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Coronavirus disease 2019 (COVID-19): Infection control in

health care and home settings
Author: Tara N Palmore, MD
Section Editor: Daniel J Sexton, MD
Deputy Editors: Jennifer Mitty, MD, MPH, Allyson Bloom, MD

All topics are updated as new evidence becomes available and our peer review process is complete.

Literature review current through: Jul 2020. | This topic last updated: Aug 14, 2020.

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
characterize it as a pandemic in March 2020. The virus that causes COVID-19 is designated severe
acute respiratory syndrome coronavirus 2 (SARS-CoV-2); previously, it was referred to as 2019-
nCoV.

Understanding of COVID-19 is evolving. Interim guidance has been issued by the WHO and by the
United States Centers for Disease Control and Prevention [1,2]. (See 'Society guideline links'
below.)

This topic will provide an overview of infection control issues when caring for patients with COVID-
19. The use of specific infection control precautions as they pertain to select specialties is
presented elsewhere.

● (See "Coronavirus disease 2019 (COVID-19): Critical care and airway management issues".)
● (See "Coronavirus disease 2019 (COVID-19): Anesthetic concerns, including airway
management and infection control".)
● (See "Coronavirus disease 2019 (COVID-19): Clinical manifestations and diagnosis in children"
and "Coronavirus disease 2019 (COVID-19): Clinical manifestations and diagnosis in children",
section on 'Introduction'.)
● (See "Coronavirus disease 2019 (COVID-19): Pregnancy issues".)
● (See "Coronavirus disease 2019 (COVID-19): Arrhythmias and conduction system disease".)
 ● (See "Coronavirus disease 2019 (COVID-19): Myocardial infarction and other coronary artery
disease issues".)
● (See "Coronavirus disease 2019 (COVID-19): Issues related to kidney disease and
hypertension".)

OVERVIEW OF TRANSMISSION

Many experts agree that transmission occurs primarily through droplets (when virus released in
the respiratory secretions of a person with infection makes direct contact with mucous
membranes) [3-5]. Transmission is also felt to occur through inhalation of aerosolized secretions,
which travel further, remain suspended in air longer, and contain infectious particles that are
smaller than typically described for respiratory droplets; however, the relative contribution of this
mode of transmission outside of aerosol-generating procedures is uncertain [6]. 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. More detailed
information on the transmission of SARS-CoV-2, including the risk of asymptomatic transmission,
is discussed in a separate topic review. (See "Coronavirus disease 2019 (COVID-19): Epidemiology,
virology, and prevention", section on 'Transmission'.)

INFECTION CONTROL IN THE HEALTH CARE SETTING

Infection control interventions to reduce transmission of COVID-19 include universal source

control (eg, covering the nose and mouth to contain respiratory secretions), early identification and
isolation of patients with suspected disease, the use of appropriate personal protective equipment
(PPE) when caring for patients with COVID-19, and environmental disinfection. Limiting
transmission of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is an essential
component of care in patients with suspected or documented COVID-19. In an early report of
COVID-19 in 138 patients from China, it was estimated that 43 percent acquired infection in the
hospital setting [7]. In Washington State, suboptimal use of infection control procedures
contributed to the spread of infection to 81 residents, 34 staff members, and 14 visitors in one
long-term care facility [8].

Measures for all patients, visitors, and personnel

Screening prior to and upon entry into the health care facility

● Patients – Patients should be screened for clinical manifestations consistent with COVID-19
(eg, fever, cough, myalgias, sore throat, dyspnea, anosmia/hyposmia) prior to entry into a
health care facility. The clinical manifestations of COVID-19 are presented in detail elsewhere.
 (See "Coronavirus disease 2019 (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 the health care setting. (See "Coronavirus
disease 2019 (COVID-19): Outpatient evaluation and management in adults" and
'Infection control in the home setting' below.)

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

• However, if a dedicated clinic is not available or 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.

All patients should also be screened for respiratory symptoms upon entry into a health care
setting. Separate waiting areas for patients with respiratory symptoms should be designated,
with seating spaced such that patients are at least six feet (two meters) apart. Screening
upon entry will also identify those who warrant additional infection control precautions. (See
'Patients with suspected or confirmed COVID-19' below.)

To identify patients with asymptomatic or presymptomatic infection, many institutions have

also implemented universal nucleic acid testing prior to all elective procedures and upon
admission to the hospital. Guideline panels support this type of testing, when resources allow,
to help guide decisions about the need for non-urgent procedures and to ensure the use of
appropriate infection control precautions [3,4,9]. However, in asymptomatic patients with prior
COVID-19 who met initial criteria for discontinuation of precautions, repeat testing is not
warranted if the patient's onset of illness was within the prior three months [10]. Additional
information on the use of infection control precautions in patients with prior COVID-19 is
found below. (See 'Patients with prior COVID-19' below.)

Patients without symptoms should also be questioned about unprotected exposures to

COVID-19 within the last 14 days to determine the need for quarantine.

If quarantine is required, patients should be placed in a private room with the door closed. If
that is not possible, the patient should be separated from others by at least six feet [3].
Additional information on infection control precautions in this setting is discussed below.
(See 'Patients who have had an exposure to COVID-19' below.)

● Visitors – During the COVID-19 pandemic, most hospitals have restricted visitors in the health
care setting. Exempted visitors should also be screened for exposure to and symptoms of
 COVID-19; those with evidence of infection or a known exposure in the last fourteen days
should not be allowed to enter the health care setting.

● Health care workers – The approach to screening health care workers entering the health
care setting depends upon the institution's policies. In general, health care workers should
monitor themselves for fever and symptoms of COVID-19 and stay home if they are ill. In one
report of 48 health care workers with confirmed COVID-19 in King County, Washington, 65
percent reported working for a median of two days while exhibiting symptoms of COVID-19
[11]. In addition, symptom screening alone did not identify all cases. Thus, additional
measures, such as universal use of masks, are recommended. (See 'Universal use of masks'
below.)

Health care workers 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. (See 'After potential or known exposure' below.)

Universal use of masks — All patients and any exempted visitors should bring or be given
masks (eg, nonmedical or cloth 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 the mask throughout their visit.
Once patients are in an appropriate room (eg, single room with the door closed for patients with
suspected COVID-19), they can usually remove the mask. However, patients should put the mask
back on for source control whenever a health care worker enters the room. If the patient cannot
don the mask themselves, the health care worker should put the mask on the patient while in the
room. If a patient cannot or will not wear a mask, a face shield provides additional protection. (See
'Type of PPE' below and 'Patients who are NOT suspected of having COVID-19' below.)

Health care workers should also wear a mask while in the hospital setting [3,12]. A medical mask
(eg, surgical mask) or respirator must be used when caring for patients. These typically provide
both source control and respiratory protection. However, 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. Detailed information on the use of masks and other infection control
measures when caring for patients with or without suspected or confirmed COVID-19 is discussed
below. (See 'Patients with suspected or confirmed COVID-19' below and 'Patients who are NOT
suspected of having COVID-19' below.)

When supplies are limited, cloth masks may be reasonable for certain workers in health care
settings, but only for those who do not engage in patient care and for providers when they are not
involved in direct patient care activities (eg, when they are in the breakroom) [3]. These masks
should not have exhalation valves. (See "Coronavirus disease 2019 (COVID-19): Epidemiology,
virology, and prevention", section on 'Personal preventive measures'.)

Hand hygiene should be performed immediately before and after any contact with the face masks,
including cloth masks. Masks should be changed if they become soiled, damp, or difficult to
breathe through. Cloth masks should be laundered regularly (eg, daily and when soiled) [12,13].

The goal of universal masking is to reduce transmission of SARS-CoV-2 from unsuspected virus
carriers [14,15]. Symptom screening alone may not be sufficient to identify individuals with COVID-
19 since presymptomatic and asymptomatic transmission can occur [16,17]. The universal use of
masks also simplifies the management of exposures should a health care worker become ill with
COVID-19 [18]. (See 'After potential or known exposure' below.)

Emerging data have demonstrated a reduction in SARS-CoV-2 infections in health care workers
after implementation of universal masking [19,20]. In one report that evaluated nearly 10,000
health care workers from Massachusetts who were tested for SARS-CoV-2 (mainly because of
symptoms), the proportion with positive test results steadily declined after universal masking
(from 14.7 to 11.5 percent over 29 days), despite an increase in the number of cases in the
community [20]. 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 [19].

Additional information on the use of masks as source control in community settings is presented
elsewhere. (See "Coronavirus disease 2019 (COVID-19): Epidemiology, virology, and prevention",
section on 'Personal preventive measures'.)

Patients with suspected or confirmed COVID-19

Approach for most patients — The following infection control precautions should be used for
all patients with suspected or confirmed COVID-19.

Type of room — Patients should be placed in a well-ventilated single-occupancy room with a

closed door and dedicated bathroom [3,4]. 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.

An airborne infection isolation room (AII; ie, a single-patient, negative-pressure room) should be
prioritized for patients undergoing aerosol-generating procedures. Additional information on AII
rooms, and what to do when these are not available, is found below. (See 'Aerosol-generating
procedures/treatments' below.)

Type of PPE — All health care workers 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 or medical mask, and eye or face protection:

● Gown and gloves – Isolation gowns and non-sterile gloves should be put on upon entry into
the patient room or area. Some institutions require double gloving for health care workers
caring for patients with suspected or confirmed COVID-19 to reduce the risk of skin
contamination when doffing; however, there are insufficient data on whether this further
reduces transmission to support the routine use of this approach.

On COVID-19 units, gowns do not need to be routinely changed between patients unless the
gown is soiled or the patient requires additional contact precautions (eg, for a drug-resistant
organism), in which case a new gown should be used.

● Respirator or medical mask – A respirator (eg, N95 or other respirators that offer a higher
level of protection) should be worn instead of a medical mask (eg, surgical mask) during
aerosol-generating procedures and certain types of environmental cleaning. If the respirator
has an exhalation valve or vent, a medical mask should be placed on top of it for source
control. (See 'Universal use of masks' above and 'Aerosol-generating procedures/treatments'
below and 'Environmental disinfection' below.)

However, guidelines differ regarding the preference for a medical mask or respirator for other
types of care. As an example, the World Health Organization (WHO) recommends a medical
mask, whereas the United States Centers for Disease Control and Prevention (CDC)
recommends a respirator but acknowledges that medical masks are an acceptable alternative
when the supply of respirators is limited [3,6,12]. Cloth masks are not considered PPE and
should not be worn for the care of patients. A discussion of extended use and reuse of masks
and respirators when PPE is limited is found below. (See 'When PPE is limited' below.)

There are no studies comparing the use of respirators or medical masks when caring for
patients with suspected or confirmed COVID-19. We agree with CDC recommendations and
suggest the use of respirators when caring for all patients with suspected or confirmed
COVID-19 when supplies allow, since the relative importance of various possible modes of
transmission of SARS-CoV-2 is unclear. In particular, there is experimental evidence that
airborne transmission may occur [3,21], especially high-velocity, small-particle aerosols
generated by coughing and sneezing, with particles that remain airborne for longer and travel
farther than usual respiratory droplets. (See "Coronavirus disease 2019 (COVID-19):
Epidemiology, virology, and prevention", section on 'Route of person-to-person transmission'.)

However, other experts feel that medical masks (when combined with other PPE including
face shields and hand hygiene) are sufficient during non-aerosol-generating care, since
droplet transmission is likely the main mode of transmission, and available data from patients
with SARS-CoV-2 or other viral respiratory infections suggest that N95 respirators offer no
 clear benefit over medical masks during routine care [22,23]. In addition, several reports
during the COVID-19 pandemic found that transmission to health care workers is greatly
reduced when standard, contact, and droplet precautions with eye protection are used for
most patients, with N95 respirators reserved for aerosol-generating procedures [24-27]. As an
example, in a report from a Hong Kong hospital in which respirators were used for patients
with suspected COVID-19, medical masks were used for other patients, and respirators were
used for all aerosol-generating procedures (regardless of apparent patient risk factors), 11 of
413 health care workers (2.7 percent) cared for patients with COVID-19 wearing a medical
mask rather than a respirator for routine care, and none developed infection [24].

● Eye or face protection – For eye or face protection, goggles or a disposable face shield that
covers the front and sides of the face should be used; glasses are not sufficient. If a powered
air-purifying respirator (PAPR) is used, additional eye protection is not needed.

Some institutions also require shoe covers for providers caring for patients on a dedicated COVID-
19 ward or intensive care unit. Reports suggest that SARS-CoV-2 RNA can be widely distributed on
surfaces, such as floors, particularly in the intensive care unit, and can be found on shoes after
intubation [28,29], but whether this reflects infectious virus is unknown. Hair covers may be used
as well, but are usually not mandatory outside of the operating room setting.

Health care workers should pay special attention to the appropriate sequence of putting on (figure
1) and taking off (figure 2) PPE and the use of hand hygiene to avoid contamination. Videos
demonstrating the proper donning and doffing of PPE are available. Errors in removal of PPE are
common, even by trained clinicians, and are associated with contamination of health care workers
with pathogens [30]. This can result in indirect (secondary) transmission. In a Cochrane review
that evaluated methods to increase compliance with donning and doffing of PPE, several
interventions appeared to have some benefit in preventing contamination, including the use of
CDC protocols and face-to-face training [31].

Available evidence supports these PPE recommendations [32-36], and infection rates among
health care workers appear to parallel those of the general population in the setting of appropriate
PPE use [37-40]. In a meta-analysis of observational studies evaluating the risk of transmission of
SARS-CoV-2, SARS-CoV, and Middle East respiratory syndrome coronavirus (MERS-CoV), use of
medical masks or respirators (adjusted odds ratio [OR] 0.15) and eye protection (adjusted OR
0.22) were each associated with a reduced risk of infection [33]. In one study, there was no
evidence of SARS-CoV-2 transmission (based upon nucleic acid and serologic testing) in a group
of 420 health care workers who were provided with appropriate PPE, all of whom had direct
contact with COVID-19 patients and performed at least one aerosol-generating procedure [34].

Transporting patients outside the room — Patients with confirmed or suspected COVID-19
should wear a medical mask if being transported out of the room (eg, for studies that cannot be
performed in the room). If a portable tent system with high-efficiency particulate air (HEPA)
filtration is used to transport patients with COVID-19, the patient does not need to wear a mask,
but health care workers transporting the patient should wear PPE in case of a failure of the
powered HEPA filtration.

Approach in select settings

Aerosol-generating procedures/treatments — In patients with COVID-19, aerosol-generating

procedures and treatments should be avoided when possible to reduce the potential risk of
transmission to health care workers.

● Aerosol-generating procedures – In patients with COVID-19, aerosol-generating procedures

assumed to be associated with an increased risk of infection typically include (listed
alphabetically):

• Bronchoscopy (including mini bronchoalveolar lavage)

• Cardiopulmonary resuscitation
• Colonoscopy
• Filter changes on the ventilator
• High-flow oxygen
• Manual ventilation before intubation
• Nasal endoscopy
• Noninvasive ventilation
• Open suctioning of airways
• Tracheal intubation and extubation
• Tracheotomy
• Upper endoscopy (including transesophageal echocardiogram)
• Swallowing evaluation

However, there is poor consensus as to what constitutes an aerosol-generating procedure,

and out of an abundance of caution, some society guidelines have categorized other types of
procedures (eg, certain laparoscopic procedures) as aerosol-generating procedures that could
increase the risk of SARS-CoV-2 transmission [41,42]. However, the risk of transmission from
procedures that do not directly involve the respiratory tract is unclear.

● Aerosol-generating treatments – Aerosol-generating treatments typically include nebulized

medications, thus inhaled medications should be administered by metered-dose inhaler when
feasible, rather than through a nebulizer, to avoid the risk of aerosolization of SARS-CoV-2
through nebulization.

If avoiding aerosol-generating procedures or use of a nebulizer is not possible, appropriate PPE for
health care workers includes use of N95 or other respirators (eg, a powered air-purifying respirator
[PAPR]) that offer a higher level of protection [3-5]. Other precautions include eye protection (eg,
goggles or a disposable face shield that covers the front and sides of the face), gloves, and a
gown. (See 'Type of PPE' above.)

Aerosol-generating procedures should take place in an airborne infection isolation room (AII)
whenever possible. These are single-patient rooms at negative pressure relative to the surrounding
areas, and with a minimum of six air changes per hour (12 air changes per hour are recommended
for new construction or renovation). When an AII room is not available, a portable HEPA unit can
be placed in the room, although it does not compensate for the absence of negative air flow. In
one institution, a negative-pressure canopy was used for patients receiving continuous positive
airway pressure (CPAP), high-flow nasal cannula, and noninvasive ventilation [43].

Health care workers and other personnel (eg, environmental services, maintenance) should not
enter the room until sufficient time has passed since an aerosol-generating procedure to allow for
removal of infectious particles. The rate of removal depends upon the number of air exchanges
per hour, as described on the CDC website [44].

Specimen collection for respiratory viral pathogens — In the setting of the COVID-19
pandemic, respiratory specimens for viral pathogens should be obtained in a single-occupancy
room with the door closed, and visitors should not be present during specimen collection.
Nasopharyngeal or oropharyngeal specimen collection is not considered an aerosol-generating
procedure that warrants an airborne infection isolation room.

When collecting a nasopharyngeal or oropharyngeal specimen in a patient with suspected or

confirmed COVID-19, the United States CDC recommends that health care workers in the room
wear an N95 or higher level respirator (or medical mask if a respirator is not available), eye
protection (eg, face shield or goggles), gloves, and a gown [45]. As noted above, the CDC suggests
using a respirator rather than a medical mask when caring for all patients with suspected or
confirmed COVID-19. However, when supplies are limited, respirators should be prioritized for
aerosol-generating procedures. (See 'Approach for most patients' above and 'Aerosol-generating
procedures/treatments' above.)

Drive-up testing centers have proliferated as a standard setting in which to conduct testing for
SARS-CoV-2. They offer the advantage of high throughput and minimal contact with symptomatic
individuals, as patients remain in their cars and undergo sample collection by health care workers
who are wearing PPE.

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.
(See "Coronavirus disease 2019 (COVID-19): Clinical features", section on 'Incubation period'.)

In this setting, clinicians should use infection control precautions similar to those used for patients
with suspected disease, as described above; however, such patients should not be cohorted or
share a room with patients who have COVID-19. (See 'Approach for most patients' above.)

Patients should continue infection control precautions specific for COVID-19 for the duration of
their quarantine (14 days after their last contact with the patient).

Some institutions are testing asymptomatic patients after an exposure. However, a negative test
does not rule out subsequent development of infection with SARS-CoV-2, and therefore, infection
control precautions should be continued for the duration of the incubation period, despite a
negative result.

Patients with prior COVID-19 — Some patients have recovered from COVID-19 and have met initial
criteria for discontinuation of precautions but are subsequently rehospitalized. Precautions for
such patients depend on the interval since the prior illness.

● If the onset of prior illness was within three months, we use the following approach, which is
consistent with CDC guidelines [10]:

• If the patient has no symptoms consistent with COVID-19, repeat SARS-CoV-2 testing is
not recommended, and enhanced infection control precautions specific for COVID-19 are
not required. This means that health care centers should not perform routine screening
of asymptomatic patients who had past infection with SARS-CoV-2 within the last three
months.

• If the patient has symptoms consistent with COVID-19, we use infection control
precautions for patients with suspected COVID-19 pending the initial evaluation. If
another etiology (eg, influenza) is not identified, the decision to continue these
precautions must be determined on a case-by-case basis. Although reinfection/relapse in
patients with prior COVID-19 has not yet been identified, data are limited.

● If the onset of prior illness was more than three months ago, the patient should be managed
similarly to patients without prior COVID-19.

Patients who are NOT suspected of having COVID-19 — When there is ongoing community
transmission of SARS-CoV-2, it is reasonable to use certain enhanced infection control
precautions when caring for patients who are not suspected of having COVID-19 [4,45], even those
who had a negative test for SARS-CoV-2 upon entry into the health care setting. These precautions
include the use of:

● A medical mask (eg, surgical mask) when providing routine care for patients; this provides
protection for the health care worker and is also used for source control.

A respirator, rather than a medical mask, should be used for aerosol-generating procedures
and surgical procedures that generate potentially infectious aerosols or involve anatomic
regions where viral loads might be higher, such as 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.)

● Face or eye protection (goggles or face shields), in addition to masks. This is particularly
important when caring for patients who are unable to reliably use a mask and when
performing aerosol-generating procedures.

● Gloves and gowns 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 for aerosol-generating procedures or surgery should be determined by the individual
institution.

The use of enhanced precautions in patients without suspected or confirmed COVID-19 is based
upon concerns that some patients with COVID-19 are asymptomatic and polymerase chain
reaction (PCR) testing does not reliably detect SARS-CoV-2 in all patients. However, there are no
data to support that these additional precautions are necessary to reduce the risk of SARS-CoV-2
transmission, and it is unclear if SARS-CoV-2 can be transmitted from non-respiratory sites.
Additional information on transmission and diagnosis of SARS-CoV-2 is presented elsewhere. (See
"Coronavirus disease 2019 (COVID-19): Epidemiology, virology, and prevention", section on 'Person-
to-person' and "Coronavirus disease 2019 (COVID-19): Clinical features", section on 'Incubation
period' and "Coronavirus disease 2019 (COVID-19): Diagnosis".)

When PPE is limited — Limited availability of personal protective equipment (PPE) has
complicated medical care of patients with suspected or documented COVID-19 (and other
transmissible conditions) worldwide. The CDC has made a spreadsheet available that facilities
can use to calculate their "burn rate," or average daily usage rate for PPE, using the change in
inventory.

Optimizing the supply of PPE — In the United States, the CDC offers guidance on optimizing the
supply of PPE when sudden increases in patient volume threaten a facility's PPE capacity [46].

Strategies include:

● Canceling non-urgent procedures or visits that would warrant use of PPE and favoring home
care rather than hospitalization when appropriate.

● Limiting movement outside the patient's room, prioritizing the use of certain PPE for the
highest risk situations (eg, aerosol-generating procedures), and designating entire units within
a facility to care for known or suspected patients with COVID-19 (ie, cohorting).
 ● Minimizing face-to-face encounters with the patient, which can be done by excluding
nonessential personnel and visitors, limiting the number of people who examine the patient,
using medications with extended intervals to reduce nursing encounters, and allowing certain
types of consultants or other clinical providers (eg, dieticians) to perform telephone
interviews with hospitalized patients. In some facilities, patients can convey needs to
providers using tablets or other electronic interfaces, further reducing some in-person
interactions.

● Utilizing alternatives to N95s, such as elastomeric half-mask and full-facepiece air-purifying

respirators, as well as PAPRs [47-49].

Extended or limited reuse of PPE is reasonable in certain situations. As an example, some

hospitals encourage users to disinfect, store, and reuse face shields unless they become visibly
soiled or no longer fit. When a face shield is used for repeated encounters with different patients,
the provider should not touch or remove the face shield between patient encounters. The provider
should perform hand hygiene before removing the face shield, and the face shield should be
disinfected with an Environmental Protection Agency (EPA)-registered product and stored in a
clean container.

Similarly, the same medical mask can be used for repeated close contact encounters with several
different patients (assuming it is not visibly damaged or soiled) [50]. When this strategy is used,
the provider should not touch or remove the mask between patient encounters, since the outside
surface is presumably contaminated. If the provider does touch the mask, they must immediately
perform hand hygiene. The CDC suggests that masks can be used for 8 to 12 hours [50], whereas
the WHO states medical masks can be used for up to six hours when caring for a cohort of
patients with COVID-19 [51].

Extended use of N95 has been implemented in many hospital settings, although there is some
concern that respirators may not provide sufficient protection with repeated use. In one study of
68 health care workers, approximately one-third failed a fit test that was performed using
respirators worn for various durations; duckbill masks were more likely to fail compared with
dome-shaped masks (71 versus 28 percent) [52]. More detailed information on extended use and
reuse of medical masks and N95 respirators can be found on the CDC and WHO websites
[46,50,51,53].

Decontamination of PPE for reuse — Decontamination of personal protective equipment (PPE)

for reuse, such as select face shields and N95 respirators [54,55], is now routinely done in many
medical centers. The CDC and WHO have highlighted several methods for decontamination of
respirators when supplies are critically low (crisis standards) [51,56]. These include:

● Ultraviolet light – Decontamination with ultraviolet (UV) light was evaluated in the context of
the H1N1 influenza pandemic; in experimental models, UV irradiation was observed to reduce
 H1N1 influenza viability on N95 respirator surfaces at doses below the threshold observed to
impair the integrity of the respirator [57-59]. Coronaviruses can also be inactivated by UV
irradiation, but comparable studies have not been performed with SARS-CoV-2, and the dose
needed to inactivate the virus on a respirator surface is unknown. Nebraska Medicine has
implemented a protocol for UV irradiation of N95 respirators in the context of the COVID-19
pandemic based on the dose generally needed to inactivate other single-stranded RNA viruses
on surfaces [60].

● Hydrogen peroxide vapor – Duke University Health System and others are using hydrogen
peroxide vapor for N95 decontamination [61]. Hydrogen peroxide vapor has been observed to
inactivate other non-coronavirus single-stranded RNA viruses on environmental surfaces
[62,63]. In one report, there were no effects on filtration efficiency or quantitative fit testing
when N95 respirators were decontaminated with 59% vaporized hydrogen peroxide [64]. In the
United States, The US Food and Drug Administration granted an emergency use authorization
for use of low-temperature vaporous hydrogen peroxide sterilizers, used for medical
instruments, to decontaminate N95 respirators [65,66].

● Moist heat – Moist heat has been observed to reduce the concentration of H1N1 influenza
virus on N95 respirator surfaces [58]. In this study, moist heat was applied by preparing a
container with 1 L of tap water in the bottom and a dry horizontal rack above the water; the
container was sealed and warmed in an oven to 65°C/150°F for at least three hours; it was
then opened, the respirator placed on the rack, and the container resealed and placed back in
the oven for an additional 30 minutes. No residual H1N1 infectivity was found. The optimal
time and temperature to inactivate SARS-CoV-2 are uncertain; several studies observed
inactivation of SARS-CoV after 30 to 60 minutes at 60°C/140°F [67-69].

If decontamination of PPE is done, staff should be cautioned to not wear makeup, use lotions or
beard oils, or write on masks, as they make decontamination difficult or impossible.

Environmental disinfection — To help reduce the spread of COVID-19, environmental infection

control procedures should be implemented [3,4,70-72]. In United States health care settings, the
CDC states routine cleaning and disinfection procedures are appropriate for 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
WHO websites.

Many hospitals have implemented enhanced environmental cleaning and disinfection protocols
for rooms used by patients with known or suspected COVID-19 and for areas used by health care
workers caring for such patients to prevent secondary transmission from fomites. As an example,
adjunctive disinfection methods, such as ultraviolet (UV) light and hydrogen peroxide vapor, are
used in some facilities to disinfect the rooms that have housed or been used for aerosol-
generating procedures on patients with COVID-19. The use of upper-room germicidal UV (GUV)
fixtures has also been proposed [73]; these fixtures contain bulbs that produce UV-C irradiance
that has higher energy than normal sunlight. Although GUV fixtures have been used to reduce
airborne transmission of pathogens such as tuberculosis [73,74], the clinical utility of GUV for
reducing transmission of SARS-CoV-2 is unknown. There are also safety concerns, since GUV light
fixtures can produce sunburn-like skin reactions and eye damage as well as generate ozone if
strict safety measures are not utilized in their installation and maintenance [75].

Environmental services workers who are cleaning areas potentially contaminated with SARS-CoV-
2 should be trained to conduct the cleaning in appropriate PPE [3]. Workers should be fit tested
and trained to wear N95 respirators and face shields (or PAPRs) when cleaning patient rooms that
are or have been occupied by persons with known or suspected COVID-19 or have been used for
aerosol-generating procedures on patients with COVID-19. Environmental services workers can
use droplet and contact precautions, plus eye protection (surgical mask, face shield or goggles,
gown, and gloves) when cleaning areas used by health care workers who are caring for COVID-19
patients.

The importance of environmental disinfection was illustrated in a study from Singapore, in which
viral RNA was detected on nearly all surfaces tested (handles, light switches, bed and handrails,
interior doors and windows, toilet bowl, sink basin) in the airborne infection isolation room of a
patient with symptomatic mild COVID-19 prior to routine cleaning [76]. Viral RNA was not detected
on similar surfaces in the rooms of two other symptomatic patients following routine cleaning
(with sodium dichloroisocyanurate). Of note, viral RNA detection does not necessarily indicate the
presence of infectious virus. The role of environmental contamination in transmission of SARS-
CoV-2 is discussed elsewhere. (See "Coronavirus disease 2019 (COVID-19): Epidemiology, virology,
and prevention", section on 'Environmental contamination'.)

INFECTION CONTROL IN THE HOME SETTING

Home management is appropriate for patients with mild infection who can be adequately isolated
in the outpatient setting [70,77,78]. (See "Coronavirus disease 2019 (COVID-19): Outpatient
evaluation and management in adults" and "Coronavirus disease 2019 (COVID-19): Management
in hospitalized adults".)

Management of such patients should include instructions on how to prevent transmission to

others.

Isolation at home — Outpatients with suspected or confirmed COVID-19 (including those awaiting
test results) should stay at home and try to separate themselves from other people and animals in
the household [79,80]. They should also avoid having visitors enter the home.
Patients should wear a face mask if they must be in the same room (or vehicle) as other people
for source control. The World Health Organization (WHO) recommends a medical mask [12];
however, the United States Centers for Disease Control and Prevention (CDC) states a cloth mask
can be used so that medical masks can be prioritized for health care workers [71]. Detailed
information on the use of cloth masks can be found on the CDC website [13]. The WHO has also
issued standards for the ideal composition of a cloth mask to optimize fluid resistance and
filtration efficiency [12]. Masks with exhalation valves or vents should be avoided since they do not
provide source control.

The WHO recommends that caregivers and those sharing a living space with individuals with
known or suspected COVID-19 wear medical masks when in the same room as the patient, if
available [12]. When medical masks are not available, household contacts commonly use a cloth
mask, but it is unclear if cloth masks provides protection for caregivers of individuals with known
or suspected COVID-19 in the home setting.

Other steps to reduce transmission in the home include [81-84]:

● Limiting the number of caregivers and, if possible, using caregivers who do not have risk
factors for developing severe disease. (See "Coronavirus disease 2019 (COVID-19): Clinical
features", section on 'Risk factors for severe illness'.)

● Having patients use a separate bedroom and bathroom, if available.

● Minimizing patients' exposure to shared spaces and ensuring shared spaces in the home
have good air flow, such as an air conditioner or an opened window. When sharing spaces
cannot be avoided, patients and caregivers should try to remain six feet (two meters) apart, if
possible, and face masks should be used.

● Ensuring caregivers perform hand hygiene after any type of contact with patients or their
immediate environment. In addition, caregivers should wear gloves when touching the
patient's blood, stool, or body fluids, such as saliva, sputum, nasal mucus, vomit, and urine.

● Educating caregivers on how to carefully put on and take off PPE. As an example, caregivers
should first remove and dispose of gloves, and then immediately clean their hands with soap
and water or alcohol-based hand sanitizer. After that, the mask (if used) should be removed,
and the caregiver should again perform hand hygiene.

● Instructing family members to avoid sharing dishes, drinking glasses, cups, eating utensils,
towels, bedding, or other items with the patient. After the patient uses these items, they
should be washed thoroughly; disposable gloves should be worn when handling these items.
In addition, thermometers should not be shared, or should be thoroughly disinfected before
use by other household members.
For those who require nebulizer treatments, certain precautions should be taken to reduce the risk
of aerosol transmission to others. As an example, the nebulizer should be used in a location that
avoids/minimizes exposure to other members of the household, and should be used in a location
where air is not recirculated into the home (eg, a porch, patio, or garage) [85]. For patients with
sleep apnea, the use of a continuous positive airway pressure (CPAP) machine may also lead to
aerosolization of virus, and the decision to use CPAP during infection must be determined on a
case-by-case basis [86].

Behavioral interventions that stress the importance of infection control measures in the home and
provide strategies to overcome barriers may enhance adherence to these precautions [87].

More detailed recommendations on home management of patients with COVID-19 can be found
on the World Health Organization and CDC websites [70,71,88].

Disinfection — Disinfection of frequently touched surfaces is also important. In the home, high-
touch surfaces should be cleaned and disinfected daily. These include tables, hard-backed chairs,
doorknobs, light switches, remote controls, handles, desks, toilets, and sinks. For disinfection,
diluted household bleach solutions, alcohol solutions with at least 70% alcohol, and most common
Environmental Protection Agency-registered household disinfectants are thought to be effective.
More detailed information on how to clean and disinfect, including guidance for patients, is found
on the CDC and World Health Organization websites [81,89].

DISCONTINUATION OF PRECAUTIONS

Non-test-based and test-based strategies can be used to inform when infection control
precautions should be discontinued in patients with COVID-19 [90,91]. Non-test-based strategies
allow for discontinuation of precautions based on improvement in symptoms and/or specific time
intervals, whereas test-based strategies require two negative reverse-transcription polymerase
chain reaction (RT-PCR) tests for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)
on sequential respiratory specimens collected ≥24 hours apart. A detailed discussion of testing is
found in a separate topic review. (See "Coronavirus disease 2019 (COVID-19): Diagnosis".)

If patients are ready to be discharged home prior to meeting criteria for discontinuation of
precautions, they can be sent home with instructions to self-isolate until they meet criteria. (See
'Non-test-based strategies' below and 'Test-based strategies' below.)

Once infection control precautions/home isolation are discontinued, patients should still continue
to follow public health recommendations for wearing masks in public settings. (See "Coronavirus
disease 2019 (COVID-19): Epidemiology, virology, and prevention", section on 'Personal preventive
measures'.)

Special considerations for health care workers are found below. (See 'After infection' below.)
Deciding whether to use a test- or non-test-based strategy — For most patients with COVID-19, a
non-test-based strategy should be used to determine when precautions can be discontinued. This
approach is supported by both the United States Centers for Disease Control and Prevention
(CDC) and the World Health Organization (WHO) [90-92]. Non-test-based strategies depend upon
the severity of disease and the presence of certain underlying conditions. (See 'Non-test-based
strategies' below.)

The decision to use a test-based strategy should be determined on a case-by-case basis. A test-
based strategy may be reasonable for certain patients who are severely immunocompromised or if
it would result in a shorter time to discontinuation of precautions than symptom-based criteria
would allow.

Non-test-based strategies are based on evidence that transmission most likely occurs during the
early stage of infection and that isolation of infectious virus more than 10 days after illness onset
is rare in patients who have improved after nonsevere infection [10]. However, data are limited, and
recovery of replication-competent virus for longer periods of time after symptom onset has been
occasionally described, mainly in patients with severe disease or in those who have severe
immunocompromise. (See "Coronavirus disease 2019 (COVID-19): Epidemiology, virology, and
prevention", section on 'Viral shedding and period of infectiousness'.)

Previously, test-based strategies were routinely used to discontinue precautions; however, some
patients have persistently positive polymerase chain reaction (PCR) testing for SARS-CoV-2 for
weeks after resolution of symptoms, and this can unnecessarily prolong the need for infection
control precautions and isolation since prolonged viral RNA shedding after symptom resolution is
not clearly associated with prolonged infectiousness. (See 'Test-based strategies' below.)

Protocols in other countries and at specific institutions may differ. Information on other
institutional protocols is found elsewhere. (See "Coronavirus disease 2019 (COVID-19):
Management in hospitalized adults", section on 'Institutional protocols'.)

Patients with confirmed infection

Non-test-based strategies

Patients with non-severe disease — For patients with non-severe disease the decision to
discontinue precautions depends upon the presence of symptoms and the degree of
immunocompromise.

● Immunocompetent patients – For patients with mild to moderate disease (eg, signs and
symptoms of COVID-19 without hypoxia [oxygen saturation ≥94 percent on room air]), the CDC
states that infection control precautions specific for COVID-19/home isolation can be
discontinued when the following criteria are met [90,91]:

• At least 10 days have passed since symptoms first appeared AND

 • At least one day (24 hours) has passed since resolution of fever without the use of fever-
reducing medications AND

• There is improvement in symptoms (eg, cough, shortness of breath)

Some patients have laboratory-confirmed SARS-CoV-2 infection without any symptoms. For
such patients, infection control precautions specific for COVID-19/home isolation can be
discontinued when at least 10 days have passed since the date of their first positive COVID-19
test, as long as there was no evidence of subsequent illness. If symptoms developed, the
symptom-based strategy should be used.

The World Health Organization (WHO) endorses the use of similar non-test-based strategies
to end precautions/isolation [92], but for symptomatic patients, they suggest patients be
without any respiratory symptoms for at least three days [92].

● Immunocompromised patients – Non-test-based strategies can also be used for most

immunocompromised patients with non-severe disease, as described above [91]. However, for
those with significant immunocompromise (eg, patients within one year of receiving a
hematopoietic stem cell or solid organ transplant, patients with cancer receiving
chemotherapy, patients with HIV and a CD4 count <200 cells/microL, combined primary
immunodeficiency disorder, receipt of prednisone >20 mg/day for more than 14 days), the
CDC recommends that the duration of time from symptom onset to discontinuing infection
control precautions specific for COVID-19 be extended. Such patients can discontinue
precautions when the following criteria are met:

• At least 10 and up to 20 days have passed since symptoms first appeared AND

• At least one day (24 hours) has passed since resolution of fever without the use of fever-
reducing medications AND

• There is improvement in symptoms (eg, cough, shortness of breath)

Similarly, severely immunocompromised patients who have laboratory-confirmed SARS-CoV-2

infection without any symptoms should continue infection control precautions specific for
COVID-19 until at least 10 to 20 days have passed since the date of their first positive COVID-
19 test, as long as there was no evidence of subsequent illness. If symptoms developed, the
symptom-based strategy should be used.

The decision to discontinue precautions within this 10- to 20-day time frame should be
individualized based upon available data on transmission [10] and made in consultation with
infection prevention or public health experts when they are locally available. A more detailed
discussion of SARs-CoV-2 transmission is presented elsewhere. (See "Coronavirus disease
2019 (COVID-19): Epidemiology, virology, and prevention", section on 'Viral shedding and
period of infectiousness'.)
 Patients who have severe or critical disease — Patients with severe or critical illness (eg,
oxygen saturation <94 percent on room air, need for oxygenation or ventilatory support) may
discontinue infection control precautions specific for COVID-19 when the following criteria are met
[90,91]:

● At least 10 and up to 20 days have passed since symptoms first appeared AND

● At least one day (24 hours) has passed since resolution of fever without the use of fever-
reducing medications AND

● There is improvement in symptoms (eg, cough, shortness of breath)

These criteria are the same for all patients, regardless of underlying conditions (eg, degree of
immunocompromise). The decision to discontinue precautions within this 10- to 20-day time
frame should be individualized based upon available data on transmission [10] and made in
consultation with infection prevention or public health experts when they are locally available. A
more detailed discussion of SARs-CoV-2 transmission is presented elsewhere. (See "Coronavirus
disease 2019 (COVID-19): Epidemiology, virology, and prevention", section on 'Viral shedding and
period of infectiousness'.)

Test-based strategies — If a test-based strategy is used, symptomatic patients may

discontinue infection control precautions specific for COVID-19 in the health care setting when
there is:

● Resolution of fever without the use of fever-reducing medications AND

● Improvement in symptoms (eg, cough, shortness of breath) AND

● Negative results of a molecular viral assay for SARS-CoV-2 from at least two consecutive
respiratory specimens collected ≥24 hours apart (total of two negative specimens). In the
United States, this should be a US Food and Drug Administration emergency use authorized
test.

Patients with SARS-CoV-2 infection who are asymptomatic also require negative results of a
molecular viral assay from at least two consecutive respiratory specimens collected ≥24 hours
apart (total of two negative specimens).

There is no clear guidance as to when repeat testing should be performed. The timing depends in
part upon why a test-based strategy is being used (see 'Deciding whether to use a test- or non-test-
based strategy' above). However, if the first test is positive, we wait 72 hours before obtaining a
second test. Once the first test is negative, the second test should be obtained 24 hours later.

We use the same approach to discontinuing precautions when using a test-based strategy in
patients who are being cared for at home, although the CDC does not specify improvement in fever
and symptoms when using this strategy outside of the health care setting.
When a test-based strategy is used, some patients may have persistently positive PCR testing for
SARS-CoV-2 for weeks after resolution of symptoms. This can pose unresolved questions in the
health care setting, since concerns that the patient could still be infectious may result in continued
infection control precautions and possible further delay of important elective procedures or tests.
There is no standardized approach when this occurs, since viral culture, the gold standard for
determining infectivity, is not routinely available. However, available data suggest that prolonged
viral RNA shedding after symptom resolution is not clearly associated with prolonged
infectiousness, particularly in those with mild to moderate disease. This is why symptom- and
time-based approaches for discontinuing precautions are recommended for most patients, as
described above. More detailed information on the transmission of SARs-CoV-2 is presented
elsewhere. (See "Coronavirus disease 2019 (COVID-19): Epidemiology, virology, and prevention",
section on 'Viral shedding and period of infectiousness'.)

There has been interest in the use of cycle threshold (Ct) to help guide decisions regarding
infectivity in patients with persistently positive tests; the higher the Ct, the fewer the RNA copies.
In one study, infectivity was not observed in patients with symptoms greater than eight days and a
Ct value >24 [93,94]. Although Ct may be included in the decision-making process when evaluating
a patient with persistently positive PCR testing, these assays have not been standardized, and the
results can vary with different assays. (See "Coronavirus disease 2019 (COVID-19): Diagnosis",
section on 'Cycle threshold'.)

There has also been interest in whether development of antibody correlates with disease activity.
However, similar to Ct, there are insufficient data to use this information to guide decisions at this
time. (See "Coronavirus disease 2019 (COVID-19): Diagnosis", section on 'Serology to identify
prior/late infection'.)

Suspected cases with negative initial testing — In some patients, initial testing is negative, but
there is still suspicion for COVID-19. In this setting, a second test should be performed, and
infection control precautions should be continued pending the result. When two tests are negative,
precautions for COVID-19 can often be discontinued; however, if concern for COVID-19 remains
high, such as a patient with consistent clinical symptoms and an exposure to a person with known
or suspected COVID-19, infection control precautions should be continued at least until criteria for
discontinuation of precautions using a symptom-based strategy are met. (See 'Non-test-based
strategies' above.)

The accuracy and predictive values of SARS-CoV-2 testing have not been systematically evaluated,
and a single negative test may not sufficiently exclude the diagnosis. In addition, the quality of
nasopharyngeal swab collection may vary. Additional information on diagnostic testing is
presented elsewhere. (See "Coronavirus disease 2019 (COVID-19): Diagnosis".)

Suspected cases when testing was not performed — In some cases, testing for COVID-19 may not
be accessible, particularly for individuals who have a compatible but mild illness that does not
warrant hospitalization. In areas where community transmission of SARS-CoV-2 is widespread,
these patients are often treated presumptively for COVID-19 (eg, home isolation, supportive care)
and the decision to discontinue transmission-based precautions should be made using the
symptom-based strategy described above. (See 'Non-test-based strategies' above.)

ADDITIONAL CONSIDERATIONS

Return to work for health care workers

After potential or known exposure — For health care workers who have had a potential
exposure to COVID-19, the United States Centers for Disease Control and Prevention (CDC) has
provided guidelines for work restriction and monitoring [18]. The approach depends upon 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 procedure
was performed. Some institutions may choose to test asymptomatic health care workers after an
exposure to help identify those with asymptomatic/presymptomatic infection [95]. However,
testing is not used to determine work restrictions, and there is no clear guidance as to when this
testing should be performed.

After infection — For health care workers with confirmed or suspected COVID-19, decisions
about return to work should be made in the context of the provider's local circumstances (eg,
availability of testing, staffing shortages) [96]. Non-test-based strategies are generally
recommended. More detailed information regarding criteria for return to work, as well as return to
work practices and work restrictions, is found on the CDC website.

Long-term care facilities — Similar to other health care settings, certain measures should be used
for all patients, visitors, and providers entering long-term care facilities. These include symptom
screening and use of masks for everyone entering the facility, regardless of symptoms. The CDC
also recommends that nursing homes employ a strategy of frequent nucleic acid testing 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 "Coronavirus disease 2019 (COVID-19): Management
in nursing homes and short-term rehabilitation facilities".)

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. If that is
not possible, they should wear a mask and be separated by at least six feet (two meters) from the
nearest patient. Staff should wear PPE as described above. A more detailed discussion of
infection control in dialysis centers is presented in a separate topic review. (See "Coronavirus
disease 2019 (COVID-19): Issues related to kidney disease and hypertension", section on 'Patients
receiving in-center hemodialysis'.)

Role of serologic testing — Serologic tests, as soon as generally available and adequately
evaluated, should 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 and, until their sensitivity and specificity are further assessed, they should not be
used for determining the use of infection control precautions. Additional information on serologic
testing is presented elsewhere. (See "Coronavirus disease 2019 (COVID-19): Diagnosis", section
on 'Serology to identify prior/late infection'.)

Preventing infection in the community — To reduce the risk of transmission in the community,
individuals should be advised to practice diligent hand hygiene, as well as respiratory hygiene (eg,
covering their cough), and to avoid close contact with ill individuals, if possible. In addition,
residents should greet each other without contact, refrain from shaking hands, and avoid gathering
in groups. If community transmission of severe acute respiratory syndrome coronavirus 2 (SARS-
CoV-2) is present, residents should be encouraged to practice social distancing by staying home
as much as possible and maintaining six feet (two meters) distance from others when they have
to leave home. In many locations, masks are advised in all public settings. Additional measures
are discussed in detail in a separate topic review. (See "Coronavirus disease 2019 (COVID-19):
Epidemiology, virology, and prevention", section on 'Personal preventive measures'.)

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: Coronavirus disease 2019
(COVID-19) – International public health and government guidelines" and "Society guideline links:
Coronavirus disease 2019 (COVID-19) – Guidelines for specialty care" and "Society guideline links:
Coronavirus disease 2019 (COVID-19) – Resources for patients".)

INFORMATION FOR PATIENTS

UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics."
The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading
level, and they answer the four or five key questions a patient might have about a given condition.
These articles are best for patients who want a general overview and who prefer short, easy-to-
read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and
more detailed. These articles are written at the 10th to 12th grade reading level and are best for
patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or
e-mail these topics to your patients. (You can also locate patient education articles on a variety of
subjects by searching on "patient info" and the keyword(s) of interest.)

● Basics topics (see "Patient education: Coronavirus disease 2019 (COVID-19) overview (The
Basics)" and "Patient education: Coronavirus disease 2019 (COVID-19) and pregnancy (The
Basics)" and "Patient education: Coronavirus disease 2019 (COVID-19) and children (The
Basics)")

SUMMARY AND RECOMMENDATIONS

● 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
characterize it as a pandemic in March 2020. The virus that causes COVID-19 is designated
severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). (See 'Introduction' above.)

● Limiting transmission of SARS-CoV-2 is an essential component of care in patients with

suspected or documented COVID-19. This includes universal source control (eg, covering the
nose and mouth to contain respiratory secretions), early identification and isolation of
patients with suspected disease, use of appropriate personal protective equipment (PPE)
when caring for patients with COVID-19, and environmental disinfection. (See 'Measures for
all patients, visitors, and personnel' above and 'Infection control in the health care setting'
above and 'Infection control in the home setting' above.)

● Person-to-person spread of SARS-CoV-2 is thought to occur mainly via respiratory droplets,

resembling the spread of influenza. However, given the current uncertainty regarding
transmission mechanisms of SARS-CoV-2, airborne precautions are recommended in certain
settings. Thus, in hospitalized patients, the following types of infection control precautions
should be used for those with suspected or confirmed COVID-19 (see 'Patients with
suspected or confirmed COVID-19' above):

• Patients should ideally be placed in a single-occupancy room with a closed door and
dedicated bathroom; however, when this is not possible, patients with confirmed COVID-
19 can be housed together. An airborne infection isolation room (ie, a single-patient
negative-pressure room) should be prioritized for patients undergoing aerosol-generating
procedures. (See 'Approach for most patients' above and 'Aerosol-generating
procedures/treatments' above.)
 • All health care workers 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. This includes the use of a gown, gloves, a respirator or medical mask, and eye
or face protection. For respiratory protection, an N95 respirator should be used for all
aerosol-generating procedures (respirators with exhalation valves are not sufficient for
source control). When supplies allow, we suggest an N95 respirator rather than a medical
mask when caring for all patients with suspected or confirmed COVID-19 (Grade 2C).
Medical masks are an acceptable alternative for non-aerosol-generating procedures
when PPE is limited. This approach is consistent with recommendations from the United
States Centers for Disease Control and Prevention. (See 'Approach for most patients'
above and 'Aerosol-generating procedures/treatments' above and 'When PPE is limited'
above.)

• Health care workers should pay special attention to the appropriate sequence of putting
on (figure 1) and taking off (figure 2) PPE to avoid contamination. (See 'Approach for
most patients' above.)

● For some hospitalized patients, the suspicion for COVID-19 remains high despite initial
negative testing. In such cases, transmission-based precautions for COVID-19 should be
continued pending additional testing. In areas of ongoing transmission, enhanced infection
control precautions (eg, respirators for aerosol-generating procedures, face shields), in
addition to universal masking, are reasonable to use for all patients regardless of the
individual suspicion for COVID-19. (See 'Suspected cases with negative initial testing' above
and 'Patients who are NOT suspected of having COVID-19' above.)

● When availability of PPE is limited, strategies to preserve the supply include canceling non-
urgent 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 and
decontamination of PPE for reuse can also be considered in select situations. (See 'When PPE
is limited' above.)

● To help reduce the spread of COVID-19, environmental infection control procedures should be
implemented in both health care and home settings. 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. (See 'Environmental disinfection' above and 'Disinfection' above.)

● Outpatients with suspected or confirmed COVID-19 (including those awaiting test results)
who do not require hospitalization should stay at home and separate themselves from other
people and animals in the household. Other strategies to help prevent transmission within the
household include use of masks, not sharing items such as dishes, towels, and bedding, and
disinfection of frequently touched surfaces. (See 'Infection control in the home setting'
above.)
 ● In most patients with COVID-19, non-test-based strategies should be used to inform when
infection control precautions can be discontinued. The specific criteria depend upon the
severity of disease and the presence of certain underlying conditions (table 1). Test-based
strategies can also be used to discontinue precautions in select settings; however, the
decision to use this approach should be individualized, since some patients have persistently
positive polymerase chain reaction (PCR) testing for SARS-CoV-2. (See 'Discontinuation of
precautions' above.)

● If patients are ready to be discharged home prior to meeting criteria for discontinuation of
precautions, they can be sent home with instructions to self-isolate until criteria are met. Once
infection control precautions/home isolation are discontinued, patients should still continue
to follow public health recommendations for wearing masks in public settings. (See
'Discontinuation of precautions' above.)

● Additional infection control considerations for health care workers and long-term health care
facilities are discussed above. (See 'Additional considerations' above.)

Use of UpToDate is subject to the Subscription and License Agreement.

REFERENCES

1. Centers for Disease Control and Prevention. 2019 Novel coronavirus, Wuhan, China. Informat
ion for Healthcare Professionals. https://www.cdc.gov/coronavirus/2019-nCoV/hcp/index.ht
ml (Accessed on February 14, 2020).

2. World Health Organization. Novel Coronavirus (2019-nCoV) technical guidance. https://www.

who.int/emergencies/diseases/novel-coronavirus-2019/technical-guidance (Accessed on Fe
bruary 14, 2020).

3. Centers for Disease Control and Prevention. Interim Infection Prevention and Control Recom
mendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pand
emic. https://www.cdc.gov/coronavirus/2019-nCoV/hcp/infection-control.html (Accessed o
n July 02, 2020).

4. World Health Organization. Infection prevention and control during health care when novel co
ronavirus (nCoV) infection is suspected. January 25, 2020. https://www.who.int/publications
-detail/infection-prevention-and-control-during-health-care-when-novel-coronavirus-(ncov)-inf
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Topic 127501 Version 23.0

GRAPHICS

Putting on personal protective equipment

Sequence for putting on personal protective equipment.

Reproduced from: Centers for Disease Control and Prevention. Protecting Healthcare Personnel: Sequence for Donning and
Removing Personal Protective Equipment. Available at: https://www.cdc.gov/hai/prevent/ppe.html (Accessed on March 20, 2020).

Graphic 127473 Version 1.0

Taking off personal protective equipment
Reproduced from: Centers for Disease Control and Prevention. Protecting Healthcare Personnel: Sequence for Donning and Removing Personal Protec
Available at: https://www.cdc.gov/hai/prevent/ppe.html (Accessed on March 20, 2020).

Graphic 127474 Version 1.0

Non-test-based strategies for discontinuing infection control precautions in patients with COVID-19*

Population Strategy

Symptomatic 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. This should be
extended up to 20 days for severely immunocompromised patients. Δ◊
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).

Symptomatic patients with severe or Symptom-based (before discontinuing precautions, all of the following conditions
critical disease ¶ 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).

Asymptomatic patients with laboratory- Time-based (before discontinuing precautions, all of the following conditions must be
confirmed COVID-19 met):

10 days have passed since the date of their first positive viral diagnostic test.
This should be extended up to 20 days for severely immunocompromised
patients. ¶◊
No subsequent illness developed.

This table describes non-test-based approaches to discontinuing infection control precautions in patients with COVID-19 based
upon recommendations from the United States Centers for Disease Control and Prevention 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 in public settings.

COVID-19: coronavirus disease 2019.

* For most patients with confirmed COVID-19, a non-test-based strategy should be used to discontinue infection control precautions/home
isolation. The decision to use a test-based strategy should be determined on a case-by-case basis. Refer to the UpToDate topic that
discusses infection control in health care and home-based settings for additional information.
¶ 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 more detailed discussion of disease severity.
Δ Conditions associated with severe immunocompromise include various hereditary and acquired immune deficiencies (eg, combined
primary immunodeficiency disorder, receiving 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, receipt of prednisone >20 mg/day for more than 14 days).
◊ The decision to discontinue precautions within this 10- to 20-day time frame should be individualized based upon available data on
transmission and made in consultation with infection prevention or public health experts when they are locally available.

Graphic 127962 Version 4.0

Contributor Disclosures
Tara N Palmore, MD Nothing to disclose Daniel J Sexton, MD Grant/Research/Clinical Trial Support: Centers
for Disease Control and Prevention; National Institutes of Health [Healthcare epidemiology].
Consultant/Advisory Boards: Magnolia Medical Technologies [Medical diagnostics]; Johnson & Johnson
[Mesh-related infections]. Equity Ownership/Stock Options: Magnolia Medical Technologies [Medical
diagnostics]. Jennifer Mitty, MD, MPH Nothing to disclose Allyson Bloom, MD Nothing to disclose

Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are
addressed by vetting through a multi-level review process, and through requirements for references to be
provided to support the content. Appropriately referenced content is required of all authors and must conform
to UpToDate standards of evidence.

Conflict of interest policy