Guidance

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

Updated 15 December 2021

1. Scope

This guidance is intended for staff and managers in health and social care settings and includes:

• guidance relating to health and social care staff if they develop coronavirus (COVID-19) symptoms, receive a positive test result or are identified as a contact of a COVID-19 case
• guidance on isolation requirements for patients and residents in health and social care settings after contact with COVID-19 cases
• guidance on repeat testing for COVID-19 for staff, patients and residents in health and social care settings

There is separate guidance on investigation and clinical management of possible cases available.

Guidance for stepdown of infection control precautions and discharging COVID-19 patients and asymptomatic SARS-CoV-2 infected patients and Admission and care of residents in a care home during COVID-19 provide information specific to hospital and care home settings respectively, including isolation requirements following positive SARS-CoV-2 polymerase chain reaction (PCR) results.

Staff who have travelled to England from another country are required to adhere to national entry and self-isolation requirements. There are specific instructions for those entering from countries on the Red list.

Health and social care staff entering from any country not on the red list are required to take a PCR test on or before day 2 after their return. They must self-isolate until they receive a negative PCR test result. If the PCR test result is positive, they must start 10 full days isolation from the day of their test and follow the Stay at home guidance. If the PCR test result is negative they can return to work but they are also required to take a daily LFD Ag test until day 10 after return from travel. If any LFD Ag test is positive, follow the guidance below.

This guidance has been written by UK Health Security Agency primarily for a health and care professional audience in England. Country specific advice may be available for each country across the United Kingdom. Please refer to Health Protection Scotland, Public Health Wales, or Public Health Agency in Northern Ireland.

2. Guidance for health and social care staff on COVID-19 symptoms, test results and being identified as a contact of a case

All staff who come into contact with COVID-19 cases – whether or not they are protected by the use of personal protective equipment (PPE) or by other factors – should remain vigilant to the possibility of contracting infection, and should follow the guidance in this document if they develop symptoms.

2.1 If a staff member develops COVID-19 symptoms

If a health or social care staff member develops any of the symptoms of COVID-19, however mild:

• they should follow the stay at home guidance and arrange to have a PCR test either through their workplace arrangements or the NHS Test and Trace service, as soon as possible (testing is most sensitive within 3 days of the development of symptoms)
• if at home (off-duty), they should not attend work whilst awaiting their PCR test result and should notify their employer or line manager immediately
• if at work, they should inform their employer or line manager and return home as soon as possible

2.2 If a staff member receives a positive SARS-CoV-2 PCR test result

If a staff member receives a positive SARS-CoV-2 PCR test result, they must self-isolate for 10 days. The isolation period includes the day the symptoms started or the day their PCR test was taken if they do not have symptoms, and the next 10 full days. Their household contacts should follow the stay at home guidance which outlines details on self-isolation requirements.

Any staff admitted to hospital with COVID-19 symptoms will be subject to the guidance for isolation for patients within guidance for stepdown of infection control precautions and discharging COVID-19 patients.

2.3 If a staff member receives a positive SARS-CoV-2 self-reported lateral flow device (LFD) antigen test result

If a staff member’s self-reported SARS-CoV-2 LFD antigen test result is positive, they should self-isolate immediately. They should arrange to have a follow-up PCR test as soon as possible, either through their workplace arrangements or the NHS Test and Trace service and should continue to self-isolate whilst awaiting their PCR test result.

If the follow-up PCR result is positive, the staff member must self-isolate for 10 full days, from the date of their positive PCR test result. They and their household contacts should follow the stay at home guidance, which outlines details on self-isolation requirements. If the follow-up PCR test result is negative, the staff member can stop self-isolating.

2.4 Returning to work criteria

2.4.1 If a staff member is symptomatic when returning to work after a negative PCR test or after their isolation period has ended

Staff who receive a negative PCR test result can usually return to work providing they are medically fit to do so, subject to discussion with their line manager or employer and a local risk assessment.

Staff who receive a positive PCR test result can return to work after their isolation period has ended (see section 2.2), provided their symptoms have improved, they have been afebrile (not feverish) for 48 hours without the use of medication to control fever, and are medically fit to return. Staff may still return to work if they still have any of the other symptoms and are fit enough to do so, as these may persist for some time after the infection has resolved.

Staff who receive an inconclusive PCR test result should continue to self-isolate and arrange another PCR test. They can return to work after their isolation period has ended or if their PCR test is negative (see section 2.2).

2.4.2 If a staff member was asymptomatic when returning to work after isolating following a positive PCR or LFD antigen test

Staff who test positive for SARS-CoV-2 (either by PCR or a self-reported LFD antigen test followed by PCR) and who were asymptomatic at the time of the test can return to work after their isolation period ended (see section 2.2) if they do not develop symptoms. However, if they develop symptoms during the 10 days isolation, they should self-isolate for 10 full days from the day of symptom onset. They can return to work after 10 full days of self-isolation, subject to improvement of symptoms outlined above.

2.5 If a staff member is identified as a contact of a COVID-19 case

If a staff member is providing care to or is in close contact with an individual with SARS-CoV-2 infection and is wearing the correct PPE appropriately in accordance with the UK IPC guidance and How to work safely guidance, they will not be considered as a contact for the purposes of contact tracing and isolation. This applies regardless of the vaccination status of the staff member or the circulating variant of SARS-CoV-2.

If there has been a breach of recommended PPE during the care episode then the staff member would be considered a contact and should follow the advice below.

In non-patient facing areas, IPC precautions may unintentionally be less stringently adhered to – if IPC precautions have been compromised, or PPE has been worn incorrectly or breached, the staff member should be considered a contact and follow the advice below.

2.5.1 Exemptions from self-isolation if a staff member is fully vaccinated^{[footnote 1]} and is identified as a contact of a case

Staff members notified that they are a contact of a COVID-19 case are not required to self-isolate if they are fully vaccinated. They should inform their line manager or employer immediately if they are required to work in the 10 days following their last contact with a COVID-19 case.

If the staff member develops symptoms of COVID-19 during this period, follow the guidance in section 2.1.

The majority of fully vaccinated health and social care staff will be able to continue in their usual role. The following apply to staff returning to work:

• the staff member should not have any COVID-19 symptoms
• the staff member should not have any travel related isolation requirements
• the staff member should immediately arrange for a PCR test, either through their workplace arrangements or via the NHS Test and Trace service, and the result of this PCR test should be negative prior to returning to work
• following the negative PCR result, the staff member should undertake an LFD antigen test every day for the 10 days following their last contact with the case (even on days they are not at work)
• if a staff member has had a SARS-CoV-2 infection in the past 90 days, they should not have a PCR test and should only undertake daily LFD antigen tests
• on days the staff member is working, the LFD antigen test should be taken before starting their shift, and the result should be negative
• the staff member should comply with all relevant infection control precautions and PPE should be worn properly throughout the day
• if the staff member works with patients or residents who are highly vulnerable to COVID-19 (as determined by the organisation), a risk assessment should be undertaken, and consideration given to redeployment during their 10 day self-isolation period

If any of the above cannot be met, the staff member should not come to work and should follow the stay at home guidance for the full 10-day period.

2.5.2 If an unvaccinated or partially vaccinated staff member is identified as a contact of a COVID-19 case

If an unvaccinated or partially vaccinated staff member is notified as a contact of a COVID-19 case, by NHS Test and Trace or their workplace, they must self-isolate as advised unless they are exempt (because they are under 18, unable to be vaccinated due to medical reasons or are taking part or have taken part in a clinical trial for a COVID-19 vaccine).

If a staff member is unvaccinated and is exempt from self-isolation in the community they should not attend work, or should be redeployed for the period of time they would be required to self-isolate. If a staff member is to be redeployed, they should comply with the mitigations outlined in 2.5.1.

If they develop symptoms of COVID-19 during this period, they should follow the guidance in section 2.1.

3. Self-isolation requirements for patients and residents in health and social care settings after exposure to a case of COVID-19

3.1 Self-isolation requirements for inpatients who are identified as contacts of a case of COVID-19

Inpatients who are known to have been exposed to a confirmed COVID-19 case while in hospital should be isolated or cohorted (grouped together) with other similarly exposed patients who do not have COVID-19 symptoms, until 14 days after last exposure if they remain in hospital. This applies to all patients, irrespective of whether they have been fully vaccinated or had a prior SARS-CoV-2 infection.

If inpatients are discharged to care settings, they should be advised to remain isolated from others for the remainder of their 14-day-exposure window. If they are asymptomatic and fully vaccinated refer to admission and care of residents in a care home during COVID-19 for further information.

If inpatients are discharged to their own home they and their household should be advised to follow the stay at home guidance.

If symptoms or signs consistent with COVID-19 occur in the self-isolation period following exposure then relevant diagnostic tests, including for SARS-CoV-2, should be performed. If they test positive for SARS-CoV-2, then all the patients they have been cohorted with will need to re-start their 14-day-isolation period from the date of their last exposure to a newly diagnosed case. This includes patients who are discharged to a care home facility.

If their SARS-CoV-2 PCR test result is positive, follow the guidance for stepdown of infection control precautions and discharging COVID-19 patients and asymptomatic SARS-CoV-2 infected patients which includes information on self-isolation requirements.

3.2 Isolation requirements for residents of social care settings who are identified as contacts of a case of COVID- 19

Residents who are known to have been exposed to a confirmed COVID-19 case should be isolated or cohorted for 14 full days after their last exposure to a COVID-19 case. If they are cohorted, this should only be with other residents who do not have COVID-19 symptoms but who have also been exposed to a confirmed COVID-19 case. This also applies to residents who have previously recovered from COVID-19.

Asymptomatic and fully vaccinated residents will not require self-isolation if certain additional mitigations are in place. Refer to the guidance on admission and care of residents in a care home during COVID-19 for further information.

If symptoms or signs consistent with COVID-19 develop in residents in the 14-day period since last exposure, then testing for SARS-CoV-2 (along with any relevant testing for other potential diagnoses) should be performed.

If individuals who have been cohorted with other residents subsequently test positive for SARS-CoV-2, then all the residents they have been cohorted with will need to re-start their 14-day-isolation period from the date of their last exposure to newly diagnosed case.

4. Repeat testing for COVID-19

4.1 Exemptions from routine testing for individuals who have previously tested positive for SARS-CoV-2 within 90 days

Fragments of inactive virus can be persistently detected by PCR in respiratory tract samples following infection, and for some time after a person has completed their isolation period and is no longer infectious.

Staff, patients and residents who do not have severe immunosuppression, and who have previously tested positive for SARS-CoV-2 by PCR, should be exempt from routine re-testing, by PCR or LFD antigen tests, if within 90 days from their initial illness onset or test date (if asymptomatic), unless they develop new COVID-19 symptoms or are required to take a PCR test upon entry into the UK.

This exemption includes patients without severe immunosuppression, who require routine testing within 48 hours prior to discharge to a care home. However, any hospitalised care home resident who tests positive and is being discharged within their 14-day-isolation period should only be discharged to a designated setting.

4.2 Assessment of repeat positive test results within 90 days of a prior positive test

If an individual is re-tested by PCR within 90 days from their initial illness onset or prior positive PCR test date and their test is positive, a clinical risk assessment should be used to decide whether new infection (‘reinfection’) is a possibility and to inform subsequent action including whether isolation is required. Additional consideration should be given to whether the patient/resident or staff member is at risk of being a case of a new and emerging variant. Guidance on reinfection and performing clinical risk assessment is detailed in the Investigation and management of suspected SARS-CoV-2 reinfections: a guide for clinicians and infection specialists.

The advice of an infection specialist should be sought to inform clinical risk assessment.

If staff are re-tested with an LFD antigen test within 90 days of a positive PCR test and are found to be positive, they should arrange to have a follow-up PCR test and should self-isolate whilst awaiting their test result. If the PCR is negative, they can stop isolating. If the PCR is positive, the guidance in the preceding paragraph should be followed.

4.3 Isolation requirements for repeat positive test results 90 days or more after a prior positive test

If an individual is re-tested 90 days or more after their initial illness onset or prior test date, and is found to be PCR positive, this should be considered as a possible new infection. They must immediately self-isolate from when their symptoms started or their test date if they do not have symptoms, and follow stay at home guidance. Reinfection should be considered and further management including need for isolation assessed according to guidance on the investigation and management of suspected SARS-CoV-2 reinfections.

5. Associated legislation

This guidance is of a general nature and employers should consider the specific conditions of each individual place of work and comply with all applicable legislation, including the Health and Safety at Work etc. Act 1974 and the Health Protection (Coronavirus, Restrictions) (Self-Isolation) (England) Regulations 2020/1045.

1. Fully vaccinated: 14 days after having received 2 doses of an approved vaccine (such as Pfizer-BioNTech, AstraZeneca or Moderna/Spikevax) or one dose of the single-dose Janssen vaccine. ↩