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Discontinuing infection control precautions in patients with COVID-19

Discontinuing infection control precautions in patients with COVID-19
Population Approach in the health care setting Approach in the community setting
Patients without moderate or severe immunocompromise
Patients with asymptomatic SARS-CoV-2 infection Time-based (before discontinuing precautions, all of the following conditions must be met):
  • At least 10 days have passed since the date of their first positive viral diagnostic test.
  • No subsequent illness developed.
Time-based:
  • Home isolation can end if all the following conditions are met:
    • At least 5 days have passed since the date of their first positive viral diagnostic test.
    • No subsequent illness developed.
    • If repeat testing is performed toward the end of the 5-day isolation period, a viral test (ideally an antigen test) should be negative.
  • After discontinuing home isolation, patients must continue to wear a well-fitting mask around others for another 5 days. The total duration of isolation plus strict masking is 10 days. During this time, patients should avoid people who are immunocompromised or at high risk for severe disease, as well as health care and nursing home settings.*

If a viral test is performed toward the end of the 5-day isolation period and is positive, or if strict mask wearing is not possible, home isolation should continue for a total of 10 days since the date of the first positive viral test.

For patients who have some degree of immunocompromise, the decision to use this strategy must be individualized.

Patients with mild to moderate disease Symptom-based (before discontinuing precautions, all of the following conditions must be met):
  • At least 10 days have passed since symptoms first appeared.
  • At least 1 day (24 hours) has passed since resolution of fever without the use of fever-reducing medications.
  • There is improvement in symptoms (eg, cough, shortness of breath).
Symptom-based for patients with mild disease:
  • Home isolation can end if all the following conditions are met:
    • At least 5 days have passed since symptoms first appeared.
    • Patient's symptoms are resolving and they have been afebrile for 24 hours.
    • If repeat testing is performed toward the end of the 5-day isolation period, a viral test (ideally an antigen test) should be negative.
  • After discontinuing home isolation, patients must continue to wear a mask around others for another 5 days. The total duration of isolation plus strict masking is 10 days. During this time, patients should avoid people who are immunocompromised or at high risk for severe disease, as well as health care and nursing home settings.*

If a viral test is performed toward the end of the 5-day isolation period and is positive, or if strict mask wearing is not possible, home isolation should continue for a total of 10 days since the date symptoms first appeared.

For patients who have some degree of immunocompromise, the decision to use this strategy must be individualized.

Symptom-based for patients with moderate disease: Same as for health care settings.
Patients with severe or critical disease Symptom-based (before discontinuing precautions, all of the following conditions must be met):
  • At least 10 and up to 20 days have passed since symptoms first appeared.
  • At least 1 day (24 hours) has passed since resolution of fever without the use of fever-reducing medications.
  • There is improvement in symptoms (eg, cough, shortness of breath).

A test-based strategy may be useful to help guide when to discontinue precautions within this time frame.

Same as for health care settings.
Moderately to severely immunocompromised patients – Conditions associated with moderate to severe immunocompromise include various hereditary and acquired immune deficiencies (eg, combined primary immunodeficiency disorder, receiving certain chemotherapy for cancer, being within 1 year of receiving a hematopoietic stem cell or solid organ transplant, HIV and a CD4 count <200 cells/microL, receiving CAR-T cell therapy or B-cell-depleting therapies, receipt of prednisone ≥20 mg/day for more than 14 days, or a tumor necrosis factor blocker).
Patients with asymptomatic SARS-CoV-2 infection Test-basedΔ (before discontinuing precautions, all of the following conditions must be met):
  • Results are negative from at least two consecutive respiratory specimens collected ≥24 hours apart (total of two negative specimens) tested using an antigen test or NAAT.
  • No subsequent illness developed.
Same as for health care settings.
Patients with symptomatic disease Test-basedΔ (all conditions must be met):
  • Resolution of fever without the use of fever-reducing medications, and
  • Symptoms (eg, cough, shortness of breath) have improved, and
  • Results are negative from at least two consecutive respiratory specimens collected ≥24 hours apart (total of two negative specimens) tested using an antigen test or NAAT.
Same as for health care settings.

This table describes the approach to discontinuing infection control precautions in patients with COVID-19 based upon recommendations from the United States Centers for Disease Control and Prevention (CDC) for patients at home and in health care settings. Protocols in other countries and at specific institutions may differ. Hospitalized patients who are ready to be discharged prior to meeting criteria for discontinuation of precautions can be sent home with instructions to self-isolate until they meet the above criteria. If discharged to a nursing home or other long-term care facility, the patient should go to a facility with an ability to adhere to infection prevention and control recommendations for the care of residents with COVID-19. Once infection control precautions/home isolation are discontinued, all patients should still continue to follow public health recommendations for wearing face covers.

When using a time-based strategy (ie, for patients who are asymptomatic), day 0 is the date the specimen was collected for the positive test. When using a symptom-based strategy, day 0 is the first day of symptoms.

COVID-19: coronavirus disease 2019; SARS-CoV-2: severe acute respiratory syndrome coronavirus 2; CAR-T: chimeric antigen receptor T; NAAT: nucleic acid amplification test; RT-PCR: reverse-transcription polymerase chain reaction.

* Additional information on restrictions (eg, travel) for patients who are able to leave home isolation after 5 days can be found on the CDC website.

¶ Patients with mild to moderate COVID-19 typically have signs and symptoms of COVID-19 without hypoxia (eg, oxygen saturation ≥94% on room air); by contrast, those with severe or critical disease usually have an oxygen saturation <94% on room air and/or need oxygenation or ventilatory support. Refer to the topic that discusses the clinical features of COVID-19 for a discussion of disease severity.

Δ The CDC states an antigen test or NAAT (eg, RT-PCR) can be used for a test-based strategy. However, we prefer a molecular test when testing is performed in the health care settings since it is more sensitive than antigen testing.
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