Now let's discuss how exposures to and infections with coronavirus disease-19 are managed. Upon completion of this section, we would like you to be able to understand the difference between quarantine and isolation. We would also like for you to have an understanding of what constitutes exposure to residents and staff. Finally, we will discuss release from isolation for residents and return to work criteria for staff. First, let's review the difference between quarantine and isolation. Quarantine restrict movement and contact of healthy people who have been exposed to SARS-coronavirus-2. The duration of quarantine is based on the length of the incubation period for SARS-CoV-2 which from previous modules, you may recall is 2-14 days after exposure. On the other hand, isolation keeps sick or an infected individual separate from healthy people. The duration of isolation is often mistaken as lasting 14 days similar to quarantine. However, the duration of isolation is actually based on the infectious period and may depend on the severity of illness and individual's immunocompetence. We will further discuss those criteria later in this section. I have included this graphic as a visual reminder that the incubation period and the infectious period are not the same and often have different durations. The incubation period is the time it takes from when an exposure occurs until disease develops and the infectious period is the time in which an individual is infectious to others. Again, quarantine is for the duration of the incubation period, while isolation is the duration of the infectious period. Now that we understand the differences between quarantine and isolation, let's explore what constitutes an exposure that would require quarantine. We will start with residents and non-healthcare personnel. Close contact is defined as being within six feet of an infectious individual for 15 minutes or more, or having direct contact with an infectious person's respiratory secretions. If residents or non-healthcare personnel meet the definition of close contact, they are considered to be exposed regardless of any PPE they were wearing at the time. Additionally, if healthcare personnel are exposed outside of a healthcare setting and they meet the definition of close contact, they too would be considered exposed regardless of PPE worn. So what then constitutes exposure to healthcare personnel and why do they have different considerations than residents or non-healthcare personnel? There are three different scenarios that constitute exposure to health care personnel. The first occurs when a staff member did not wear a face mask or a respirator while in close contact with an infectious individual. Again, close contact is being within six feet of an infectious person for 15 minutes or more. The second scenario in which a healthcare personnel is considered to be exposed, is when the staff member did not wear eye protection while in close contact with an infectious individual who was not wearing a cloth face covering or face mask. Lastly, healthcare personnel are considered exposed if they did not wear all recommended personal protective equipment which includes gowns, gloves, eye protection, and respirator during aerosol generating procedure. Note that face masks are surgical masks and that cloth masks do not count as PPE for healthcare personnel. Healthcare personnel are assessed differently than residents or non-healthcare personnel because they have received training on the selection, donning, and doffing of appropriate PPE whereas residents and non-healthcare personnel often do not. Any residents, non-healthcare personnel, or healthcare personnel who are determined to have been exposed based on the previously discussed criteria to someone who is infectious with COVID-19 should quarantine for 14 days from the last known date of exposure. This ensures that exposed individuals are away from healthy individuals during their incubation period, reducing the likelihood of further transmission. If a community is experiencing healthcare personnel staffing shortages due to a need for quarantine, the community should consult the Centers for Disease Control and Prevention Strategies for Mitigating Healthcare Personnel Staffing Shortages. Exposed individuals will also need a monitor for signs and symptoms consistent with COVID-19. Residents' temperatures should be checked twice per day at a minimum and exposed individuals who develop signs or symptoms of COVID-19 should seek evaluation from a medical care provider and or consult with public health officials. Consider the following questions when thinking through assessment of exposures and a need for quarantine. First, who will be identifying exposed residents and staff? Once identified, who is responsible for providing those individual with instructions for quarantine? The answers to these questions will depend on multiple factors specific to each community. First, in which type of community did the exposure occur? What regulations are in place that would permit or prohibit the community from collecting such information? Another consideration is what the local and or state health departments response process looks like. Perhaps the health department has dedicated contact tracers for congregate living settings. Maybe the health department instead asks certain settings to do their own tracing. Community should be knowledgeable about any expectations set by health departments in their area. Finally, processes set either by the community or the local or state public health departments may depend on where we are in the context of the pandemic and what resources are currently available. For example, health departments may have been doing all tracing initially and then contracted with volunteers or external agencies to provide support for contact tracing once cases increase beyond a certain threshold. All this is to say that contact tracing may be subject to process changes over time and by location. Now that we have covered management of exposures in quarantine, let's wrap up this module by discussing release from isolation for residents and return to work for staff who have been infected with COVID-19. I mentioned at the beginning of this section that the duration of isolation is dependent on severity of illness and immunocompetence. Definitions for these criteria can be found on the CDC website. The boxes on the next few slides provide isolation discontinuation criteria based on those factors. Criteria for those with symptomatic and asymptomatic infections are often similar although there are some nuance differences. I will start by discussing criteria for symptomatic residents to discontinue isolation. For symptomatic residents with mild to moderate illness who are not severely immunocompromised, the following criteria must be met before they can discontinue isolation. Ten days must have passed since symptoms first appeared, and the individual needs to be at least 24 hours free of fever without the use of fever reducing medication, and all symptoms must be improving. For symptomatic residents with severe illness or who are severely immunocompromised, at least 10 days and up to 20 days must have passed since symptoms first appeared. The individual needs to be fever free for at least 24 hours without the use of fever reducing medication, and all symptoms must be improving. Consultation with infectious disease experts could be considered for help advising on duration of isolation in this case. But what if the infected resident is asymptomatic? What are the criteria then? Asymptomatic residents infected with COVID-19, who are not severely immunocompromised should remain in isolation for 10 days since the date of the first positive viral diagnostic test. This means that isolation should last 10 days from the collection date of the test, not the date for which the positive result was returned. For those who are severely immunocompromised, isolation should remain in place for at least 10 days and up to 20 days since the date of the first positive viral diagnostic test. Again, that is the collection date, not the test result date. Note that various local and state public health jurisdictions may have further recommendations or requirements for when an entire unit of cohorted residents can be deescalated from transmission-based precautions. The criteria explained here are intended to describe general criteria for resident release from isolation as set forth by the CDC. You will find that the criteria for staff return to work after infection with COVID-19 are the same as they are for resident release from isolation. For symptomatic staff with mild-to-moderate illness who are not severely immunocompromised, criteria are again, 10 days from onset, 24 hours free of fever without fever reducing medication, and all symptoms are improving. For staff with severe illness who are severely immunocompromised, the time frame could be extended from at least 10 days to up to 20 days. Again, consider consultation with infectious disease experts in the situation. For asymptomatic staff, it's 10 days from collection of the first positive test, and for severely immunocompromised individuals, that may be extended up to 20 days. There are lots of factors to consider when determining release from isolation. But don't worry, if there's a detail you can't remember, all of this information is easily accessible on the CDC website.