Isolation and Quarantine Q&A

Updates as of November 9, 2022:

• Updated definition of close contact.
• Updated time during which infected persons should not test, shortening the time from 90 days to 30 days, based on recent CDC recommendations.
• Removed recommendations for work exclusion and quarantine for correctional facilities and homeless, emergency and cooling/warming shelters, to align with recent CDC recommendations for healthcare settings.
• Clarified that healthcare personnel working in settings not covered by AFL 21-08.8 may follow the guidance outlined in AFL 21-08.8, and that skilled nursing facilities should follow the guidance for management of exposed residents in AFL 22-13.1.

Questions and Answers

Why has CDPH updated its guidance for exposures in certain settings?

On September 23, 2022, CDC updated its Infection Control Guidance for Healthcare Personnel regarding testing and management of exposed workers in healthcare settings.

As such, CDPH is updating recommendations for asymptomatic exposed individuals in correctional facilities and homeless, emergency and cooling/warming shelters, removing Table 3 from the previous guidance, and recommending that such facilities follow Table 2 of the updated guidance.  With this update, CDPH has also shortened the time frame within which those previously infected are not recommended to test. In non-healthcare settings, CDPH is also further clarifying the definition of close contact to assist entities in prioritizing responses to potential exposures and acknowledging the role of direct (short range) and indirect (long-range) aerosol exposures given different volumes of air in indoor spaces.

Does this updated guidance apply to all persons in a workplace setting?

In some workplaces, employers are subject to the Cal/OSHA COVID-19 Prevention Emergency Temporary Standards (ETS) and some workplaces are subject to Cal/OSHA Aerosol Transmissible Diseases (ATD) Standard and should consult those regulations for applicable requirements.

Healthcare personnel working in settings not covered by AFL 21-08.8 may follow the guidance outlined in AFL 21-08.8.  Skilled nursing facilities should follow the guidance for management of exposed residents in AFL 22-13.1

Other healthcare settings not covered by AFL 21-08.8 include, for example, outpatient clinics, free-standing urgent care facilities, dental clinics, pharmacies, infusion centers, behavioral health clinics, and school clinics.

How should healthcare facilities respond to a potential exposure when using this updated definition?

Healthcare facilities should continue to use the CDC's risk assessment framework to determine exposure risk for healthcare personnel (HCP) with potential occupational exposure to patients, residents, and visitors with COVID-19 in a health care setting. CDC provides additional considerations for assessing exposure risk for patients or residents exposed to HCP with COVID-19 in a health care setting. CDPH guidance for assessing community-related exposures should be applied to HCP with potential exposures outside of work (e.g., household), HCP exposed to each other while working in non-patient care areas (e.g., administrative offices), and for patients/residents exposed to other patients/residents or visitors in health care and non-patient care areas (e.g., waiting rooms, dining areas). Healthcare facilities should prioritize identifying and responding to such contacts based on their proximity to the case, duration or intensity of the exposure, and risk of severe illness or death from exposure, as described above.

Healthcare personnel working in settings not covered by AFL 21-08.8 may follow the guidance outlined in AFL 21-08.8.  Skilled nursing facilities should follow the guidance for management of exposed residents in AFL 22-13.1

What is the definition of a "close contact"? 

The definition of close contact depends on the size of the indoor space, the distance between the case and the contact, and the arrangement within the indoor environment. Specifically, a close contact is defined as follows:

1. In indoor spaces 400,000 or fewer cubic feet per floor (such as home, clinic waiting room, airplane etc.), a close contact is defined as sharing the same indoor airspace for a cumulative total of 15 minutes or more over a 24-hour period (for example, three individual 5-minute exposures for a total of 15 minutes) during an infected person's (confirmed by COVID-19 test or clinical diagnosis) infectious period.

2. In large indoor spaces greater than 400,000 cubic feet per floor (such as open-floor-plan offices, warehouses, large retail stores, manufacturing, or food processing facilities), a close contact is defined as being within 6 feet of the infected person for a cumulative total of 15 minutes or more over a 24-hour period during the infected person's infectious period.

Spaces that are separated by floor-to-ceiling walls (e.g., offices, suites, rooms, waiting areas, bathrooms, or break or eating areas that are separated by floor-to-ceiling walls) must be considered distinct indoor airspaces.

Why is CDPH updating its definition of close contact in large indoor spaces?

SARS-CoV-2 aerosols are generated and released by a person with COVID-19 through activities such as breathing, speaking, and coughing. These aerosols enter the air around the infected person and then spread out evenly throughout the air.

In indoor environments, exposure to SARS-CoV-2 aerosols can occur in two ways: 1) directly, through face-to-face interactions with a person with COVID-19 and 2) indirectly, by inhalation of aerosols that have spread out from the person with COVID-19 and accumulated in the air in a space.  Both types of exposures to SARS-CoV-2 aerosols can lead to infection and COVID-19.

The risk of infection from direct face-to-face interactions depends on the distance from the infected person, with the highest risk being within six feet. The risk of infection from exposure to aerosols that have accumulated in the air, however, depends on the size (volume) of the room and the levels of ventilation and air filtration as key factors amongst others.

In addition to the infection risk from face-to-face interactions in an indoor space, air quality models predict that spending 15 minutes anywhere in a 400,000 cubic ft indoor space or smaller with an infected person poses an infection risk from indirect exposure to aerosols that have accumulated in the air; the infection risk increases with duration of time spent in the space. 

For larger indoor spaces greater than 400,000 cubic feet, the infection risk from exposure to aerosols that have accumulated in the air is expected to be <10% even after 8 hours because of the large volume of air present. The infection risk in these large settings is thus mainly limited to direct, face-to-face exposure with the infected person.

What is the difference between direct and indirect exposure?

Direct, short-range exposure occurs when someone inhales SARS-CoV-2 aerosols during face-to-face interactions with a person with COVID-19. The infected person generates and releases aerosols through breathing, speaking, coughing, and sneezing. The concentration of the aerosols containing SARS-CoV-2 is highest close to the infected person and decreases as the aerosols spread out through the air, especially in larger spaces where there is sufficient air volume to dilute the aerosols that may accumulate.

Indirect, long-range exposure occurs when someone inhales SARS-CoV-2 aerosols that have traveled away from a person with COVID-19 and accumulated in the air in an indoor space. The aerosols tend to mix evenly throughout a space because of dilution and air mixing. Smaller spaces will tend to have higher concentrations of accumulated aerosols than larger spaces, because there is less air to dilute the aerosols in a smaller space.

For both direct and indirect exposures, the risk of infection depends on the duration of exposure, whether the infected person has symptoms, and whether the infected and exposed persons were wearing a respirator or mask. The risk of infection from direct exposure also depends on the distance from the infected person, with the highest risk being within six feet. The risk of infection from indirect exposure also depends on the size (volume) of the room and the levels of ventilation and air filtration. Therefore, the risk of infection from indirect exposure is the about same for everyone in a smaller indoor space regardless of the distance from the infected person. This is because they are all exposed to about the same aerosol concentration after it mixes throughout the room.  In a large indoor space, SARS-CoV-2 aerosols get diluted, and the risk of indirect exposures is low.

Why is CDPH updating the time during which infected persons should not test?

On August 11, 2022, CDC updated it testing guidance, shortening the time when individuals who have been previously infected are not recommended to test from 90 days to 30 days.  This update reflects the current science and the increased immune escape of the recent Omicron variant leading to more repeat infections.

Do close contacts in high-risk settings still have separate quarantine and work exclusion recommendations than close contacts in the general public?

No, close contacts in both high-risk and in the general public are no longer recommended to quarantine or to be excluded from work. All close contacts in correctional facilities and homeless, emergency and cooling/warming shelters should follow the recommendations in Table 2 of the COVID-19 Isolation and Quarantine Guidance.

Additionally, CDPH recommends that for healthcare facilities that may serve more vulnerable populations at risk for severe disease or illness (for example, outpatient oncology settings, other long-term care facilities not specifically identified in AFL 21-08.8),  should consider current CDC healthcare infection control guidance for quarantine of HCP, patients and residents.

Local correctional facilities may also consider current CDC recommendations for isolation and quarantine.

For specific requirements for staff and residents in Long-Term Care Settings & Adult and Senior Care Facilities licensed by the California Department of Social Services, entities must reference applicable Provider Information Notices.  

What is the definition of Healthcare and Long-Term Care Settings?

Healthcare settings refer to places where healthcare is delivered and includes, but is not limited to, acute care facilities, long-term acute-care facilities, inpatient rehabilitation facilities, nursing homes, home healthcare, vehicles where healthcare is delivered (e.g., mobile clinics), and outpatient facilities, such as dialysis centers, physician offices, dental offices, and others.

Long-term care settings are care facilities that provide a variety of services, both medical and personal care, to people who are unable to live independently. They refer to skilled nursing facilities, hospice facilities, PACE Centers, and other adult and senior care residential facilities licensed by the California Department of Social Services.

Why are the recommendations for work exclusion and quarantine for certain facilities removed?

On September 23, 2022, the CDC updated its Infection Control Guidance for Healthcare Personnel regarding testing and management of exposed workers in healthcare settings.  As a result, CDPH has similarly updated its recommendations in correctional facilities and homeless, emergency and cooling/warming shelters to remove work exclusion and quarantine recommendations.

Does this guidance apply to children?

• Children less than 18 years of age, who test positive for COVID-19, should isolate and follow the recommendations included in Table 1 of the Isolation and Quarantine Guidance. However, as per CDPH masking guidance, children under 2 years of age should not wear a mask during their isolation period.
• Children less than 18 years of age, regardless of vaccination status, who have been exposed to someone with COVID-19 do not need to quarantine but should follow all recommendations in Table 2 of the guidance. However, as per CDPH masking guidance, children under 2 years of age should not wear a mask.

Does this guidance apply to children in childcare and K-12 schools settings?

Childcare providers and programs should consult the Guidance for Child Care Providers and Programs and K-12 schools should consult the CDPH K-12 Schools Guidance.

Does this guidance apply to outbreaks?

No, this guidance should not be used for outbreak management purposes. CDPH recommends consulting with the Local Health Jurisdiction for outbreak guidance.

Workplaces covered under the Cal/OSHA ETS should also consult those regulations for applicable outbreak management requirements.

When is a person considered to have "completed their primary series"?

For the definition of "Completed a primary series" please see CDPH Vaccine Records Guidelines and Standards.

When is a person considered "boosted?"  Do they have to wait two weeks after receiving the booster dose?

Persons are considered boosted as soon as they receive their booster dose, as a booster dose typically refreshes protection more quickly than after the primary series.  They do not need to wait two weeks after receiving their booster dose to be considered boosted.  

Isolation

If a person tests positive for COVID-19, does that person still need to isolate, even if they are boosted?

Yes, all persons who test positive for COVID-19, regardless of their vaccination status, whether they do or do not have symptoms, or had previous infection should isolate and follow CDPH recommendations for isolation in Table 1 of the guidance. 

What should persons do if they experience COVID-19 rebound, whether it occurs with or without antiviral medicine treatment?

For COVID-19 rebound (characterized by a recurrence of symptoms or a new positive viral test after having tested negative) following Paxlovid treatment, persons should re-isolate for at least 5 days and follow the recommended actions in Table 1 above to prevent further transmission.

When is a person considered infectious?

The COVID-19 infectious period used to determine exposure of contacts starts 2 days before symptom onset or 2 days before first positive specimen collection date (if asymptomatic) and may go through day 10 after symptom onset (or after positive specimen collection date if remaining asymptomatic) if the infected person does not test negative prior to day 10. 

For the purposes of identifying close contacts and exposures, infected persons who test negative on or after day 5 and end isolation, in accordance with the guidance, are no longer considered to be within their infectious period. Such persons should continue to follow CDPH isolation recommendations, including wearing a well-fitting face mask through day 10. For calculating infectious period, day 0 is symptom onset/positive test date (see below).

When does the clock start for isolation?

The five-day clock for the isolation period starts on the date of symptom onset (day 0) for people who test positive after symptoms develop, with day 1 being the first full day of isolation after symptom onset.

The five-day clock for people who are and remain asymptomatic begins the day of the first positive specimen collection (day 0). If an asymptomatic person who has tested positive subsequently develops symptoms, the five-day clock is restarted on the day of symptom onset, with the date of symptom onset being day 0. The isolation clock continues to day 10 if the infected person tests positive on day 5 or later or does not meet the other criteria for discontinuing isolation earlier.

Does someone need to be fever-free for a full 24-hours prior to leaving isolation (as had been stated in previous guidance)?

Yes. Before discontinuing isolation, persons in isolation need to be fever-free for 24 hours without the use of fever-reducing medication. This is a good general guideline for other infections as well.

Can a person who tests positive on day 5 of isolation test again on subsequent days to see if they can discontinue isolation?

If a person tests positive on day 5 of isolation, they may continue to test again on day 6, 7, and so forth, and may discontinue isolation when any subsequent test comes back as negative as long as they meet other criteria for discontinuing isolation before 10 days.  Persons do not have to wait until day 10 to retest and do not need a negative test in order to discontinue isolation after day 10.

What if I still test positive on day 10 of isolation?

Persons in the general public who test positive on day 10 may leave isolation after 10 days regardless of their test result. Healthcare personnel covered by AFL-21-08.8 should consult the AFL to determine any additional requirements or recommendations regarding additional precautions (including use of N95 respirators for source control and care for patients at high risk for severe disease).

Quarantine

Even if CDPH no longer recommends quarantine, are there times when I should consider self-quarantine?

Yes, *high-risk contacts and those in **high-risk settings may consider self-quarantine for at least 5 days if exposed to someone with COVID-19 and asymptomatic. 

*high-risk contacts are those who:

1.  May be at risk for severe illness if they become infected with COVID-19 OR

2. Who are more likely to transmit the virus to those who are at higher risk of severe COVID-19, OR

3. Who are likely to spread the virus to others due to high intensity/duration of indoor exposure

**high-risk settings, is one in which transmission risk is high (e.g., setting with a large number of persons who may not receive the full protection from vaccination due to co-existing medical conditions), and populations served and/or residing in those settings are at risk of more serious COVID-19 disease consequences including hospitalization, severe illness, and death.

Regardless of whether you self-quarantine or not, all persons who are exposed and remain asymptomatic should test within 3–5 days after the last exposure and should wear a well-fitting mask around others for a total of 10 days.

All persons with COVID-19 symptoms, regardless of vaccination status or previous infection, should self-isolate and test as soon as possible to determine infection status.

What should close contacts who develop symptoms but test negative do? 

Close contacts in non-high-risk settings who are presenting symptoms and who test negative on an antigen test within the first 1–2 days of symptoms should retest at least 24 hours later during the 3–5 day window following exposure with an antigen or PCR test. If the second test is also negative, the negative result can be accepted. Symptomatic persons who test negative on a PCR test do not need to be retested and the results can be accepted as negative. In general, individuals with symptoms should still mask around others and should minimize contact with others until symptoms have resolved to prevent spread of other infectious diseases.

Close contacts in high-risk settings (which include Healthcare Settings, Long Term Care Settings & Adult and Senior Care Facilities) should follow recommendations as indicated in AFL 21-08.8.  Healthcare settings not covered by AFL 21-08.8 may follow the guidance outlined in AFL 21-08.8 Skilled nursing facilities should follow the guidance for management of exposed residents in AFL 22-13.1.

Do persons who are exposed to an infected person in their home need to quarantine or be excluded from work?

Close contacts who are asymptomatic regardless of vaccination status no longer have to quarantine or be excluded from work after exposure to an infected household member, but they are considered a high-risk contact with a much higher likelihood of infection and should more carefully follow all the recommended actions in Table 2, including getting tested and wearing a well-fitting mask around others and around the infected person while they are isolating at home.

What are the recommendations for households with an infected household member?

• Cases who cannot separate from others in the home should mask when in common areas and when around others for 10 days, AND
• Asymptomatic household contacts of cases should mask in the home when not separated from the isolated case.

What are the testing recommendations for asymptomatic household contacts?

• Household contacts who were likely to have been exposed at the same time as the case should test immediately to determine if they are already infected.
• Household contacts who cannot separate from the case in the home should test every 3–5 days while the case is in isolation and 3–5 days after the case ends isolation (or 3-5 days after their last exposure to the case during case's isolation period).
• Household contacts who are able to separate from the case in the home should test 3–5 days after their last exposure to the case.
• Household contacts may consider testing more frequently if resources are available.
• Household contacts who tested positive for COVID-19 in the previous 30 days do not need to get tested if they have had no new symptoms; if they develop symptoms, they should get tested using an antigen test.
• Household contacts who develop symptoms should isolate and test immediately. If they test positive, they should follow isolation recommendations in Table 1 of the Isolation and Quarantine Guidance. If they test negative and symptoms continue, they should retest at least once in 1–2 days.

Other Recommendations

Are there additional precautionary measures that should be followed if a person leaves isolation before day 10?

While persons may exit isolation after day 5 (based on lack of symptoms or improved symptoms, no fever and a negative COVID-19 test), the following additional precautionary measures are recommended through day 10:

• Avoid indoor public settings where you are unable to wear a mask, such as restaurants, bars, and indoor mega events where food and drink are served.
• Avoid people who are immunocompromised or at high risk for severe disease.
• Avoid nursing homes and other high-risk congregate settings.
• Avoid eating around others at home and at work.
• Avoid non-essential travel

What if a person needs to travel immediately after discontinuing isolation?

• Persons who have tested positive for COVID-19 should not travel until a full 10 days after symptom onset or 10 days after the date their positive test if they do not have symptoms.
• Persons who were exposed to someone with COVID-19 are discouraged from traveling until testing negative 5 days after exposure. Travel is discouraged before the 10 days are completed, but if travel is unavoidable, persons should wear a well-fitting mask with good filtration when around others during travel for the entire 10 days.
• Please refer to CDC's travel guidance for more information.