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Updated: October 13, 2020

When can a healthcare worker return to work once they’ve had COVID-19?

Summary

The following is a summary of evidence sources that provide high quality information on return to work guidance for health care professionals once they have had COVID-19. For additional information about each of the sources, see the Table below.

The authors of one observational study found that among mild COVID-19 cases, most patients tested negative for COVID-19 ten days post-symptom onset, while severe cases remained positive after this same period [1]. The authors suggested that this provides some evidence that severity of clinical presentation is associated with a patient’s infectious period and noted that the infectious period for mild cases is likely around 10 days [1].

In its Criteria for Return to Work for Healthcare Personnel with Suspected or Confirmed COVID-19 (Interim Guidance), the Centers for Disease Control and Prevention (CDC) recommends that the following three healthcare return to work protocols should be used: 1) the symptom-based strategy; 2) test-based strategy; and 3) time-based strategy [2]. With a symptom-based strategy, a worker may return to work after at least 72 hours since symptoms resolution (i.e., no fever without fever-reducing medications and improvement in respiratory symptoms) and at least 10 days since symptoms first appeared [2]. With a test-based strategy, a worker may return to work with the resolution of symptoms (noted above) and two negative COVID-19 screening tests from specimens collected at least 24 hours apart [2]. Lastly, a time-based strategy is used if the worker is asymptomatic and the worker may return to work once 10 days have passed since their first positive COVID-19 test if no symptoms develop [2]. The CDC advises that if symptoms develop among isolated asymptomatic workers, a symptom-based strategy or test-based strategy should be used [2]. The Ontario Ministry of Health and the British Columbia Centre for Disease Control (BCCDC) both advise that the symptom-based strategy is adequate, unless the worker was hospitalized throughout their infection or if they are immunocompromised, in which case a test-based strategy is more appropriate [4,6]. In the COVID-19 Return to Work Guide for Healthcare Workers, Alberta Health Services further notes that workers who have been in contact with a positive COVID-19 case without appropriate personal protective equipment (PPE) are required to self-isolate for 14 days before returning to work [5].

In its Strategies to Mitigate Healthcare Personnel Staffing Shortages, the CDC suggests that during staffing shortages, asymptomatic healthcare workers with unprotected exposure to COVID-19 but with no known infection, may continue to work if the worker wears a facemask and monitors their symptoms [3]. The CDC report also notes that if the staff shortage worsens, a healthcare worker with a suspected or confirmed infection may work prioritizing their duties in the following order: 1) perform tasks where they do not interact with other workers or patients; 2) provide care for patients with confirmed COVID-19; and 3) provide care for patients with suspected COVID-19 [3]. In its Interim Guidance on Return to Work for Health Care Workers with Symptoms of COVID-19, BCCDC recommends that the decision to discontinue any worker self-isolation should be discussed with Workplace Health and Safety, and should consider: 1) the severity and length of illness; 2) feasibility of getting tested; 3) risk of understaffing; 4) if the staff member works with a vulnerable population; and 5) individual factors (e.g., immunocompromised individuals may shed longer) [6].

Evidence

What‘s Trending on Social Media and Media

Return to work guidance in Ontario gained media attention when a healthcare worker who tested positive for COVID-19 three weeks post-infection was asked to return to work. The CBC article reported that Ontario’s Ministry of Health (MOH) supports their recommendation deeming the healthcare worker safe for work, following a symptom-based strategy where a worker may work after a minimum of 72 hours without symptoms. According to the article, Hamilton Health Sciences, MOH and an infectious disease expert agree that although a virus may be detectable from a recent infection (i.e., a positive test result) does not mean the worker is infectious.  
 
In Hamilton, Ontario, as of May 12th, almost one quarter of the city’s COVID-19 cases, most of which were mild, were infected health care workers including 127 staff and volunteers in hospitals, retirement homes, re-habitation facilities and others.
 
In Vancouver, a Global News item describes healthcare workers’ concern about returning to work after a COVID-19 infection. Workers remain worried about putting colleagues and patients at risk.

Organizational Scan

Two COVID-19 risk assessment tools for healthcare workers (HCW) were identified in Alberta and British Columbia. The Alberta Health Services created the COVID-19 Assessment Tool for Health Care Workers and Those Involved in Public Health Enforcement  which guides decision making regarding whether continued self-isolation or return to work is most appropriate depending on presentation of symptoms, contact with potential infected persons, recent travel, and how critical work is deemed by the employer [7]

The BC Centre for Disease Control has released a Health Care Worker Exposure Risk Assessment Tool. The tool assesses HCW exposure risk to COVID-19 and the appropriate recommendations that should follow including: 1) testing; 2) who to notify; and 3) self-isolation regulations [8]
 
The Government of Ontario offers a portal of COVID-19 supports for frontline workers in various types of working environments (e.g., health, food premises, homeless shelters) including: 1) information about worker rights; 2) sector-specific guidance; and 3) resources [9].

Review of Evidence

Resource Type/Source of Evidence Last Updated
Viral dynamics in mild and severe cases of COVID-19
— Liu et al.
Observational Study

This study found that among mild cases, 90% of patients tested negative on RT-PCR (reverse transcription polymerase chain reaction) ten days post-symptom onset, while all severe patients remained positive by day ten. More severe patients tend to have a higher viral load and longer virus-shedding period. The authors suggest that approximately ten days is likely the infectious period for mild cases, while the infectious period remains unknown for severe cases.

Last Updated: May 31, 2020
Criteria for Return to Work for Healthcare Personnel with Suspected or Confirmed COVID-19 (Interim Guidance)
— CDC: Centers for Disease Control and Prevention
National Guidance

This report identifies three options to guide return to work policy:1) symptom-based; 2) test-based; and 3) time-based strategies. A symptom-based strategy describes that a worker may return to work after at least 72 hours since symptoms (resolution of fever without fever-reducing medications and improvement in respiratory symptoms) and at least 10 days since symptoms first appeared. Test-based strategy says to exclude staff from work until the resolution of symptoms (noted above) and two negative COVID-19 RNA (ribonucleic acid) screening tests from specimens collected at least 24 hours apart. A time-based strategy excludes asymptomatic staff from work until 10 days have passed since their first positive COVID-19 diagnostic test if no symptoms develop. The CDC advises that if symptoms develop, a symptom-based or test-based strategy should be used. Strategies are deemed acceptable depending on local circumstances.

Last Updated: August 9, 2020
Strategies to Mitigate Healthcare Personnel Staffing Shortages
— CDC: Centres for Disease Control and Prevention
National Guidance

The CDC notes that during staffing shortages, asymptomatic healthcare workers who have had an unprotected exposure to SARS-CoV-2 but are not known to be infected, may work if the worker monitors symptoms and wears a facemask.

If staff shortages worsen, the CDC advises that a healthcare worker with a suspected or confirmed infection may work prioritizing their duties in the following order: 1) perform tasks where they do not interact with other workers or patients; 2) provide care for patients with confirmed COVID-19; and 3) provide care for patients with suspected COVID-19.

Last Updated: July 16, 2020
COVID-19 Quick Reference Public Health Guidance on Testing and Clearance
— MOH: Ministry of Health
Provincial Guidance

This MOH guidance suggests that healthcare workers should use a non-test-based approach that involves ending isolation after 14 days from symptom onset or positive test collection where there is no fever and other symptoms are improving. MOH advises that if the healthcare worker required hospitalization, a test-based approach should be used (i.e., two consecutive negative specimens collected at least 24 hours apart). 

Last Updated: May 19, 2020
COVID-19 Return to Work Guide for Healthcare Workers
— Alberta Health Services
Provincial Guidance

This guidance describes that workers who have been in contact with COVID-19, without appropriate PPE, are required to self-isolate for 14 days. If workers develop COVID-19 related symptoms during their isolation but test negative, they must continue to self-isolate for 14 days and until the resolution of symptoms.

Last Updated: June 17, 2020
Interim Guidance on Return to Work for Health Care Workers with Symptoms of COVID-19
— BC Centre for Disease Control - BC Ministry of Health
Provincial Guidance

This report notes that a residual cough after 10 days from symptom onset may persist for several weeks and is not considered infectious, if all other symptoms are resolved. A test-based strategy is only required if the worker: 1) was hospitalized; 2) is immunocompromised; or 3) to allow them to return to work prior to completing 10-day isolation period.

BCCDC advises that any decision to discontinue self-isolation should be discussed with Workplace Health and Safety while considering the following: 1) severity and length of illness; 2) feasibility of getting tested; 3) risk of understaffing; 4) population staff member works with; and 5) individual factors (e.g., immunocompromised individuals may shed longer).

Last Updated: April 27, 2020
COVID-19 Assessment Tool For Health Care Worker and Those Involved In Public Health Enforcement
— Alberta Government
Organizational Scan Last Updated: May 22, 2020
BC Health Care Worker Exposure Risk Assessment Tool
— Centre for Disease Control
Organizational Scan Last Updated: May 22, 2020
COVID-19 Support for Workers
— Government of Ontario
Organizational Scan Last Updated: May 22, 2020
Disclaimer: The summaries provided are distillations of reviews that have synthesized many individual studies. As such, summarized information may not always be applicable to every context. Each piece of evidence is hyperlinked to the original source.

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