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COVID-19: General approach to infection prevention in the health care setting

COVID-19: General approach to infection prevention in the health care setting
Authors:
Tara N Palmore, MD
Becky A Smith, MD
Section Editor:
Daniel J Sexton, MD
Deputy Editor:
Jennifer Mitty, MD, MPH
Literature review current through: Aug 2022. | This topic last updated: Feb 28, 2022.

INTRODUCTION — At the end of 2019, a novel coronavirus was identified as the cause of a cluster of pneumonia cases in Wuhan, a city in the Hubei Province of China. It rapidly spread, prompting the World Health Organization (WHO) to declare a public health emergency in late January 2020 and to characterize it as a pandemic in March 2020. The virus that causes coronavirus disease 2019 (COVID-19) is designated severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2).

Infection prevention interventions to reduce transmission of SARS-CoV-2 include universal source control (eg, covering the nose and mouth to contain respiratory secretions), early identification and isolation of patients with suspected disease, vaccination, quarantine after exposure, the use of appropriate personal protective equipment (PPE), and environmental disinfection.

This topic will review general infection prevention principles when caring for patients in areas with community transmission of SARS-CoV-2. Detailed information on prevention in the community and infection prevention policies and procedures when caring for patients with suspected or confirmed COVID-19 in the health care and home settings is presented elsewhere. (See "COVID-19: Infection prevention for persons with SARS-CoV-2 infection".)

OVERVIEW OF TRANSMISSION — Many experts agree that transmission occurs through droplets (when virus released in the respiratory secretions of a person with infection makes direct contact with mucous membranes) and through inhalation of aerosolized secretions, which can travel further, remain suspended in air longer, and contain infectious particles that are smaller than typically described for respiratory droplets [1-4]. The relative contribution of each mode of transmission is uncertain [5]. Indirect (secondary) transmission, which occurs when a susceptible person touches a contaminated surface and then touches his or her eyes, nose, or mouth, is also possible but is not thought to be a major route of transmission. More detailed information on the transmission of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), including the risk of asymptomatic transmission, is discussed in a separate topic review. (See "COVID-19: Epidemiology, virology, and prevention", section on 'Transmission'.)

SCREENING PRIOR TO AND UPON ENTRY INTO THE HEALTH CARE FACILITY

Patients

Prior to entry – Prior to entry into a health care facility, patients should be screened for clinical manifestations consistent with COVID-19 (eg, fever or chills, cough, shortness of breath or difficulty breathing, fatigue, myalgias, headache, sore throat, dyspnea, anosmia/hyposmia, congestion or rhinorrhea, nausea, vomiting, or diarrhea), a history of COVID-19 exposure, and residence in a congregate living setting. The clinical manifestations of COVID-19 are presented in detail elsewhere. (See "COVID-19: Clinical features", section on 'Clinical manifestations'.)

Ideally, initial screening should be done over the phone before the patient actually presents to a facility.

Many patients with signs and symptoms of COVID-19 can be managed from home through telemedicine and will not need to enter a health care facility. (See "COVID-19: Evaluation of adults with acute illness in the outpatient setting" and "COVID-19: Infection prevention for persons with SARS-CoV-2 infection", section on 'Infection prevention in the home setting'.)

For those who require additional evaluation, referral to a respiratory clinic dedicated to the evaluation and management of patients with presumptive COVID-19 may be appropriate.

However, if a dedicated clinic is not available or if the patient requires a higher level of care (for COVID-19- or non-COVID-19-related symptoms), referral to an urgent care or emergency room may be needed. The receiving clinic or emergency center should be notified in advance of the patient’s arrival.

Upon entry to the health care facility – Patients should be screened for symptoms of COVID-19 upon entry into a health care setting, even if they were screened prior to arrival. Efforts should be made to place patients with suspected COVID-19 into private rooms as soon as possible. If an examination room is not immediately available, such patients should not wait among other patients. In this setting, it may be reasonable to have patients wait in a personal vehicle or in a well-ventilated space where patients can be separated by at least six feet, in addition to being masked. Persons accompanying such patients should either be placed in the same private room or asked to wait in their car. (See 'Patient and visitors' below.)

Patients without symptoms should also be questioned about any unprotected exposures to a person with COVID-19 within the last 10 days. Patients who have had close contact with someone with suspected or confirmed COVID-19 may need to quarantine. This is discussed in greater detail below. (See "COVID-19: Infection prevention for persons with SARS-CoV-2 infection", section on 'Patients who have had an exposure to COVID-19'.)

Admission/preprocedural testing – Many institutions have implemented universal nucleic acid testing upon admission to the hospital and prior to elective aerosol-generating procedures and major surgeries to identify patients with asymptomatic or presymptomatic infection, even if there are no risk factors for COVID-19. Guideline panels have supported this type of testing, when resources allow, to help guide decisions about the need for nonurgent procedures and to ensure the use of appropriate infection prevention precautions [1,3,6]. However, the benefit of this type of testing in persons who have received all of their recommended COVID-19 vaccines remains unclear, and there is no standardized approach to screening; policies depend in part upon local infection rates and the efficacy of COVID-19 vaccines against different variants. (See "COVID-19: Vaccines", section on 'Breakthrough infections after vaccination'.)

Admission or preprocedural testing is generally not warranted for asymptomatic patients with prior COVID-19 if the patient's onset of illness was within the prior 90 days and they met criteria for discontinuation of precautions (table 1). Reinfection is less likely during this period, and some patients may have prolonged viral RNA shedding, which is not clearly associated with prolonged infectiousness [7]. (See "COVID-19: Epidemiology, virology, and prevention", section on 'Viral shedding and period of infectiousness'.)

More detailed information on COVID-19 testing as well as the use of testing as part of the preoperative evaluation is presented elsewhere. (See "COVID-19: Diagnosis" and "COVID-19: Perioperative risk assessment and anesthetic considerations, including airway management and infection control", section on 'Preoperative screening and testing'.)

Visitors — During the COVID-19 pandemic, most hospitals have restricted visitors in the health care setting. Exempt visitors should be screened for symptoms of and exposure to COVID-19; those with evidence of infection or a known exposure in the last 10 days should not be allowed to enter the health care setting, even if they have been fully vaccinated with one of the available COVID-19 vaccines and boosted (if eligible). Visitors with recent severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection should not be allowed (even with a mask) until at least 10 days have passed, due to the medical fragility of hospitalized patients (table 1); in some persons, this duration may need to be extended. (See "COVID-19: Infection prevention for persons with SARS-CoV-2 infection", section on 'Discontinuation of precautions'.)

Health care personnel — The approach to screening health care personnel (HCP) entering the health care setting depends upon the institution's policies. At a minimum, HCP should monitor themselves for fever and other symptoms of COVID-19 and stay home if they are ill (table 2). They should then contact occupational health for additional guidance. In one report of 48 HCP with confirmed COVID-19, 65 percent reported working for a median of two days while exhibiting symptoms of COVID-19 [8].

HCP should also be educated about the need to report all known or possible unprotected exposures to COVID-19 (both in the community and at work) to occupational health services so they can determine the need for work restrictions, self-quarantine, and testing.

A more detailed discussion of screening for HCP is presented in a separate topic review. (See "COVID-19: Occupational health issues for health care personnel".)

UNIVERSAL USE OF MASKS — Universal masking is required for all patients, visitors, and health care personnel (HCP) in the health care setting [3,9]. The goal of universal masking is to reduce transmission of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) from unsuspected virus carriers [10,11]. Symptom screening alone is insufficient to identify individuals with COVID-19 since presymptomatic and asymptomatic transmission can occur [12,13]. An experimental study by the United States Centers for Disease Control and Prevention (CDC) suggested even greater protection to the wearer from adjusting the fit of a surgical mask using mask extenders, knotting the ear loops, or tucking in the side folds to reduce gaps around the mask [14]. Updated personal protective equipment (PPE) guidelines from the CDC emphasize optimizing mask fit to improve source control and protection of the wearer from infectious particles [3].

The approach to masking in the health care setting differs from that in the community. Information on the use of masks as source control in community settings is presented elsewhere. (See "COVID-19: Epidemiology, virology, and prevention", section on 'Personal preventive measures'.)

Patient and visitors — All patients and exempted visitors should bring or be given well-fitting masks to wear upon entry into the health care setting for universal source control [3]. Masks with exhalation valves or vents should be avoided since they do not provide source control. Patients or visitors wearing one of these masks should be provided with an appropriate alternative.

Visitors should be asked to wear a well-fitting mask when in the hospital setting. Special considerations for visitors and patients who have received all of their recommended vaccines (table 3) are discussed below. (See 'Non-patient care activities' below.)

For patients, once they are in an appropriate room (eg, single room with the door closed for patients with suspected COVID-19), they can usually remove their mask. However, patients should be instructed to replace their masks when HCP enter their room.

If the patient cannot don the mask themselves, the HCP should wear a face shield or goggles and a respirator. The use of a respirator and face shield or goggles provides additional protection in the event that a patient cannot or will not wear a mask; this is particularly important in areas with moderate to substantial rates of community SARS-CoV-2 transmission. (See 'Precautions for those NOT suspected of having COVID-19' below.)

Health care personnel — HCP should wear a well-fitting medical mask in the health care setting. Hand hygiene should be performed immediately before and after contact with face masks. These masks provide both source control and respiratory protection. Masks should be worn even when the HCP is not caring for patients. The impact of vaccination on universal masking for HCP is discussed below. (See 'Impact of vaccination' below.)

When caring for patients, the type of mask (eg, respirator or medical mask) may depend upon the clinical setting (eg, aerosol-generating procedures, routine care, suspicion for COVID-19) and the degree of community transmission, as discussed below and in a separate topic review. (See 'High-risk procedures (eg, aerosol-generating procedures)' below and 'Routine care in the ambulatory or hospital setting' below and "COVID-19: Infection prevention for persons with SARS-CoV-2 infection", section on 'Type of PPE'.)

Respirators with exhalation valves or vents should not be used in the health care setting since they do not provide source control. However, if needed in the setting of PPE shortages, a medical mask must be placed on top of the respirator.

Masks should be changed if they become soiled, damp, or difficult to breathe through. If they are used during the care of a patient for whom a National Institute for Occupational Safety and Health (NIOSH)-approved respirator or facemask is indicated for PPE (eg, during a surgical procedure, or during care of a patient on droplet precautions), they should be removed after the patient care encounter and a new one should be donned prior to the next encounter [3]. Depending upon hospital policy, respirators should be discarded or removed and stored for later use. Considerations for extended use/reuse of PPE when caring for patients with confirmed or suspected COVID-19 who are on the same unit are discussed elsewhere. (See "COVID-19: Infection prevention for persons with SARS-CoV-2 infection", section on 'Extended or limited reuse of PPE'.)

The need for universal masking has been demonstrated in several studies. In one report, 238 patients were exposed to a HCP with COVID-19, and the only clear case of SARS-CoV-2 transmission occurred when neither the provider nor the patient was wearing a mask [15]. In another study of 703 unvaccinated HCP, 50 were found to be positive for SARS-CoV-2 using polymerase chain reaction (PCR) testing; risk factors for infection included being in the break room without a medical mask for more than 15 minutes, consuming food within one meter of an HCP, and failing to keep a safe social distance from other HCP [16].

With universal masking, studies have demonstrated a reduction in SARS-CoV-2 infections in HCP [17,18]. In one report that evaluated nearly 10,000 HCP in Massachusetts who were tested for SARS-CoV-2 (mainly because of symptoms), the proportion with positive test results steadily declined after the introduction of universal masking (from 14.7 to 11.5 percent over 29 days) despite an increase in the number of cases in the community [18]. Similarly, in a study from North Carolina, the cumulative incidence rate of health care-acquired COVID-19 stabilized after the introduction of universal masking despite an increased incidence of COVID-19 in the community [17].

For HCP, the universal use of masks or respirators also reduces the risk of having an exposure that would require quarantine. (See "COVID-19: Occupational health issues for health care personnel".)

PRECAUTIONS FOR THOSE NOT SUSPECTED OF HAVING COVID-19 — When there is ongoing community transmission of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), enhanced infection prevention precautions should be used when caring for patients who are not suspected of having COVID-19, even those who are vaccinated and/or had a negative test for SARS-CoV-2 upon entry into the health care setting [1,3,19]. The types of precautions depend on the degree of community transmission and whether the health care worker is providing routine care or is involved with high-risk procedures (eg, aerosol-generating procedures or treatments). (See 'Routine care in the ambulatory or hospital setting' below and 'High-risk procedures (eg, aerosol-generating procedures)' below.)

This use of enhanced precautions is based on concerns that some patients with COVID-19 are asymptomatic or presymptomatic, and a single polymerase chain reaction (PCR) test does not reliably rule out SARS-CoV-2 in all patients. In one outbreak that included 14 patients and 38 employees, the index case was a patient with chronic lung disease who was originally admitted for a procedure but was found to be dyspneic and tachycardic [20]. The patient tested negative for SARS-CoV-2 two times, 12 hours apart, on admission but subsequently developed a fever on day 4 and tested positive for SARS-CoV-2. Factors felt to contribute to transmission included the imperfect sensitivity of testing, the increased risk of transmission in symptomatic patients early in the course of disease, the potential role of nebulizers in enhancing transmission, the inconsistent use of eye protection in health care personnel (HCP), inconsistent mask wearing in patients, shared patient rooms, and that the index patient turned out to be in a positive-pressure room. In another case, an outbreak of COVID-19 that involved nine HCP occurred when an unmasked child had close contact with HCP who were not wearing face shields [21].

Emerging data suggest that using precautions such as face masks and eye protection for all patients may help reduce the risk of SARS-CoV-2 transmission. As an example, test positivity rates among HCP in one hospital rose steadily from 0 to 12.9 percent over 11 weeks; however, after implementation of several interventions, including universal face shields for all HCP upon entry into the hospital, the rate of positivity declined to 2.3 percent over the subsequent two weeks [22].

Routine care in the ambulatory or hospital setting — We suggest the following precautions for HCP providing routine care in the ambulatory or hospital setting (ie, not during aerosol-generating procedures or treatments) in areas of substantial to high community transmission:

A medical mask (eg, surgical mask) or respirator without an exhalation valve should be used at all times; this provides protection for the HCP and is also used for source control. When supplies allow, the use of National Institute for Occupational Safety and Health (NIOSH)-approved N95 (or equivalent) or higher-level respirators is preferred, particularly if there are multiple risk factors for transmission of SARS-CoV-2 (eg, if the patient has not received all of their recommended vaccines, is unable to use source control, and/or the area is poorly ventilated).

Available data have not demonstrated that respirators reduce occupational acquisition of SARS-CoV-2 compared with medical masks when providing routine care for patients without suspected COVID-19. However, respirators are often preferred when caring for patients in areas with substantial to high community transmission since there is increasing evidence that SARS-CoV-2 is transmitted via aerosols as well as droplets, and limited data suggest respirators may provide additional protection when caring for those with COVID-19 [23-25]. (See 'Overview of transmission' above.).

In addition, the use of a respirator with eye protection reduces the likelihood that a health care worker would have a high-risk exposure warranting quarantine. (See "COVID-19: Occupational health issues for health care personnel", section on 'Determining the need for quarantine'.)

Face or eye protection (goggles or face shields) should be worn in addition to a mask or respirator. Universal use of eye or face protection has been implemented in many institutions and is particularly important when caring for patients who are unable to reliably use a mask and when performing aerosol-generating procedures. HCP who use a full-face shield should be reminded that face shields alone do not provide adequate respiratory protection or source control (ie, they should still wear a medical mask under the face shield).

Gloves and gowns should be worn in addition to masks and face or eye protection when evaluating patients with an undiagnosed respiratory infection or when contact precautions are warranted.

In places with minimal to no community transmission, the use of face/eye protection and respirators should be determined by the individual institution. In the United States, information on the degree of community transmission can be found on the United States Centers for Disease Control and Prevention (CDC) website.

High-risk procedures (eg, aerosol-generating procedures) — During the COVID-19 pandemic, a respirator, rather than a medical mask, should be used for all aerosol-generating procedures or treatments and surgical procedures that generate potentially infectious aerosols or involve anatomic regions where viral loads might be higher (eg, the nose, throat, oropharynx, and respiratory tract). If the respirator has an exhalation valve or vent, a medical mask should be placed on top of it since these types of respirators are not sufficient for source control. (See 'Universal use of masks' above.)

A respirator should be used in addition to gloves, gowns, and eye or face protection. We prefer that HCP wear a full-face shield rather than goggles whenever possible. A full-face shield provides eye protection and a double layer of protection for the nose and mouth. It also prevents contamination of the respirator or mask. Full-face shields may be reused as long as they can be adequately cleaned with an approved disinfectant.

Although there is poor consensus and poor quality of scientific evidence as to what constitutes an aerosol-generating procedure, aerosol-generating procedures assumed to be associated with an increased risk of SARS-CoV-2 transmission include (listed alphabetically):

Bronchoscopy (including mini bronchoalveolar lavage)

Cardiopulmonary resuscitation

Chest physiotherapy

Filter changes on the ventilator

High-flow oxygen

Manual ventilation before intubation

Nasal endoscopy

Nebulizer treatments

Noninvasive ventilation

Open suctioning of airways

Swallowing evaluation

Tracheal intubation and extubation

Tracheotomy

Upper endoscopy (including transesophageal echocardiogram)

Additional information on infection control as it relates to anesthetic care is presented elsewhere. (See "COVID-19: Perioperative risk assessment and anesthetic considerations, including airway management and infection control", section on 'Infection control for anesthesia'.)

PATIENTS WHO HAVE HAD AN EXPOSURE TO COVID-19 — Some patients who require hospitalization for a reason unrelated to COVID-19 may have had close contact with someone with suspected or confirmed COVID-19, including during the 48 hours prior to that patient developing symptoms.

Symptomatic patients — All patients with symptoms of COVID-19 should be treated as if they have COVID-19, pending additional evaluation. (See "COVID-19: Infection prevention for persons with SARS-CoV-2 infection".)

Asymptomatic patients — For asymptomatic patients who have had close contact with someone with suspected or confirmed COVID-19, the approach to quarantine depends primarily upon the patient’s vaccination status and history of recent COVID-19 (within the last 90 days), as well as the predominant circulating variant. Additional considerations include the patient population and the specific needs of the institution (eg, if space or personal protective equipment [PPE] is limited). These decisions should be made in consultation with public health officials or infection prevention experts.

Recommendations for quarantine in the health care setting can vary and may differ from the approach to quarantine in the community. (See "COVID-19: Epidemiology, virology, and prevention", section on 'Post-exposure management'.)

Patients without recent SARS-CoV-2 infection

Who requires quarantine In general, we quarantine all asymptomatic hospitalized patients without recent severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection if they have had close contact with someone with SARS-CoV-2 infection, regardless of their vaccination status. Hospitalized patients may include certain groups (eg, older or highly immunocompromised patients) who may not have mounted a sufficiently protective immune response to vaccination. In addition, given the risk of breakthrough infection and transmission among vaccinees (even among those who received their COVID-19 booster), suspending quarantine may pose an unnecessary risk to other patients and staff. (See "COVID-19: Vaccines", section on 'Immunocompromised individuals' and "COVID-19: Vaccines", section on 'Breakthrough infections after vaccination'.)

This approach differs somewhat from that of the United States Centers for Disease Control and Prevention (CDC). The CDC states that quarantine is generally not indicated for those who are up to date with all of their recommended vaccines (table 3), unless they are moderately or severely immunocompromised or there is an ongoing outbreak in the health care facility [3].

Duration of quarantine The duration of quarantine depends upon whether the patient completed their primary vaccine series at least two weeks prior to the exposure and received a booster shot (if eligible) (table 3). When quarantine is discontinued, patients should continue to use masks as dictated by the policy in the specific health care setting.

Patients who have received all recommended vaccines (including booster if eligible) – Quarantine can generally be discontinued seven days after an exposure if two viral tests (one obtained on day 2 and one obtained on day 5 to 7) are negative [3]. Most patients will develop SARS-CoV-2 infection within this time period, although there is a very small risk of a longer incubation in some patients. We prefer nucleic acid amplification testing (NAAT) rather than antigen testing in the health care setting because of its greater and earlier sensitivity for detecting infection.

Patients whose vaccination status is not up to date – In the health care setting, unvaccinated patients who have had close contact with someone with suspected or confirmed COVID-19 should quarantine for 10 days after their last contact with the infected source. We use this same approach for vaccinated patients who completed their initial vaccine series <2 weeks prior to the exposure and those who competed the primary series but have not received their recommended booster shot. (See "COVID-19: Vaccines", section on 'Role of booster vaccinations/waning efficacy'.)

In such patients, we test for SARS-CoV-2 soon after the exposure (but no sooner than two days after) and if negative, five to seven days after the exposure. The goal of testing in this setting is to document the onset of asymptomatic infection; these results should not be used to shorten the duration of quarantine.

Although the United States Centers for Disease Control and Prevention (CDC) has issued guidance regarding a shortened quarantine for those in the community (five days at home followed by five days wearing a mask if a viral test done at day 5 is negative), this is not the preferred approach in the health care setting since wearing a mask around others may not be possible, and there is an increased risk of missed infection with the shortened quarantine [26]. (See "COVID-19: Epidemiology, virology, and prevention", section on 'Testing and masking precautions'.)

Patients with SARS-CoV-2 infection in the last 90 days — In general, most asymptomatic patients who had confirmed SARS-CoV-2 infection within the last 90 days do not need to quarantine after an exposure to COVID-19 since such patients are unlikely to develop recurrent infection in that time frame. However, in some cases, the approach to quarantine may vary depending upon the patient population (eg, degree of immunocompromise) and the likelihood that the patient was infected with the currently circulating predominant variant. These decisions should be made in consultation with infection prevention experts.

Types of precautions — When caring for patients who are being quarantined, clinicians should use infection prevention precautions similar to those used for patients with suspected disease. However, such patients should not be cohorted or share a room with patients who have COVID-19. (See "COVID-19: Infection prevention for persons with SARS-CoV-2 infection", section on 'General approach'.)

Additional information on the use of infection control precautions for patients requiring quarantine can be found on the CDC website [3].

PRECAUTIONS FOR PATIENTS WITH SUSPECTED OR CONFIRMED COVID-19 — In the health care setting, isolation precautions for patients with suspected or confirmed COVID-19 should be implemented until at least 10 days have passed since the onset of symptoms or first positive test. The duration of isolation may need to be extended for immunocompromised patients and those who had severe disease. This approach differs from that in the community. (See "COVID-19: Infection prevention for persons with SARS-CoV-2 infection", section on 'Discontinuation of precautions'.)

Patients with suspected or confirmed COVID-19 should be placed in a well-ventilated single-occupancy room with a closed door and dedicated bathroom [1,3]. When this is not possible, patients with confirmed COVID-19 can be housed together. Patients with confirmed COVID-19 should not be in a positive-pressure room.

All health care personnel (HCP) who enter the room of a patient with suspected or confirmed COVID-19 should wear personal protective equipment (PPE) to reduce the risk of exposure. Standard PPE for patients with suspected or confirmed COVID-19 includes the use of a gown, gloves, a respirator, and eye or face protection.

A detailed discussion of infection prevention precautions for patients with suspected or confirmed COVID-19 is presented in a separate topic review. (See "COVID-19: Infection prevention for persons with SARS-CoV-2 infection".)

ENVIRONMENTAL CLEANING AND DISINFECTION — To help reduce the spread of COVID-19, environmental infection prevention procedures should be implemented [1,3,27-29]. In United States health care settings, the Centers for Disease Control and Prevention (CDC) states routine cleaning and disinfection procedures are appropriate for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) [3]. Products approved by the Environmental Protection Agency (EPA) for emerging viral pathogens should be used; a list of EPA-registered products can be found here. Specific guidance on environmental measures, including those used in the home setting, is available on the CDC and World Health Organization (WHO) websites and is discussed in greater detail elsewhere. (See "COVID-19: Infection prevention for persons with SARS-CoV-2 infection", section on 'Environmental disinfection' and "COVID-19: Infection prevention for persons with SARS-CoV-2 infection", section on 'Infection prevention in the home setting'.)

WHEN PPE IS LIMITED — When availability of personal protective equipment (PPE) is limited, strategies to preserve the supply include canceling nonurgent procedures or visits that would warrant use of PPE and prioritizing the use of certain PPE for the highest-risk situations. Cautious extended or limited reuse of PPE can also be considered in select situations. (See "COVID-19: Infection prevention for persons with SARS-CoV-2 infection", section on 'When PPE is limited'.)

ADDITIONAL CONSIDERATIONS

Impact of vaccination — Health care personnel (HCP) should receive all of their recommended COVID-19 vaccines (table 3), unless there is a contraindication (eg, allergic reactions to the vaccines or their components) [30]. A detailed discussion of COVID-19 vaccines is presented separately.(See "COVID-19: Vaccines".)

Public health guidelines for fully vaccinated and boosted persons in the community may differ from those in health care settings. (See "COVID-19: Vaccines", section on 'Post-vaccine public health precautions' and "COVID-19: Epidemiology, virology, and prevention", section on 'Prevention'.)

During patient care — When caring for patients, infection prevention policies and precautions are not impacted by the vaccine status of the HCP or patient [31]. Although vaccination has been found to be highly effective in preventing severe COVID-19, cases of COVID-19 have been reported in individuals who have received all of their recommended COVID-19 vaccines, and there is a higher rate of breakthrough infections with certain variants (eg, Omicron), which are the dominant variants in many countries. (See "COVID-19: Vaccines", section on 'General efficacy issues'.)

Non-patient care activities — As more patients and HCP have been vaccinated against COVID-19, there have been attempts to liberalize restrictions for certain asymptomatic patients, visitors, and HCP who have received all of their recommended vaccines. (See "COVID-19: Vaccines", section on 'Dose and interval' and "COVID-19: Vaccines", section on 'Role of booster vaccinations/waning efficacy'.)

However, the decision to change restrictions depends upon hospital policy, which is informed in part by the degree of community transmission. We support a cautious approach to loosening restrictions since it can be difficult to confirm vaccination status, immunocompromised patients may not have mounted a sufficient immune response to vaccination, and even immunocompetent vaccinated persons may become infected with and transmit severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in the setting of certain variants (eg, the Omicron variant). (See "COVID-19: Vaccines", section on 'Impact on transmission risk'.)

Management of HCP — Health care personnel (HCP) are at risk for developing COVID-19 through exposures in the community and in the health care setting. To reduce transmission of infection to patients and coworkers, certain work restrictions should be implemented after an exposure. The approach depends upon whether the HCP has received all of their recommended COVID-19 vaccines or had SARS-CoV-2 infection within the last 90 days; if the HCP is immunocompromised; the duration and proximity of exposure; the type of personal protective equipment (PPE) used by the provider; whether the source patient wore a mask; and whether an aerosol-generating or high-risk procedure was performed. The management of HCP after an exposure is discussed in detail elsewhere. (See "COVID-19: Occupational health issues for health care personnel", section on 'HCP exposed to SARS-CoV-2'.)

Role of serologic testing — Serologic tests may be able to identify patients who have a prolonged illness (eg, greater than 14 days) and a negative polymerase chain reaction (PCR) test, as well as those who had previous infection. However, these tests are not useful for assessing the presence of infection in an exposed patient or HCP and, until their sensitivity and specificity are further assessed, they should not be used for determining the use of infection prevention precautions. Additional information on serologic testing is presented elsewhere. (See "COVID-19: Diagnosis", section on 'Serology to identify prior/late infection'.)

Addressing barriers to PPE — Despite the benefits of personal protective equipment (PPE) in reducing transmission of COVID-19, adherence to practices, such as prolonged use of masks, respirators, and face shields, can be difficult since PPE can be burdensome and uncomfortable to use [32,33]. To help address potential barriers, certain strategies can be employed. As an example, people who wear glasses often complain of fogging of their eyewear when wearing a mask or face shield. To minimize this problem, individuals who wear eye glasses should receive instruction on how to reduce or prevent fogging by adjusting the mask fit and/or washing their eyeglasses with soapy water [34]. In addition, to address PPE-induced skin injury, the American Academy of Dermatology has released recommendations on preventing and treating occupationally induced dermatologic conditions during the COVID-19 pandemic. Additional information on preventing skin injuries related to PPE is presented elsewhere. (See "COVID-19: Cutaneous manifestations and issues related to dermatologic care", section on 'Personal protective equipment-induced skin injury'.)

SPECIAL SETTINGS

Long-term care facilities — Similar to other health care settings, certain measures should be used for all patients, visitors, and health care personnel (HCP) entering long-term care facilities. These include symptom screening and use of masks for everyone entering the facility, regardless of symptoms. The United States Centers for Disease Control and Prevention (CDC) also recommends that nursing homes employ a strategy of frequent point prevalence testing for unvaccinated HCP to preempt and identify outbreaks. In some cases, a patient may be entering a facility after being hospitalized for COVID-19. Infection control precautions for COVID-19 are still required if the patient is discharged from the hospital before criteria for discontinuing precautions are met. More detailed information on infection prevention in long-term care facilities can be found on the CDC website and in a separate topic review. (See "COVID-19: Management in nursing homes".)

Dialysis — Similar to other health care settings, dialysis centers should identify patients with signs and symptoms of respiratory infection (eg, fever, cough) before they enter the treatment area. If a patient has suspected infection when they arrive, they should be placed in a private room with the door shut, and testing should be arranged. If that is not possible, they should be cohorted to a specific well-ventilated unit, wear a mask, and be separated by at least six feet (two meters) from the nearest patient. A detailed discussion of infection control precautions in dialysis centers is presented in a separate topic review. (See "COVID-19: Issues related to end-stage kidney disease", section on 'Patients receiving in-center hemodialysis'.)

Anesthesia care — Goals for infection prevention during anesthesia include prevention of transmission of infection to care providers and prevention of contamination of the anesthesia machine and other anesthesia equipment. This is discussed in detail elsewhere. (See "COVID-19: Perioperative risk assessment and anesthetic considerations, including airway management and infection control", section on 'Infection control for anesthesia'.)

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: COVID-19 – Index of guideline topics".)

SUMMARY AND RECOMMENDATIONS

Overview of interventions – Several interventions should be used to limit transmission of SARS-CoV-2 in the health care setting. These include universal source control (eg, covering the nose and mouth to contain respiratory secretions), COVID-19 vaccination, early identification and isolation of patients with suspected disease, and use of appropriate personal protective equipment (PPE) when caring for patients with and without COVID-19. (See 'Introduction' above.)

Screening – When possible, patients should be screened for signs and symptoms of COVID-19 prior to entry into the health care setting; many patients can be managed from home through telemedicine and will not need to enter a health care facility. (See 'Screening prior to and upon entry into the health care facility' above.)

Patients, visitors, and health care personnel (HCP) who enter the health care facility should be screened for clinical manifestations consistent with COVID-19 (eg, fever, cough, myalgias, sore throat, dyspnea, anosmia/hyposmia). In addition, they should be questioned about any unprotected exposures to a person with COVID-19 within the last 10 days to determine the need for quarantine. (See 'Screening prior to and upon entry into the health care facility' above and 'Patients who have had an exposure to COVID-19' above.)

Universal masking – Universal masking is required for all patients, visitors, and HCP in the health care setting. The goal of universal masking is to reduce transmission of SARS-CoV-2 from unsuspected virus carriers. Symptom screening alone is insufficient to identify individuals with COVID-19 since presymptomatic and asymptomatic transmission can occur. (See 'Universal use of masks' above.)

Infection control precautions – Infection prevention policies and precautions are the same for all HCP, even those who have received their recommended COVID-19 vaccines (table 3) or have had SARS-CoV-2 infection within the prior 90 days. (See 'Impact of vaccination' above and 'Management of HCP' above.)

Patients with suspected/confirmed COVID-19 – Patients with suspected or confirmed COVID-19 should be placed in a well-ventilated single-occupancy room with a closed door and dedicated bathroom; when this is not possible, patients with confirmed SARS-CoV-2 infection can be housed together. All HCP who enter the room should wear PPE to reduce the risk of exposure; this includes the use of a gown, gloves, a respirator, and eye or face protection. Infection prevention precautions for patients with suspected or confirmed COVID-19 are discussed in detail in a separate topic review. (See "COVID-19: Infection prevention for persons with SARS-CoV-2 infection".)

Patients NOT suspected of having COVID-19 – In areas of ongoing transmission, enhanced infection control precautions (eg, respirators, face shields), in addition to universal masking, should be used when caring for all patients regardless of the individual suspicion for COVID-19. (See 'Precautions for those NOT suspected of having COVID-19' above.)

Environmental cleaning – To help reduce the spread of COVID-19, environmental infection prevention procedures should be implemented. In United States health care settings, the Centers for Disease Control and Prevention (CDC) states that routine cleaning and disinfection procedures are appropriate for SARS-CoV-2. (See 'Environmental cleaning and disinfection' above.)

Specific health care settings – In select health care settings (eg, long-term health care facilities, dialysis, operating room), there may be additional considerations for infection prevention policies and precautions. These are discussed in separate topic reviews. (See "COVID-19: Occupational health issues for health care personnel" and "COVID-19: Management in nursing homes" and "COVID-19: Perioperative risk assessment and anesthetic considerations, including airway management and infection control" and "COVID-19: Issues related to end-stage kidney disease".)

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Topic 130296 Version 10.0

References