The CDC recently issued guidelines allowing healthcare personnel (HCP) to continue working if they incur only “low-risk” exposures to patients with COVID-19. With some reported cases of large numbers of HCP furloughed after exposures, the CDC is moving to preserve the workforce in situations where HCP are exposed to infected patients through minor breaks in protocol or personal protective equipment (PPE).1

“As we look at the progress of this outbreak, there is going to be greater and greater numbers of [HCP] exposed. Not necessarily high-risk exposures like doing an induced sputum or something like that, but nonetheless a non-negligible exposure,” said Michael Bell, MD, deputy director of the CDC Division of Healthcare Quality Promotion, at a recent meeting at the agency.

Furloughs Present Risks

The result of routinely furloughing these workers with minor exposures for two weeks could be inadequate staff to care for patients. Thus, the CDC has designed contingency planning guidelines that would allow asymptomatic healthcare workers to still work if they have a “low-risk” exposure to a coronavirus patient. (See Table 1.) These include allowances for asymptomatic HCP to continue to work after options to improve staffing have been exhausted.

“Facilities could consider allowing asymptomatic HCP who have had an exposure to a COVID-19 patient to continue to work after consultation with their occupational health program,” the CDC stated. “These HCP should still report temperature and absence of symptoms each day prior to starting work. Facilities could have exposed HCP wear a facemask while at work for the 14 days after the exposure event if there is a sufficient supply of facemasks.”

If these workers develop even mild symptoms consistent with COVID-19, they must stop all patient care, notify their supervisor, and leave work, the CDC suggested. The thinking, in part, is to maintain the critically needed healthcare workforce rather than use arbitrary and extensive furloughs.

What Is ‘Low Risk’?

Examples of low risk include occupational exposure to a COVID-19 patient without wearing eye protection, a gown, or gloves. Wearing a surgical mask instead of an N95 respirator while exposed to a coronavirus patient also is categorized as a low risk. Of course, individual circumstances could affect these situations greatly, and the CDC recommendations are nonregulatory and optional.

The guidelines stated the CDC has “removed [the] requirement under ‘self-monitoring with delegated supervision’ for healthcare facilities to actively verify absence of fever and respiratory symptoms when HCP report for work. This is now optional.” The CDC also simplified risk exposure categories based on the most common scenarios involving source control measures, use of PPE, and the duration of contact with the patient.

“[Community transmission] means previously recommended actions (e.g., contact tracing and risk assessment of all potentially exposed HCP) are impractical for implementation by healthcare facilities,” the CDC guidelines stated. “In the setting of community transmission, all HCP are at some risk for exposure to COVID-19, whether in the workplace or in the community. Facilities should shift emphasis to more routine practices, which include asking HCP to report recognized exposures, regularly monitor themselves for fever and symptoms of respiratory infection, and not report to work when ill.”

Create Employee Screening Plan

Infection preventionists and their employee health colleagues should develop a plan for how they will screen for symptoms and evaluate sick workers. This could include requiring healthcare workers to report absence of fever and symptoms prior to starting work each day.

“I think this will make a large difference,” Bell said at meeting of the CDC’s Healthcare Infection Control Practices Advisory Committee (HICPAC). “The issue of [allowing] symptomatic personnel to work is not currently on the table. It is something, however, I think a great deal about because during cold and flu season it is a reality that many healthcare workers come to work with a minor sniffle or a scratchy throat.”

There may come a time during this outbreak where shorthanded facilities should consider letting workers with mild symptoms be allowed to work while wearing a mask.

“This is at odds with the very concrete statement that people often make of ‘don’t come to work when you’re ill,” he said. The problem with that blanket policy — and one of the explanations for the longstanding problem of presenteeism — is that many healthcare workers have limited sick leave, must use vacation days, or are not paid if they are out sick.

“I think our [HICPAC] committee is going to have to weigh in,” Bell said. “Not just for this outbreak, but looking forward. Do we want to see a change in our culture about how we manage healthcare personnel with very mild symptoms?”

The CDC will continue to grapple with these problems in healthcare, but the shift to community mitigation will dominate the coming months, he added.

“With regard to the healthcare system, right now the focus is on protecting a very critical asset to the nation,” Bell said. “At a certain point, healthcare personnel are going to be more likely to get this infection at the grocery store than they are at the hospital.”

REFERENCE

  1. Centers for Disease Control and Prevention. Interim U.S. guidance for risk assessment and public health management of healthcare personnel with potential exposure in a healthcare setting to patients with coronavirus disease 2019 (COVID-19). Available at: https://www.cdc.gov/coronavirus/2019-ncov/hcp/guidance-risk-assesment-hcp.html#table1

Table 1. Epidemiologic Risk Classification for Asymptomatic Healthcare Personnel Following Exposure to Patients with Coronavirus Disease (COVID-19) or their Secretions/Excretions in a Healthcare Setting, and their Associated Monitoring and Work Restriction Recommendations

Epidemiologic Risk Factors

Exposure Category

Recommended Monitoring
for COVID-19
(until 14 days after last potential exposure)

Work Restrictions
for Asymptomatic HCP

Prolonged close contact with a COVID-19 patient who was wearing a facemask (i.e., source control)

HCP PPE: None

Medium

Active

Exclude from work for 14 days after last exposure

HCP PPE: Not wearing a facemask or respirator

Medium

Active

Exclude from work for 14 days after last exposure

HCP PPE: Not wearing eye protection

Low

Self with delegated supervision

None

HCP PPE: Not wearing gown or glovesa

Low

Self with delegated supervision

None

HCP PPE: Wearing all recommended PPE (except wearing a facemask instead of a respirator)

Low

Self with delegated supervision

None

Prolonged close contact with a COVID-19 patient who was not wearing a facemask (i.e., source control)

HCP PPE: None

High

Active

Exclude from work for 14 days after last exposure

HCP PPE: Not wearing a facemask or respirator

High

Active

Exclude from work for 14 days after last exposure

HCP PPE: Not wearing eye protectiona

Medium

Active

Exclude from work for 14 days after last exposure

HCP PPE: Not wearing gown or glovesa,b

Low

Self with delegated supervision

None

HCP PPE: Wearing all recommended PPE (except wearing a facemask instead of a respirator)b

Low

Self with delegated supervision

None

HCP: healthcare personnel; PPE: personal protective equipment

aThe risk category for these rows would be elevated by one level if HCP had extensive body contact with the patients (e.g., rolling the patient).

bThe risk category for these rows would be elevated by one level if HCP performed or were present during a procedure likely to generate higher concentrations of respiratory secretions or aerosols (e.g., cardiopulmonary resuscitation, intubation, extubation, bronchoscopy, nebulizer therapy, sputum indication). For example, HCP who were wearing a gown, gloves, eye protection and a facemask (instead of a respirator) during an aerosol-generating procedure would be considered to have a medium-risk exposure.

Adapted from the Centers for Disease Control and Prevention, https://www.cdc.gov/coronavirus/2019-ncov/hcp/guidance-risk-assesment-hcp.html#table1