Guidance

COVID-19: management of staff and exposed patients or residents in health and social care settings

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1. Scope

This guidance provides advice on the management of staff and patients or residents in health and social care settings according to exposures, symptoms and test results. There may be further information specific to each country in the United Kingdom, as this guidance was written by Public Health England (PHE) primarily for an English health professional audience, and contact tracing and testing arrangements are variable across the 4 nations of the UK.

To see if country specific information is available, please refer to Health Protection Scotland, Public Health Wales, or Public Health Agency in Northern Ireland.

2. Introduction

Health and social care workers are aware of the recommendation to not come to work when there is a risk that they may spread infection in their workplace.

Managers have a high level of skill in assessing whether individual staff require exclusion from work and should remain the first point of contact for a health or social care worker who is unsure whether they are fit to work.

This guidance sets out general principles and should be considered alongside local risk assessment and local policies. There may need to be an individual risk assessment based on staff circumstances, for example for those who are either immunocompromised or work with individuals who are immunocompromised.

This guidance should be followed regardless of the results of any SARS-CoV-2 antibody testing. A positive antibody result signifies previous exposure, but it is currently unknown whether this correlates with immunity, including protection against future infections.

3. Background – contact isolation periods

In early December 2020, after considering the evidence on incubation periods and mathematical modelling results, the UK Chief Medical Officers announced a reduction in the number of days that contacts must self-isolate – from 14 to 10 days. The law in England has been changed to reflect this (separate legislation is applicable in the other administrations). This decision balances the benefits of potentially improved compliance with a 10-day contact self-isolation period against the low likelihood of incubation periods longer than 10 days following an exposure in the community.

In certain settings where people aged 70 or over are concentrated (for example, are permanently or temporarily resident in a care home or a hospital), a more precautionary approach is indicated because vulnerability to serious COVID-19 illness increases with age, and those aged 70 or over are considered at moderate risk. Therefore, guidance produced by the UK Infection Prevention and Control cell, PHE and Department of Health and Social Care (DHSC) recommends that the isolation period for resident and patient contacts in care homes and hospitals should remain at 14 days. For care home residents this 14-day contact-isolation period is the same as that for new residents admitted from elsewhere.

The precautionary 14-day contact-isolation period does not apply to care home or hospital staff contacts who should follow the legal requirement to isolate for 10 days.

4. Staff with symptoms of COVID-19

If a health or social care worker develops symptoms of COVID-19:

• they should follow the stay at home guidance

• while at home (off-duty), they should not attend work and notify their line manager immediately

• while at work, they should put on a surgical face mask immediately, inform their line manager and return home

• comply with all requests for testing

If a member of staff develops symptoms, they should be tested for SARS-CoV-2 by polymerase chain reaction (PCR). Testing is most sensitive within 3 days of symptoms developing. Guidelines on who can get tested and how to arrange for a test can be found in the COVID-19: getting tested guidance.

If their symptoms do not get better after 10 days, or their condition gets worse, they should speak to their occupational health department, if they have one, or use the NHS 111 online coronavirus service. If they do not have internet access, they should call NHS 111. For a medical emergency, they should call 999.

5. Staff who are PCR positive for SARS-CoV-2

Staff who have tested positive for SARS-CoV-2 by PCR in the community or at work should self-isolate for at least 10 days after illness onset. The isolation period includes the day their symptoms started (or the day their test was taken if they do not have symptoms) and the next 10 full days.

If, however, they have been admitted to hospital they should be isolated in hospital (or continue to self-isolate on discharge) for 14 days from their first positive PCR test result. This is because COVID-19 cases admitted to hospital will have more severe disease and are more likely to have pre-existing conditions, such as severe immunosuppression. For the same reasons, the 14-day isolation rule also applies to other (non-staff) COVID-19 cases admitted to hospital.

Asymptomatic staff who have not been hospitalised and have tested positive for SARS-CoV-2, should self-isolate for 10 days following their first positive PCR test.

6. SARS-CoV-2 re-testing in staff, patients and residents in health and social care settings

Immunocompetent staff, patients and residents who have tested positive for SARS-CoV-2 by PCR should be exempt from routine re-testing by PCR or LFD antigen tests (for example, repeated whole setting screening or screening prior to hospital discharge) within a period of 90 days from their initial illness onset or test (if asymptomatic) unless they develop new COVID-19 symptoms. This is because fragments of inactive virus can be persistently detected by PCR in respiratory tract samples following infection – long after a person has completed their isolation period and is no longer infectious.

If a person is re-tested by PCR within 90 days from their initial illness onset or test date and is found to still be positive for SARS-CoV-2, a clinically-led approach, taking into account several factors, should be used to decide whether reinfection is a possibility and to inform subsequent action. Such factors include:

• COVID-19 symptoms

• underlying clinical conditions

• immunosuppressive treatments and conditions

• additional information such as cycle threshold values

Seek advice from an infection specialist as required.

If a person is re-tested by PCR after 90 days from their initial illness onset or test and is found to be PCR positive, this should be considered as a possible new infection. If they have developed new COVID-19 symptoms, they would need to self-isolate again and their contacts should be traced.

All hospitalised care home residents who have previously tested PCR negative as part of routine screening or the investigation of a recent illness should be tested for SARS-CoV-2 again 48 hours prior to discharge and the result of this repeat test relayed to the receiving organisation. Immunocompetent residents who have tested positive within the previous 90 days, and remain asymptomatic, do not need to be re-tested.

Any resident who tests positive and is being discharged within their 14-day isolation period should only be discharged to a designated setting.

7. SARS-CoV-2 lateral flow device (LFD) antigen testing in health and social care staff who are asymptomatic

Staff who are having regular LFD antigen tests as part of an asymptomatic testing programme, and who test positive, should self-isolate immediately, along with their household contacts and arrange to have a confirmatory PCR test. If the PCR test result is negative, they and their household can stop isolating and return to work. If the PCR result is positive, they and their household must continue to self-isolate for 10 days.

Staff who have previously tested positive for SARS-CoV-2 by PCR in the past 90 days are exempt from re-testing (see section 6). Despite this advice, some staff may be offered and may accept an LFD antigen test as part of an asymptomatic staff testing programme. Should such re-tested staff be found to be LFD antigen positive within 90 days of a positive PCR test, they and their household should self-isolate and they should arrange to have a confirmatory PCR test. If this PCR test result is negative, they and their household can stop isolating and they can return to work. If this PCR test result is positive, then the possibility of SARS-CoV-2 reinfection should be considered – subsequent action should be guided by a clinically-led approach taking account the factors described in section 6.

8. Staff return to work criteria

8.1 If staff are symptomatic when tested

Symptomatic staff should be tested using PCR tests. Staff who test negative for SARS-CoV-2 with a PCR test can return to work when they are medically fit to do so, following discussion with their line manager and appropriate local risk assessment. Interpret negative results with caution together with clinical assessment.

Symptomatic staff who test positive for SARS-CoV-2 or who have an inconclusive test result, and symptomatic staff who have not had a test, can:

• return to work no earlier than 10 days from symptom onset, provided clinical improvement has occurred and they have been afebrile (not feverish) without medication for 48 hours and they are medically fit to return

• if a cough or a loss of or a change in normal sense of smell (anosmia) or taste is the only persistent symptom after 10 days (and they have been afebrile for 48 hours without medication), they can return to work if they are medically fit to return (these symptoms are known to persist for several weeks in some cases)

All members of a household shared with the individual should self-isolate from when the individual’s symptoms started, in line with the stay at home guidance. If the staff member’s PCR test result is positive their household must complete their full 10 day self-isolation period. However, if any household member develops symptoms of COVID-19, they should isolate for at least 10 days from the onset of their symptoms, in line with the stay at home guidance. If the staff member’s PCR test result is negative, and they and their household have no symptoms of COVID-19, the household can stop isolating.

8.2 If staff are asymptomatic when tested

Staff without symptoms may also be tested in line with NHS England, PHE, DHSC or devolved administration guidance.

Staff who test negative for SARS-CoV-2 and who were asymptomatic at the time of the test can remain at work or return to work immediately as long as they remain asymptomatic if they were tested as part of routine testing. If they were tested as part of a contact tracing investigation then they should follow instructions from NHS Test and Trace and their local health protection team.

Staff who test positive for SARS-CoV-2 (either by PCR or PCR confirmed LFD antigen test) and who were asymptomatic at the time of the test must self-isolate for 10 full days following the date of the first test. If they remain well, they can return to work after their isolation period.

If, during the 10 days isolation, they develop symptoms, they must self-isolate for 10 days from the day of symptom onset. They can:

• return to work no earlier than 10 days from symptom onset, provided clinical improvement has occurred and they have been afebrile (not feverish) without medication for 48 hours and they are medically fit to return

• if a cough or a loss of or a change in normal sense of smell (anosmia) or taste is the only persistent symptom after 10 days (and they have been afebrile for 48 hours without medication), they can return to work if they are medically fit to return (these symptoms are known to persist for several weeks in some cases)

All members of a household shared with the individual should self-isolate for 10 days from the day the individual’s test was taken. However, if any household member develops symptoms of COVID-19, they should isolate for at least 10 days from the onset of their symptoms, in line with the stay at home guidance.

9. Contact risk assessment and exemption criteria

The NHS Test and Trace service and other national (Northern Ireland, Scotland or Wales) contact tracing services have been established to minimise community transmission of COVID-19. It is designed to:

• ensure that anyone who develops symptoms of COVID-19 can quickly be tested to find out if they have the virus

• help trace close recent contacts of anyone who tests positive for COVID-19 and, if necessary, notify them that they should self-isolate at home to help stop the spread of the virus

9.1 If staff have been notified that they are a contact of a confirmed case in a health and care setting

If health and social care staff are providing direct care to a patient or a resident with COVID-19 and are wearing the correct PPE in accordance with the current IPC guidance, they will not be considered as a contact for the purposes of contact tracing and isolation. They will also not be required to self-isolate for 10 days (organisations have agreed the standards for PPE specification, fit testing and regimes of use for clinical and care activities).

It is important to note that the effectiveness of the use of face masks, face coverings, or other PPE for prevention of transmission or acquisition of coronavirus infection cannot be guaranteed in settings other than the provision of direct care with patients or residents. Therefore, the use of PPE in other settings, such as a staff room or canteen, will not necessarily exclude an individual from being considered a close contact. In addition, if health and social care staff have been in contact with a COVID-19 case and are not following appropriate IPC, including wearing correct PPE, they will be considered as a contact for the purposes of contact tracing and isolation.

If a health or social care worker is considered to be a contact, and the recommendation for them to self-isolate would have implications for the provision of the service, their employer will need to escalate this for a risk- assessment to a Tier 1 contact tracer at the local Health Protection Team (HPT). Advice about whether a risk assessment is needed may also be sought from the HPT. The risk assessment should take account of any PPE use (including its type and situational appropriateness) and other mitigating factors that may reduce the risk of infection transmission to such an extent that the individual identified as a contact does not need to self-isolate.

All staff who come into contact with COVID-19 cases – whether or not they are protected by the use of PPE or by other factors – should remain vigilant to the possibility of contracting infection and should self-isolate immediately if they develop relevant symptoms.

9.2 If staff have been notified that they are a contact of a confirmed case in the community

If staff have been notified as a contact of a confirmed case of COVID-19 in the community (outside the health or social care setting or their place of work), they should inform their line manager and self-isolate for 10 days, in line with guidance for non-household contacts.

This advice should be followed regardless of the results of any previous SARS-CoV-2 PCR test or antibody test results. A positive antibody result signifies previous exposure, but it is currently unknown whether this correlates with immunity, including protection against future infections.

10. Risk assessment for staff exposures in the workplace

If a health or social care worker has come into close contact with a confirmed COVID-19 patient, resident or service-user or a symptomatic patient, resident or service-user suspected of having COVID-19 while not wearing PPE, or had a breach in their PPE while providing personal care to a patient, resident or service-user with confirmed or suspected COVID-19, then the staff member should inform their line manager.

For appropriate PPE resources for:

• health care workers, see infection prevention and control guidance

• care home workers, see how to work safely in care homes

• home care workers, see how to work safely in domiciliary care

In assessing whether a health or social care worker has had a breach of PPE, a risk assessment should be undertaken in conjunction with local infection prevention and control (IPC) policy. Take into consideration:

• the severity of symptoms the patient/resident has

• the length of exposure

• the proximity to the patient/resident

• the activities that took place when the worker was in proximity (such as aerosol-generating procedures (AGPs), monitoring, personal care)

• whether the health or social care worker had their eyes, nose or mouth exposed

If the risk assessment concludes there has been a significant breach or close contact without PPE, the worker should remain off work for 10 days.

Examples that are unlikely to be considered breaches include if a health or social care worker was not wearing gloves for a short period of time or their gloves tore – and they washed their hands immediately – or if their apron tore while caring for a resident and this was replaced promptly.

This would also apply to other individuals present in a care environment (such as an allied health visitor, visitor or family member) if they are following instructions from that institution.

11. Patient exposures in hospital

In-patients who are known to have been exposed to a confirmed COVID-19 patient while on the ward (an exposure similar to a household setting), should be isolated or cohorted (grouped together) with other similarly exposed patients who do not have COVID-19 symptoms, until 14 days after last exposure if they remain in hospital.

This also applies to in-patients who have previously recovered from COVID-19 and have been exposed to a confirmed COVID-19 case during their hospital stay.

If symptoms or signs consistent with COVID-19 occur in the 14 days after exposure then relevant diagnostic tests, including for SARS-CoV-2, should be performed. These patients should be isolated or cohorted with other suspected cases while results are pending.

To get patients ready for discharge, the guidance for stepdown of infection control precautions and discharging COVID-19 patients should be followed.

On discharge to their own home, patients should be advised to stay at home until 10 days have elapsed since their exposure and should refer to guidance for non-household contacts.

12. Resident exposures in care settings

Residents who are known to have been exposed to a confirmed COVID-19 patient (an exposure similar to a household setting), should be isolated or cohorted only with residents who do not have COVID-19 symptoms but also have been exposed to COVID-19 residents, until 14 days after last exposure. This also applies to residents who have previously recovered from COVID-19 and have been exposed to a confirmed COVID-19 case.

If symptoms or signs consistent with COVID-19 occur in the 14 days after last exposure then relevant diagnostic tests, including for SARS-CoV-2, should be performed. If they have been cohorted with other individuals, the other residents’ follow-up isolation period recommences from the date of last exposure.

13. Additional considerations

Currently, it is not known how long immunity to COVID-19 may last. This is being reviewed as evidence emerges. In the current state of knowledge, should staff develop new COVID-19 symptoms, they should self-isolate, even if they have already had a positive SARS-CoV-2 antibody test – for example as a research study participant.

Further advice on return to work of staff with complex health needs, including immunosuppression, and of staff working with clinically extremely vulnerable individuals can be received from designated infection control leads in clinical commissioning groups (CCGs), from local health protection teams in PHE and/or from directors of public health, according to local arrangements.

For more information on interpreting test results and the actions required for both symptomatic and asymptomatic individuals, see the flowcharts illustrating the return to work process.

14. Associated legislation

Please note that this guidance is of a general nature and that an employer should consider the specific conditions of each individual place of work and comply with all applicable legislation, including the Health and Safety at Work etc. Act 1974.