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EDMUND G. BROWN JR.
Governor

State of California—Health and Human Services Agency
California Department of Public Health


AFL 21-08.9
December 2, 2022


TO:
General Acute Care Hospitals (GACHs)
Acute Psychiatric Hospitals (APHs)
Skilled Nursing Facilities (SNFs)

SUBJECT:
Guidance on Quarantine and Isolation for Health Care Personnel (HCP) Exposed to SARS-CoV-2 and Return to Work for HCP with COVID-19
(This AFL supersedes AFL 21-08.8)


AUTHORITY:     Proclamation of Emergency (PDF)


All Facilities Letter (AFL) Summary

On September 23, 2022, CDC updated their guidance for HCP isolation and quarantine to no longer routinely recommend work restrictions for asymptomatic HCP who have had a higher-risk exposure, regardless of vaccination status, if they do not develop symptoms or test positive for SARS-CoV-2. To more promptly identify SARS-CoV-2 infection in an exposed HCP, CDC now recommends testing immediately (but not earlier than 24 hours after the exposure) and, if negative, again at 3 days and if negative, again at 5 days after the exposure.

In prior versions of this AFL, CDPH aligned and consolidated the CDC's conventional, contingency and crisis framework for duration of isolation and testing considerations for SARS-CoV-2 infected HCP into "routine" and "critical staffing shortage" scenarios as outlined in the table, below.  Recognizing the staffing shortages that persist across the state and the need to bring HCP back to work, CDPH is maintaining the routine return-to-work criteria of at least 5 days with at least one negative test on day 5 or later, regardless of vaccination status. To provide an additional layer of safety, these HCP should wear a fit-tested N95 for source control through day 10.

All healthcare facilities should continue anticipating and contingency planning for staffing shortages by adjusting staff schedules, hiring additional HCP, rotating HCP to positions that support patient care activities, identifying roles that can be cross-covered by those not specifically assigned to a role, and developing regional plans to identify designated healthcare facilities or alternate care sites with adequate staffing to care for patients with SARS-CoV-2 infection. The duration of work restrictions and negative test criteria in the table below reflect CDPH recommendations; facilities and LHDs always have the option to implement more protective procedures and follow prior guidance for a longer (e.g., 10-day) isolation period and additional negative tests for infected HCP or quarantine for exposed HCP. 

Exposure Risk Assessment for HCP

Hospitals should and SNFs must continue to use the CDC's updated risk assessment framework to determine exposure risk for HCP with potential exposure to patients, residents, visitors, and other HCP with confirmed COVID-19 in a health care setting. CDPH guidance for assessing community-related exposures should continue to be applied to HCP with potential exposures outside of work (e.g., household,) and among HCP exposed to each other while working in non-patient care areas (e.g., administrative offices). For the purpose of contact tracing to identify exposed HCP, the exposure period for the source case begins from two days before the onset of symptoms or, if asymptomatic, two days before test specimen collection for the individual with confirmed COVID-19.

Management of SARS-CoV-2 Infected and Exposed HCP

Hospitals should and SNFs must use the table, below, to guide work restrictions and testing for HCP with SARS-CoV-2 infection and for asymptomatic HCP with exposures based upon facility staffing level.

Work Restrictions for HCP with SARS-CoV-2 Infection (Isolation)

Vaccination StatusRoutineCritical Staffing Shortage
All HCP, regardless of vaccination status

5 days* with at least one 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

 

Management of Asymptomatic HCP with Exposures

Vaccination StatusRoutineCritical Staffing Shortage
All HCP, regardless of vaccination statusNo work restriction with negative diagnostic test upon identification (but not earlier than 24 hours after exposure) and if negative, test at days 3 and 5No work restriction with diagnostic test upon identification (but not earlier than 24 hours after exposure) and at days 3 and 5

*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 48 hours of return. Post-exposure testing is not generally recommended for HCP who have had SARS-CoV-2 infection in the last 30 days if they remain asymptomatic.

 If most recent test is positive, then HCP should provide direct care only for patients/residents with confirmed SARS-CoV-2 infection, preferably in a cohort setting. This may not apply for staff types or in settings where practically infeasible (e.g., Emergency Departments where patient COVID status is unknown) or where doing so would disrupt safe nurse to patient ratios, and for staff who do not have direct patient/resident care roles.

HCP returning to work between days 5-9 after meeting routine criteria should wear a fit-tested N95 for source control through at least day 10 from symptoms onset or positive test (for HCP who remain asymptomatic throughout their infection). 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 until at least 10 days from symptoms onset or positive test (for HCP who remain asymptomatic throughout their infection). Similarly, exposed HCP who are working during their post-exposure testing period should also wear a N95 respirator for source control at all times while in the facility until they have a negative test result on day 5. 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. 

These recommendations will be updated as additional information becomes available, including regarding the ability of currently authorized vaccines to protect against infection with novel variants and the effectiveness of additional authorized vaccines. This could result in additional circumstances when work restrictions for HCP are recommended. 

If you have any questions regarding this AFL, quarantine guidance, or work restrictions, please contact CDPH Healthcare-Associated Infections Program via email at CovHAI@cdph.ca.gov.

If you have any questions about this AFL, please contact your local district office.

 

Sincerely,

Original signed by Cassie Dunham

Cassie Dunham

Deputy Director


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