Coronavirus Disease 2019

Health care personnel (HCP) are defined by the Centers for Disease Control and Prevention (CDC) as including but not limited to: emergency medical service personnel, nurses, nursing assistants, physicians, technicians, therapists, phlebotomists, pharmacists, students and trainees, contractual staff not employed by the healthcare facility, and persons not directly involved in patient care, but who could be exposed to infectious agents that can be transmitted in the healthcare setting (e.g., clerical, dietary, environmental services, laundry, security, engineering and facilities management, administrative, billing, and volunteer personnel).

All persons who work in healthcare facilities must be vaccinated against COVID-19 (i.e., primary COVID-19 vaccine series plus one booster when eligible) as required by the LA County and the California State Public Health Officers. Additionally, healthcare workers who are eligible are required to receive a booster dose of a COVID-19 vaccine by March 1, 2022. Workers may be exempt from the vaccination requirements based on either a) Religious Beliefs or b) a Qualifying Medical Reason. These vaccination requirements include all workers who provide services or work in outpatient clinics (including behavioral health, surgical, and dental) and dialysis centers. HCP who provide proof of recent COVID-19 infection may defer booster administration for up to 90 days after infection. The 90 days are from the onset of the initial COVID-19 symptoms. If they never had symptoms, then the 90 days are from the date of collection of the first positive viral COVID-19 test. During the 90-day period after infection with COVID-19, LAC DPH does not recommend any additional COVID-19 viral testing of asymptomatic HCP.

• LA County Order and FAQs
• CA State Order

The definition of an outpatient healthcare facility (HCF) outbreak is where there are 3 or more confirmed COVID-19 cases in patients and/or HCP with evidence of epidemiological linkage. Epidemiological linkage is defined as a potential common area of contact (e.g., same nursing unit, shared break room) or contact with same infected person within a 14-day time period.

HCF outbreaks should be reported by emailing to CovidOutpatient@ph.lacounty.gov.

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

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

*COVID-19 cases are considered to be infectious from 2 days before their symptoms started (or from 2 days before their first positive viral test if they are asymptomatic) until their isolation period ends. Asymptomatic persons with a positive SARS-CoV-2 diagnostic (viral) test are considered to be infectious from 2 days before their test was taken until 10 days after their test was taken.

Community exposures are considered higher-risk exposures if they meet the following definition of a close contact:

• They were within six (6) feet of an infectious case* for a cumulative total of 15 minutes or more over a 24-hour period**.

*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.

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

HCP who have not completed their primary series (i.e., only one dose of mRNA vaccine) or who are booster eligible but have not yet received their booster dose must* be restricted from work for at least 7 days unless there is a critical staffing shortage.

HCP who are vaccinated and boosted or vaccinated and not-yet eligible for a booster do not need to be restricted from work following their exposure as long as they remain asymptomatic and they have a negative diagnostic test result* upon identification and at 5-7 days after exposure. They must continue to follow all current infection prevention and control recommendations including source control and daily symptom monitoring as outlined in LAC DPH Infection Prevention Guidance for Healthcare Personnel.

*In general, asymptomatic HCP who have recovered from SARS-CoV-2 infection in the prior 90 days do not require work restriction nor testing following a higher-risk exposure.

For more details on return to work after exposure refer to Table 2. Work Restrictions for Asymptomatic HCP with Exposures (Quarantine).

Yes, if they are not up to date with the required COVID-19 vaccines for HCP. They must notify the HCF of their exposure and be restricted from work*. For details of when they can return to work and exceptions for critical staffing shortages, see Table 2. Work Restrictions for Asymptomatic HCP with Exposures (Quarantine).

HCP who are up to date with the required COVID-19 vaccines (i.e., they received all primary series doses and a booster or they received all primary series doses and are not booster-eligible) do not need to be restricted from work as long as they remain asymptomatic and test* negative upon identification of exposure and at 5-7 days. They should continue to follow all current infection prevention and control recommendations including source control and daily monitoring as outlined in the LAC DPH Infection Prevention Guidance for Healthcare Personnel.

*In general, asymptomatic HCP who have recovered from SARS-CoV-2 infection in the prior 90 days do not require work restriction nor testing following a higher-risk exposure.

All non-HCP who were close contacts of the infectious patient/visitor while at the HCF should be notified of their exposure and provided with Instructions for Close Contacts available at ph.lacounty.gov/covidcontacts. Close contact for non-HCP is defined anyone who shared the same indoor space (i.e., waiting room) for 15 minutes or more.

Facilities should ensure that there are systems in place to prevent exposures between patients/visitors including universal source control for all patients, visitors, and staff; limiting the number of patients in waiting rooms/common areas; and arranging seating such that patients/visitors can sit at least 6 feet apart.

When there are possible exposures from an infected patient/visitor to HCP, facilities should inform the exposed HCP and determine if there were any high-risk exposures.

Any patients or visitors who were close contacts to a HCP with COVID-19 while they were infectious must be notified of their exposure and provided with instructions for close contacts (Instructions for Close Contacts available at ph.lacounty.gov/covidcontacts). Close contact for non-HCP is defined as a person who shared the same indoor space (i.e., waiting room) for 15 minutes or more.

All co-workers who were close contacts to the infectious HCP must be informed of their possible exposure and assessed for risk.

COVID-19 vaccination is very effective at protecting people from severe COVID-19 illness, hospitalization, and death. Vaccinating all staff, including with booster doses, is a central strategy to protect staff and to lower the risk of transmission within the facility. Like all vaccines, COVID-19 vaccines are not 100% effective at preventing infection. HCP who are up to date with their COVID-19 vaccinations may still get infected or have symptomatic COVID-19. For this reason, other protective measures remain important.

HCPs should continue to wear well-fitting medical face masks or higher for universal source control at all times while they are in the healthcare facility. Non-medical face coverings do not offer reliable protection in higher risk settings. 
*Face masks may be removed when the HCP is alone in a room and when eating and drinking.

Break rooms and other common spaces where staff congregate are higher risk settings for transmission between HCP, even if they are vaccinated. Facilities should continue to focus on keeping these areas safe from COVID-19 transmission including the following: 

• Ensure 6 feet physical distancing between staff is implemented throughout the facility, particularly in the break/lunchrooms when staff remove their facemasks to eat and drink.
• Placing tables eight feet apart, where feasible, will allow for six feet of physical distancing between individuals seated at neighboring tables.
• If feasible, create outdoor break spaces and encourage eating and drinking outdoors and physically distanced from others.
• If indoor break rooms are used, optimize indoor air quality by opening windows or utilizing filtration systems. Please see: https://www.epa.gov/coronavirus/ventilation-and-coronavirus-covid-19.
• Consistently emphasize and encourage use of medical facemasks except when actively drinking and eating. To ensure that masks are worn consistently and correctly, discourage employees from eating or drinking except during their breaks when they are able to safely remove their masks and physically distance from others.
• Place signage in any common spaces (e.g., nursing stations, break rooms) to remind all to maintain physical distancing of more than 6 feet and universal masking.
• Stagger lunch breaks and ask staff to sign-up for specific time slots to minimize the number of staff sharing the break room at any one time.
• Remove chairs in break/lunchrooms to limit number of staff gathered in the room at one time.
• Ensure hand sanitizers or hand washing stations are readily available at the break rooms.
• Clean and disinfect high-touch areas and surfaces in the commonly used congregate staff rooms.

• Routinely clean and disinfect high-touch areas (e.g., doorknobs, light switches, and biometric machines) in facility.
• Clean and disinfect surfaces (e.g., exam tables, chairs) used in the care of patients.
• Validate that the product used for surface disinfection is active against SARS-CoV-2, the virus that causes COVID-19. Refer to the EPA approved list on the website: https://www.epa.gov/pesticide-registration/list-n-disinfectants-use-against-sars-cov-2-covid-19
• Follow the manufacturer’s label instructions for proper use and dilution of the disinfectant.

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.

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. Read the order and accompanying FAQs: Order FAQ 

*HCP who previously tested positive for COVID-19 and are asymptomatic should not be retested for 90 days since the date of symptom onset or date of collection of the first positive test. If the staff develop new symptoms consistent with COVID-19 <90 days of the initial positive test, if an alternative etiology cannot be identified, then retesting (preferably with antigen test) can be considered in consultation with facility medical director, infectious disease specialists, or infection control experts.

HCF should have a plan to evaluate HCP with signs and symptoms of possible COVID-19 illness.* It is recommended that symptomatic HCP be evaluated by a clinician. SARS-CoV-2 diagnostic viral testing is recommended for HCP with even mild symptoms of possible COVID-19 infection, regardless of vaccination status. Symptomatic HCP with compatible symptoms and no clear alternate diagnosis are to isolate at home pending clinical evaluation and testing.

See Return to Work for Symptomatic HCP for more details.

*If recently vaccinated (within the first 2 days after vaccination), HCF should follow the LAC DPH Post Vaccination Assessment of Symptomatic Healthcare Personnel

Perhaps not. Systemic signs and symptoms, such as fever, fatigue, headache, chills, myalgia, or arthralgia, can occur following COVID-19 vaccination [note: cough, shortness of breath, rhinorrhea, sore throat, or loss of taste or smell are NOT consistent with vaccination]. HCP with postvaccination signs and symptoms could be mistakenly considered infectious and restricted from work unnecessarily. To prevent unnecessary absences, HCF should develop a plan to evaluate HCP with symptoms of possible COVID-19 illness within 2 days after receiving a COVID-19 vaccine dose. The goal of this medical evaluation is to differentiate likely post-vaccine immune reactions from early COVID-19 disease.

HCF should follow the LAC DPH Post Vaccination Assessment of Symptomatic Healthcare Personnel

This depends on staffing issues and vaccination status. See Return To Work Protocol For HCP With Confirmed COVID-19.

Yes. Many professional societies have developed more specific guidelines for various healthcare settings. Providers and office managers should develop a plan using both general guidance developed by LAC DPH and more specific guidance tailored to the practice type to ensure a safe environment for patient care.

In alignment with CDC guidelines, HCP who enter the room of a patient with suspected or confirmed SARS-CoV-2 infection should adhere to NIOSH-approved N95 or equivalent or higher-level respirator, gown, gloves, and eye protection. Cal/OSHA Interim guidance recommends N95 respirators be used for the care of confirmed or suspected COVID-19 patients. Initial respirator fit testing is required before an employee uses a respirator, or when an employee changes to a different model, make, or size of respirator.

For more information, please 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 for Protecting Hospital Workers From Exposure to COVID-19 https://www.dir.ca.gov/dosh/coronavirus/COVID-19-Interim-Guide-for-Hospital-Workers.html