel with severe or critical illness or who are severely immunocompromised can return to work:

• At least 20 days after symptom onset AND
• At least 24 hours since last fever without fever-reducing medication AND
• Improvement in symptoms.

Note: Asymptomatic personnel who are severely immunocompromised, should wait to return to work until 20 days since first positive viral diagnostic test.

For current definitions of COVID-19 illness severity and severely immunocompromised see CDC Return to Work for Healthcare Personnel with SARS-CoV-2 Infection

Return to Work Practices and Work Restrictions

EMS personnel with confirmed COVID-19 do not need medical or LAC DPH clearance to return to work. Testing of laboratory-confirmed cases is not recommended for return to work due to the prolonged detection of SARS-CoV-2 RNA without direct correlation to viral culture. Refer to the CDC Return to Work for Healthcare Personnel with SARS-CoV-2 Infection for more information on the limitations of using a test-based strategy.

EMS Provider agencies must be prepared for staffing shortages and have plans and processes in place to mitigate them. Every effort should be made to limit exposure to both patients and co-workers. Refer to the CDC Strategies to Mitigate Healthcare Personnel Staffing Shortages for protocols on contingency and crisis strategies for mitigating staffing shortages.