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Coronavirus Disease 2019

Infection Prevention Guidance for Healthcare Personnel


1-8-22: Due to the critical staffing shortages currently being experienced across the health care continuum because of the rise in the Omicron variant, effective January 8, 2022 through February 1, 2022, CDPH is temporarily adjusting the return-to-work criteria. During this time, this guidance will supersede the tables 2 and 3 below.

During this time, HCPs who have tested positive for SARS-CoV-2 and are asymptomatic may return to work immediately without isolation and without testing, and HCPs who have been exposed and are asymptomatic may return to work immediately without quarantine and without testing. These HCPs must wear an N95 respirator for source control. Facilities implementing this change must have made every attempt to bring in additional registry or contract staff and must have considered modifications to non-essential procedures.

See CDPH AFL: https://www.cdph.ca.gov/Programs/CHCQ/LCP/Pages/AFL-21-08.aspx.

Summary of Recent Changes
Significant changes to this guidance include the following:

1-3-22

  • Updated the COVID-19 vaccination section and the Return to Work sections for exposed HCP and infected HCP to reflect new CDPH and CDC recommendations for isolation, quarantine, return to work, and testing by vaccination status for healthcare personnel during routine and critical staffing shortages.
  • Added new language to source control section including that healthcare facilities should make N95 respirators available to any HCP who wishes to wear one when not otherwise required for the care of patients or residents with suspected or confirmed COVID-19.
  • The definition of higher-risk exposure was updated to include use of a facemask (instead of a respirator) by HCP if the infected patient is not also wearing a facemask or cloth mask.
Key Points
  • Your healthcare facility (HCF) is responsible for developing and executing your facility’s plan to decrease risk of COVID exposure from potentially infectious healthcare personnel (HCP).
  • HCP refers to clinical and non-clinical staff within your HCF.
  • All HCP should self-monitor for symptoms of COVID-19
  • HCP should wear a medical-grade surgical/procedure mask or respirator for universal source control while they are in the healthcare facility.
  • COVID-19 vaccination, including a booster dose, is required for most HCP per local and state orders. HCP granted an exemption to vaccination and booster doses must be tested for COVID-19, at least weekly, based on facility type.
  • HCP who have not received all COVID-19 vaccine and booster doses must quarantine and be excluded from work for 7 days after a higher-risk work or community exposure with exceptions for critical staffing shortages.
Background

HCP may be exposed to COVID-19 in the community or at home and increase the risk of transmission to patients or other HCP, especially if they are not up-to-date with their COVID-19 vaccinations. Exposures encountered by HCP at work are unlike those that might occur in the community because HCF follow infection control prevention and control procedures and HCP use personal protective equipment (PPE) per strict standards. Due to their often extensive and close contact with vulnerable individuals, HCP with symptoms of possible COVID-19 illness and those with community or high-risk occupational exposures who have not received all COVID-19 vaccine and booster doses as recommended by CDC should be managed more conservatively.

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

In addition to following these HCP guidelines, HCF are required to follow State and Local Health Officer Orders and All Facilities Letters (AFLs) including health care worker vaccination requirements and return to work for exposed and infected HCP:

They are also expected to follow CDC and Cal/OSHA COVID-19 infection prevention guidance and requirements 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.

Employers and facilities can have policies that are stricter than those required by State and County Health Officer Orders and Cal/OSHA or recommended by the CDC.

Recommendations
COVID-19 Vaccination

Completion of a COVID-19 vaccine primary series decreases the risk of severe disease, hospitalization, and death from COVID-19, including the Omicron variant. However, vaccine effectiveness against infection with Omicron variant appears to be significantly decreased without a booster dose. Data from South Africa and the United Kingdom demonstrate that COVID-19 vaccine effectiveness against infection for two doses of an mRNA vaccine is approximately 35%. A COVID-19 vaccine booster dose restores vaccine effectiveness against infection to 75%.

HCP that are fully vaccinated and have received their booster dose as recommended by the CDC are “boosted”. In general, they do not require work restriction if they have a high-risk exposure.

HCP that are fully vaccinated and booster-eligible but have not received their booster dose and those that are unvaccinated do have work restrictions after a high-risk exposure. HCP that are not up to date with COVID-19 vaccination are required to participate in regular testing.  

Health Care Worker Vaccine Requirement

All persons who work in healthcare facilities must be vaccinated against COVID-19 as required by the California and the LA County Public Health Officers. Effective February 1, 2022 this includes receipt of a booster dose, when eligible. Workers not yet eligible for boosters must be in compliance no later than 15 days after becoming eligible for the booster dose. See Table 1 below.

Workers may be exempt from the vaccination requirements based on either a) Religious Beliefs or b) a Qualifying Medical Reason. (See the CDC’s Interim Clinical Considerations for Use of COVID-19 Vaccines for clinical guidance.)

Refer to Table 1 for current immunization requirements.

Table 1. California Immunization Requirements for Covered Workers                                  
COVID-19 Vaccine Primary vaccination series When to get the vaccine booster dose Which vaccine booster dose to receive
Moderna 1st and 2nd doses Booster dose 5 months after 2nd dose Any of the COVID-19 vaccines authorized in the United States may be used for the booster dose, but either Moderna or Pfizer-BioNTech are preferred.
Pfizer-BioNTech 1st and 2nd doses Booster dose 5 months after 2nd dose Any of the COVID-19 vaccines authorized in the United States may be used for the booster dose, but either Moderna or Pfizer-BioNTech are preferred.
Johnson and Johnson [J&J]/Janssen 1st dose Booster dose 2 months after 1st dose Any of the COVID-19 vaccines authorized in the United States may be used for the booster dose, but either Moderna or Pfizer-BioNTech are preferred.
World Health Organziation (WHO) emergency use listing COVID-19 vaccine All recommended doses Booster dose 5 months after getting all recommended doses Single booster dose of Pfizer-BioNTech COVID-19 vaccine
A mix and match series composed of any combination of FDA-approved, FDA-authorized, or WHO-EUL COVID-19 vaccines All recommended doses Booster dose 5 months after getting all recommended doses Single booster dose of Pfizer-BioNTech COVID-19 vaccine

Those workers currently eligible for booster doses per the Table above must receive their booster dose by no later than February 1, 2022. Workers not yet eligible for boosters must be in compliance no later than 15 days after the recommended timeframe above for receiving the booster dose.

Source Control
  • HCPs should wear medical-grade surgical/procedure masks or respirators for universal source control at all times while they are in the healthcare facility, regardless of vaccination status. Healthcare facilities should make N95 respirators available to any HCP who wishes to wear one when not otherwise required for the care of patients or residents with suspected or confirmed COVID-19.
  • When a surgical facemask is worn, it is important that it fits well. For more information refer to guidance in the CDC Interim Infection Prevention & Control Recommendations. CDC has also created an FAQ addressing use of 2 masks at the same time to improve the fit of facemasks in a healthcare setting.
  • N95 respirators should be worn while caring for patients with possible or confirmed COVID-19.
Symptom Monitoring
  • All HCP should routinely self-monitor for symptoms of possible COVID-19.
  • HCP with symptoms of possible COVID-19 should contact the HCF before presenting for work. It is recommended that symptomatic HCP be assessed by a clinician. The clinician should determine if further medical evaluation and COVID-19 testing is needed prior to allowing the HCP to work. See Return to Work for Symptomatic HCP.
  • Prior to the start of their shift, HCF should screen all HCP for symptoms of COVID-19. Temperature checks of HCP prior to work is helpful in ensuring a healthy workforce but is of unclear benefit in the setting of a highly vaccinated workforce and is not required. HCF should perform a risk assessment to determine the most effective methodologies to protect HCP and patients within their facilities. HCF should develop and implement screening systems that cause the least amount of delay and disruption as possible (e.g., HCP self-report, single use disposable thermometers, or thermal scanners).
  • If HCP develop symptoms of possible COVID-19 while at work, they should keep their mask/respirator on and notify their supervisor to arrange leaving the workplace and obtaining medical evaluation and/or COVID-19 testing as appropriate.
  • Afebrile HCP who develop typical vaccine-associated symptoms within 2 days of receiving a COVID-19 vaccination (e.g., headache, chills, myalgias, arthralgias) may be permitted to continue to work as long as they meet specific criteria as outlined in Post Vaccination Assessment of Symptomatic Healthcare Personnel. Note: cough, shortness of breath, rhinorrhea, sore throat, or loss of taste or smell ARE NOT consistent with COVID-19 vaccination.
Exposed HCP Quarantine and Return to Work

HCP with higher-risk workplace exposures or community exposures are managed more conservatively if they are unvaccinated OR they are vaccinated and booster eligible but have not yet received their booster dose.

HCF should follow the table below to guide the management and work restrictions for asymptomatic HCP with high-risk exposures based upon their vaccination status and facility staffing level.  

There are no work restrictions for HCP with a lower risk exposure. However, all HCP with exposure to SARS-CoV-2 who are not restricted from work should follow all recommended infection prevention and control practices, including wearing well-fitting source control, monitoring themselves for fever or symptoms consistent with COVID-19, and not reporting to work when ill or if testing positive for SARS-CoV-2 infection. Exposed unvaccinated and vaccinated HCP who are booster-eligible but have not yet received their booster dose who are working during their quarantine period should wear a N95 respirator for source control at all times while in the facility until they meet routine return-to-work criteria. 

Table 2. Work Restrictions for Asymptomatic* HCP with Exposures (Quarantine)                        
Vaccination Status Routine Critical Staffing Shortage
Boosted
OR
Vaccinated but not yet booster-eligible
No work restriction with negative diagnostic test upon identification and at 5-7 days No work restriction with diagnostic test upon identification and at 5-7 days
Unvaccinated§, OR Those that are vaccinated and booster-eligible but have not yet received their booster dose§ 7 days with diagnostic test upon identification and negative diagnostic test within 48 hours prior to return No work restriction with diagnostic test upon identification and at 5-7 days

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 discontinuation of isolation and return-to-work for SARS-CoV-2 infected HCP and for HCP who have recovered from SARS-CoV-2 infection in the prior 90 days; NAAT is also acceptable if done and negative within 48h of return.

§Includes persons with prior infection. 

Definitions of High-Risk Exposure

High-risk occupational exposure

In the healthcare setting, the following exposures to a confirmed infectious COVID-19 case* are considered high-risk:

  1. HCP not wearing a respirator (or if wearing a facemask, the person with SARS-CoV-2 infection was not wearing a cloth mask or facemask).
  2. HCP not wearing eye protection if the person with SARS-CoV-2 infection was not wearing a cloth mask or facemask.
  3. HCP not wearing all recommended PPE (i.e., gown, gloves, eye protection, respirator) while performing an aerosol-generating procedure.

Community Exposure

All close contact community exposures are considered high-risk exposures. A close contact is any of the following persons who were exposed to a laboratory-confirmed COVID-19 case while they were infectious:

  • Persons who were within six (6) feet of the case for a total of 15 minutes or more over a 24-hour period** or
  • Persons who had unprotected contact with the case’s body fluids and/or secretions, for example, being coughed or sneezed on or sharing of a drink or food utensils.

**This is regardless of use of face masks of the case or contact.

*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 isolation.

For more information, see the following CDPH guidance:

Testing Recommendations

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

HCP with SARS-CoV-2 infection Testing is required for return to work prior to completing the 10-day isolation. See Table 3. Work Restrictions for HCP with SARS-CoV-2 Infection (Isolation).

Post-exposure Testing is required for asymptomatic HCP after a high-risk occupational or community close-contact exposure to SARS-CoV-2 as outlined in Table 2. Work Restrictions for Asymptomatic HCP with Exposures (Quarantine). Testing also should be performed in response to a cluster of cases meeting the outbreak investigation threshold for hospitals in AFL 20-75.

Screening HCFs are required to routinely test unvaccinated employees that have been granted a vaccine exemption and those who are incompletely vaccinated against COVID-19, pursuant to the State and LA County Orders. CDPH-licensed health facilities must also follow instructions in relevant AFLs. Note that HCP cannot opt to regularly test instead of getting vaccinated.

HCP that are not up to date on COVID-19 vaccines (i.e., unvaccinated or fully vaccinated and booster-eligible but have not yet received their booster) are required to be tested at least once a week.

  • Acute care hospitals and long-term care facilities must test workers at least twice a week.
  • All other facilities must test workers at least once a week.

HCP that are up to date with COVID-19 vaccines (i.e., fully vaccinated and boosted or fully vaccinated and not booster-eligible)

  • Do not need to participate in routine screening testing in most settings.*
  • If the staff have a severe immunocompromising condition, the facility can consider including them in routine diagnostic screening testing.

*All HCP in Skilled Nursing Facilities must continue to test regardless of vaccination status per the LA County Health Officer Order issued December 3, 2021.

Relevant CDPH-AFLs 

Return to Work for Symptomatic HCP

HCF should have a plan to evaluate HCP with symptoms of possible COVID-19 illness. It is recommended that symptomatic HCP be evaluated by a clinician. Symptomatic HCP with compatible symptoms and no clear alternate diagnosis should be told to isolate at home pending clinical evaluation and testing.

  • A single negative sensitive SARS-CoV-2 NAAT result is adequate to exclude COVID-19 in symptomatic staff with lower epidemiologic risk and/or lower clinical suspicion.
  • Two negative RT-PCR tests at least 24 hours apart are recommended to exclude COVID-19 in HCP with higher clinical suspicion and/or higher epidemiologic risk.

For HCP who had symptoms of possible COVID-19 and had it ruled out, either with negative 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 Interim Guidance for Managing HCP with SARS-CoV-2 Infection.

Return to Work Protocol for HCP with Confirmed COVID-19
Table 3. Work Restrictions for HCP with SARS-CoV-2 Infection (Isolation)                                
Vaccination Status Routine Critical Staffing Shortage
Boosted
OR
Vaccinated but not yet booster-eligible
5 days* with negative diagnostic test† same day or within 24 hours prior to return OR
10 days without a viral test
<5 days with most recent diagnostic test result to prioritize staff placement
Unvaccinated, OR Those that are vaccinated and booster-eligible but have not yet received their booster dose 7 days* with negative diagnostic test† same day or within 24 hours prior to return OR
10 days without a viral test
5 days with most recent diagnostic test result to prioritize staff placement

*Asymptomatic or mildly symptomatic with improving symptoms, and meeting negative test criteria; facilities should refer to CDC guidance for HCP with severe to critical illness or moderately to severely immunocompromised.

† 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 discontinuation of isolation and return-to-work for SARS-CoV-2 infected HCP and for HCP who have recovered from SARS-CoV-2 infection in the prior 90 days; NAAT is also acceptable if done and negative within 48h of return. 

‡ If most recent test is positive, then HCP may provide direct care only for patients/residents with confirmed SARS-CoV-2 infection, preferably in a cohort setting. 

HCP whose most recent test is positive and are working before meeting routine return-to-work criteria must maintain separation from other HCP as much as possible (for example, use a separate breakroom and restroom) and wear a N95 respirator for source control at all times while in the facility. In addition, healthcare facilities should make N95 respirators available to any HCP who wishes to wear one when not otherwise required for the care of patients or residents with suspected or confirmed COVID-19.  

Return to Work Practices and Work Restrictions

  • HCP with confirmed COVID-19 do not need medical or LAC DPH clearance to return to work.
Contact Us

If you have questions, email LAC DPH at hcwcontacts@ph.lacounty.gov or call at 213-240-7941.


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