Coronavirus

Discontinuation of Isolation for Persons with COVID -19 Not in Healthcare Settings

The CDC is learning more about COVID-19 every day, and as new information becomes available, CDC will update the information below. This guidance is based on available information about COVID-19 and is subject to change as additional information becomes available. The approach outlined below may differ from that recommended for healthcare personnel or patients in…

The CDC is learning more about COVID-19 every day, and as new information becomes available, CDC will update the information below. This guidance is based on available information about COVID-19 and is subject to change as additional information becomes available.

The approach outlined below may differ from that recommended for healthcare personnel or patients in healthcare settings with COVID-19 due to different susceptibilities and risks associated with onward transmission in a healthcare setting.

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Accumulating evidence supports ending isolation and precautions for persons with COVID-19 using a symptom-based strategy. Specifically, researchers have reported that people with mild to moderate COVID-19 remain infectious no longer than 10 days after their symptoms began, and those with more severe illness or those who are severely immunocompromised remain infectious no longer than 20 days after their symptoms began. Therefore, CDC has updated the recommendations for discontinuing home isolation as follows:

Persons with COVID-19 who have symptoms and were directed to care for themselves at home may discontinue isolation under the following conditions:

  • At least 10 days* have passed since symptom onset and
  • At least 24 hours have passed since resolution of fever without the use of fever-reducing medications and
  • Other symptoms have improved.

*A limited number of persons with severe illness may produce replication-competent virus beyond 10 days, that may warrant extending duration of isolation for up to 20 days after symptom onset. Consider consultation with infection control experts. See Discontinuation of Transmission-Based Precautions and Disposition of Patients with COVID-19 in Healthcare Settings (Interim Guidance).

Persons infected with SARS-CoV-2 who never develop COVID-19 symptoms may discontinue isolation and other precautions 10 days after the date of their first positive RT-PCR test for SARS-CoV-2 RNA.

RT-PCR testing for detection of SARS-CoV-2 RNA for discontinuing isolation could be considered for persons who are severely immunocompromised1, in consultation with infectious disease experts. For all others, a test-based strategy is no longer recommended except to discontinue isolation or other precautions earlier than would occur under the symptom-based strategy outlined above.

The test-based strategy requires negative results using RT-PCR for detection of SARS-CoV-2 RNA under an FDA Emergency Use Authorization (EUA) for COVID-19 from at least two consecutive respiratory specimens collected ≥24 hours apart (total of two negative specimens). See Interim Guidelines for Collecting, Handling, and Testing Clinical Specimens from Persons for Coronavirus Disease 2019 (COVID-19).

All test results should be final before isolation is ended. Testing guidance is based on limited information and is subject to change as more information becomes available.

Note that recommendations for discontinuing isolation in persons known to be infected with SARS-CoV-2 could, in some circumstances, appear to conflict with recommendations on when to discontinue quarantine for persons known to have been exposed to SARS-CoV-2. CDC recommends 14 days of quarantine after exposure based on the time it takes to develop illness if infected. Thus, it is possible that a person known to be infected could leave isolation earlier than a person who is quarantined because of the possibility they are infected.

These recommendations will prevent most, but cannot prevent all, instances of secondary spread.  The best available evidence suggests that recovered persons can continue to shed detectable SARS-CoV-2 RNA in upper respiratory specimens for up to 3 months after illness onset, albeit at concentrations considerably lower than during illness, in ranges where replication-competent virus has not been reliably recovered and infectiousness is unlikely.  Studies have not found evidence that clinically recovered persons with persistence of viral RNA have transmitted SARS-CoV-2 to others.

Footnotes

*All test results should be final before isolation is ended. Testing guidance is based upon limited information and is subject to change as more information becomes available. In persons with a persistent productive cough, SARS-CoV-2-RNA might be detected for longer periods in sputum specimens than in respiratory specimens.

Updates as of July 17, 2020

  • Symptom-based criteria were modified as follows:
    • Changed from “at least 72 hours” to “at least 24 hours” have passed since last fever without the use of fever-reducing medications
    • Changed from “improvement in respiratory symptoms” to “improvement in symptoms” to address expanding list of symptoms associated with COVID-19
  • A summary of current evidence and rationale for these changes is described in a Decision Memo.

Updates as of May 29, 2020

Added information around the management of persons who may have prolonged viral shedding after recovery.

Updates as of May 3, 2020

  • Changed the name of the ‘non-test-based strategy’ to the ‘symptom-based strategy’ for those with symptoms. Added a ‘time-based strategy’ and named the ‘test-based strategy’ for asymptomatic persons with laboratory-confirmed COVID-19. Extended the home isolation period from 7 to 10 days since symptoms first appeared for the symptom-based strategy in persons with COVID-19 who have symptoms and from 7 to 10 days after the date of their first positive test for the time-based strategy in asymptomatic persons with laboratory-confirmed COVID-19. This update was made based on evidence suggesting a longer duration of viral shedding and will be revised as additional evidence becomes available. This time period will capture a greater proportion of contagious patients; however, it will not capture everyone.
  • Removed specifying use of nasopharyngeal swab collection for the test-based strategy and linked to the Interim Guidelines for Collecting, Handling, and Testing Clinical Specimens for Coronavirus Disease 2019 (COVID-19), so that the most current specimen collection strategies are recommended.

Updates as of April 4, 2020

  • Revised title to include isolation in all settings other than health settings, not just home.

1 The studies used to inform this guidance did not clearly define “severely immunocompromised.” For the purposes of this guidance, CDC used the following definition:

  • Some conditions, such as being on chemotherapy for cancer, untreated HIV infection with CD4 T lymphocyte count < 200, combined primary immunodeficiency disorder, and receipt of prednisone >20mg/day for more than 14 days, may cause a higher degree of immunocompromise and inform decisions regarding the duration of isolation.
  • Other factors, such as advanced age, diabetes mellitus, or end-stage renal disease, may pose a much lower degree of immunocompromise and not clearly affect decisions about duration of isolation.
  • Ultimately, the degree of immunocompromise for the patient is determined by the treating provider, and preventive actions are tailored to each individual and situation.

References

  • Arons MM, Hatfield KM, Reddy SC, Kimball A, James A, Jacobs JR, et al. Presymptomatic SARS-CoV-2 infections and transmission in a skilled nursing facility. N Engl J Med 2020 May 28;382(22):2081-2090. doi:10.1056/NEJMoa2008457.
  • Bullard J, Durst K, Funk D, Strong JE, Alexander D, Garnett L et al. Predicting Infectious SARS-CoV-2 From Diagnostic Samples. Clin Infect Dis 2020 May 22.  doi: 10.1093/cid/ciaa638.
  • Cheng HW, Jian SW, Liu DP, Ng TC, Huang WT, Lin HH, et al. Contact Tracing Assessment of COVID-19 Transmission Dynamics in Taiwan and Risk at Different Exposure Periods Before and After Symptom Onset. JAMA Intern Med 2020 May 1; doi:10.1001/jamainternmed.2020.2020.
  • Li N, Wang X, Lv T. Prolonged SARS-CoV-2 RNA Shedding: Not a Rare Phenomenon. J Med Virol 2020 Apr 29. doi: 10.1002/jmv.25952.
  • Liu WD, Chang SY, Wang JT, Tsai MJ, Hung CC, Hsu CL, et al. Prolonged Virus Shedding Even After Seroconversion in a Patient With COVID-19. J Infect 2020 Apr 10;S0163-4453(20)30190-0.  doi: 10.1016/j.jinf.2020.03.063
  • Midgley CM, Kujawski SA, Wong KK, Collins, JP, Epstein L, Killerby ME et al. (2020). Clinical and Virologic Characteristics of the First 12 Patients with Coronavirus Disease 2019 (COVID-19) in the United States. Nat Med 2020 Jun;26(6):861-868. doi: 10.1038/s41591-020-0877-5.
  • van Kampen J, van de Vijver D, Fraaij P, Haagmans B, Lamers M, Okba N, et al. Shedding of infectious virus in hospitalized patients with coronavirus disease-2019 (COVID-19): duration and key determinants. (Preprint) Medrxiv. 2020. Available at: https://www.medrxiv.org/content/10.1101/2020.06.08.20125310v1external icon doi: https://doi.org/10.1101/2020.06.08.20125310
  • Wölfel R, Corman VM, Guggemos W, Seilmaier M, Zange S, Müller MA, et al. (2020). Virological assessment of hospitalized patients with COVID-2019. Nature 2020 May;581(7809):465-469. doi:10.1038/s41586-020-2196-x
  • Xiao F, Sun J, Xu Y, Li F, Huang X, Li H, et al. Infectious SARS-CoV-2 in Feces of Patient with Severe COVID-19. Emerg Infect Dis 2020;26(8):10.3201/eid2608.200681. doi:10.3201/eid2608.200681
  • Young BE, Ong SWX, Kalimuddin S, Low JG, Ta, SY, Loh J, et al. Epidemiologic Features and Clinical Course of Patients Infected With SARS-CoV-2 in Singapore. JAMA 2020 Mar 3;323(15):1488-1494.  doi:10.1001/jama.2020.3204
  • Zou L, Ruan F, Huang M, Liang L, Huang H, Hong Z, et al. (2020). SARS-CoV-2 Viral Load in Upper Respiratory Specimens of Infected Patients. N Engl J Med, 382(12), 1177-1179. doi:10.1056/NEJMc200173

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