In response to the increase in Omicron variant cases, suspected increased transmissibility of the variant, and evidence of decreased disease severity with the variant, CDC has published significant changes in their COVID response recommendations.  There has been a great deal of confusion in the past ten days regarding what changes apply to healthcare workers.  After a few recalls, we believe this article is the currently accurate information and based on the December 23, 2021 guidelines as CDC has not stated other published guidelines may apply to healthcare workers.  Those who have tried to take the new guidelines apart are more than baffled with the increased complexity of the guidelines.  We could not agree more but we must present them as registered by the CDC.

CAPACITY STRATEGIES

The new guidelines make changes the concept and application of capacity strategies – the level of action taken for both exposure and return to work guidelines based on staffing needs.  CDC states these levels should be considered sequentially and include the following.

  • Conventional Response: This is the baseline response that would be recommended unless you meet the requirements of contingency response.  It assumes that in general you have enough staffing and resources to carry on your patient care in a reasonably acceptable manner.
  • Contingency Response: You may elect to use the contingency response if you have experienced staffing shortages that interfere with your capacity to effectively supply patient care.  Other contingency strategies previously noted by CDC may include adjusting and/or reducing schedules, hiring additional staff, make some limitations on non-essential care or address issues like staff transportation needs.  Although not a stated recommendation from PCS, in light of the current staffing shortage problem, it would seem that some offices may qualify for and elect to utilize the contingency standard.
  • Crisis Response: Crisis occurs when you no longer have enough staff to provide patient care.  Remember that crisis assumes you have taken into account all contingency standards first – like reducing schedules, limiting non-essential care, etc.   Unless the situation worsens even more, it would appear primary care practices would have limited access to this response classification.

 EXPOSURE GUIDELINES

The exposure window for the omicron virus is considered to be 2 days from the onset of symptoms.  This is markedly less than with the prior variants and reflective in the new guidelines.

The physical and timing aspects of exposure (close contact) are:

  • Being UNMASKED within 6 feet of a person with confirmed COVID for fifteen minutes or more
  • Having unprotected, direct contact with infectious secretions of a person with confirmed COVID
  • Contact for distances more than 6 feet (not defined) over long periods of time (consider a single exposure of 15 minutes or combinations of briefer that total 15 minutes or more over a 24-hours)

Whether you agree or not, the new exposure response guidelines have placed significant emphasis on healthcare workers receiving the full complement of vaccinations, including the initial booster.  With the published limited effectivity of the booster against the omicron variant, expect new regulations to focus on additional booster requirements.  The following are the new CDC definitions related to vaccination.

  • Boosted – have received a full dose of vaccine plus a booster dose
  • Vaccinated – have a received a full dose of vaccine but no booster
  • Unvaccinated – have received no vaccines

For exposure guidelines, vaccinated healthcare workers fall under the same guidelines as unvaccinated.

The new guidelines also significantly increase the application and frequency of testing which many fear will lead to a shortage in testing supplies.  The new guidelines state nucleic acid amplification tests (NAAT) are preferred over antigen tests but a negative result from either test is acceptable as both show adequately low false negative results.

Work Restrictions for Asymptomatic HCP with High-Risk Exposure

High-risk exposure is defined as an HCP who has had prolonged, close contact with an individual with confirmed COVID infection where:

  • HCP and infected individual were both NOT wearing facemasks, or
  • HCP was not wearing eye protection if the infected individual was NOT wearing a facemask, or
  • HCP was not wearing ALL PPE (gown, gloves, eye protection, respirator) while performing an aerosol generating procedure
VACCINATION STATUS CONVENTIONAL CONTINGENCY CRISIS
Boosted No restrictions with negative test not earlier than 24 hours after exposure and days 5-7 No work restrictions No work restrictions
Vaccinated or unvaccinated 10-day quarantine that may be reduced to 7 days with negative test within 48 hours of returning to work No work restrictions with a negative test on days 1,2,3 and 5-7 No work restrictions

 Work Restrictions for Asymptomatic HCP with Low-Risk Exposure

Low risk is defined as anything not defined by the high-risk criteria above.

VACCINATION STATUS CONVENTIONAL CONTINGENCY CRISIS
All No restrictions or testing – monitor for symptoms No restrictions or testing – monitor for symptoms No restrictions or testing – monitor for symptoms

NOTE:  There appears to be a common issue not directly addressed by these guidelines – what if an employee calls Monday morning stating they were exposed the previous Thursday night?  This is outside the two-day exposure window.  It would appear reported exposure outside the two-day window with no symptoms would be considered a low-risk exposure but each doctor can make their own policy.

RETURN TO WORK GUIDELINES

Return to work recommendations are now based on the severity of the illness, symptoms and immunity status of the HCP.  These are far more tedious than prior guidelines.

Work Restrictions for HCP With Confirmed Infection – Asymptomatic Throughout

  • Subjective based – note new reports assign over 200 signs/symptoms to omicron
VACCINATION STATUS CONVENTIONAL CONTINGENCY CRISIS
All ·        7 days from the date of the first positive test with a new negative test, or

·        10 days without testing

5 days with/without a negative test if mildly or asymptomatic and symptoms improving No work restrictions

Work Restrictions for HCP With Confirmed Infection – Mild to Moderate Illness

  • Mild – various signs/symptoms without shortness or breath or abnormal chest imaging
  • Moderate – lower respiratory disease confirmed by imaging and Sp02 >94%
VACCINATION STATUS CONVENTIONAL CONTINGENCY CRISIS
All ·        10 days without testing, or

·        7 days with negative test and no fever within 24 hours with no fever-reducing medication, and

·        symptoms improving

5 days with or without a negative test if mildly or asymptomatic and symptoms improving No work restrictions

Work Restrictions for HCP With Confirmed Infection – Severe to Critical Illness

  • NOTE: Complex definition – recommend discussion with PCP
VACCINATION STATUS CONVENTIONAL CONTINGENCY CRISIS
All ·        20 days since first symptom, and

·        at least 24 hours since last fever without use of fever-reducing medications, and

·        improvement in symptoms

5 days with/without a negative test if mildly or asymptomatic and symptoms improving No work restrictions

If the HCP is moderately to severely immune-compromised, consultation with an infectious disease specialist is recommended before returning to work.  These are defined as:

  • Active treatment for solid tumor and hematologic malignancies
  • Receipt of solid-organ transplant and taking immunosuppressive therapy
  • Receipt of CAR-T-cell therapy or hematopoietic cell transplant (HCT) (within 2 years of transplantation or taking immunosuppression therapy)
  • Moderate or severe primary immunodeficiency (e.g., DiGeorge syndrome, Wiskott-Aldrich syndrome)
  • Advanced or untreated HIV infection (people with HIV and CD4 cell counts <200/mm3, history of an AIDS-defining illness without immune reconstitution, or clinical manifestations of symptomatic HIV)
  • Active treatment with high-dose corticosteroids (i.e., ≥20 mg prednisone or equivalent per day when administered for ≥2 weeks), alkylating agents, antimetabolites, transplant-related immunosuppressive drugs, cancer chemotherapeutic agents classified as severely immunosuppressive, tumor necrosis factor (TNF) blockers, and other biologic agents that are immunosuppressive or immunomodulatory.

THE CDC states that data is coming in at “unprecedented rates and volumes” and the guidelines could change at any time.