Author: COVID-19 NEWS

As COVID-19 continues to spread across the country and the world, we all must remain vigilant. The changes we have had to make to routines and daily life are extremely hard, but these changes are even more important now and in the future. We must stop the spread of this new and dangerous virus. The more steps you and your family can take to prevent the spread of COVID-19, the safer you will be.

Summary of Changes to the Guidance
Below are changes to the guidance as of November 4, 2020:
Provided different options for screening individuals (healthcare personnel, patients, visitors) prior to their entry into a healthcare facility
Provided information on factors that could impact thermometer readings
Provided resources for evaluating and managing ventilation systems in healthcare facilities
Added link to Frequently Asked Questions about use of Personal Protective Equipment

Background
This interim guidance has been updated based on currently available information about COVID-19 and the current situation in the United States. Most recommendations in this updated guidance are not new (except as noted in the summary of changes above); they are organized into the following sections:
Recommended infection prevention and control (IPC) practices for routine healthcare delivery during the pandemic
Recommended IPC practices when caring for a patient with suspected or confirmed SARS-CoV-2 infection
This guidance is applicable to all U.S. settings where healthcare is delivered.  This guidance is not intended for non-healthcare settings (e.g., restaurants) OR for persons outside of healthcare settings. For information regarding modes of transmission, clinical management, air or ground medical transport, or laboratory settings, refer to the COVID-19 website.

Additional Key Resources:

1. Recommended routine infection prevention and control (IPC) practices during the COVID-19 pandemic
CDC recommends using additional infection prevention and control practices during the COVID-19 pandemic, along with standard practices recommended as a part of routine healthcare delivery to all patients. These practices are intended to apply to all patients, not just those with suspected or confirmed SARS-CoV-2 infection (See Section 2 for additional practices that should be used when caring for patients with suspected or confirmed SARS-CoV-2 infection). Facilities should develop policies and procedures to ensure recommendations are appropriately applied in their setting (e.g., emergency department, home healthcare delivery).
These additional practices include:
Implement Telehealth and Nurse-Directed Triage Protocols
Continue to use telehealth strategies to reduce the risk of SARS-CoV-2 transmission in healthcare settings while maintaining high quality patient care.
When scheduling appointments for routine medical care (e.g., annual physical, elective surgery):
Advise patients that they should put on their own cloth mask before entering the facility.
Instruct patients to call ahead and discuss the need to reschedule their appointment if they have symptoms of COVID-19 within the 10 days prior to their appointment, if they have been diagnosed with SARS-CoV-2 infection within the 10 days prior to their appointment, or if they have had close contact with someone with suspected or confirmed SARS-CoV-2 infection within 14 days prior to their scheduled appointment.

When scheduling appointments for patients requesting evaluation for possible SARS-CoV-2 infection, use nurse-directed triage protocols to determine if an appointment is necessary or if the patient can be managed from home.
If the patient must come in for an appointment, instruct them to take appropriate preventive actions (e.g., follow triage procedures, put on their own cloth mask before entry and throughout their visit or, if a cloth mask cannot be tolerated, hold a tissue against their mouth and nose to contain respiratory secretions) and immediately inform triage personnel upon arrival (e.g., call from car) so they can be placed in an examination room.

Screen and Triage Everyone Entering a Healthcare Facility for Signs and Symptoms of COVID-19
Although screening for symptoms will not identify asymptomatic or pre-symptomatic individuals with SARS-CoV-2 infection, symptom screening remains an important strategy to identify those who could have COVID-19 so appropriate precautions can be implemented.
Take steps to ensure that everyone adheres to source control measures and hand hygiene practices while in a healthcare facility
Post visual alertspdf icon (e.g., signs, posterspdf icon) at the entrance and in strategic places (e.g., waiting areas, elevators, cafeterias) to provide instructions (in appropriate languages) about wearing a cloth face covering or facemask for source control and how and when to perform hand hygiene.
Provide supplies for respiratory hygiene and cough etiquette, including alcohol-based hand sanitizer (ABHS) with 60-95% alcohol, tissues, and no-touch receptacles for disposal, at healthcare facility entrances, waiting rooms, and patient check-ins.

Limit and monitor points of entry to the facility.
Establish a process to ensure everyone (patients, healthcare personnel, and visitors) entering the facility is assessed for symptoms of COVID-19,  or exposure to others with suspected or confirmed SARS-CoV-2 infection and that they are practicing source control.
Options could include (but are not limited to): individual screening on arrival at the facility; or implementing an electronic monitoring system in which, prior to arrival at the facility, people report absence of fever and symptoms of COVID-19, absence of a diagnosis of SARS-CoV-2 infection in the prior 10 days, and confirm they have not been exposed to others with SARS-CoV-2 infection during the prior 14 days.
Fever can be either measured temperature ≥100.0°F or subjective fever. People might not notice symptoms of fever at the lower temperature threshold that is used for those entering a healthcare setting, so they should be encouraged to actively take their temperature at home or have their temperature taken upon arrival.
Obtaining reliable temperature readings is affected by multiple factors, including:
The ambient environment in which the temperature is measured: If the environment is extremely hot or cold, body temperature readings may be affected, regardless of the temperature-taking device that is used.
Proper calibration of the thermometers per manufacturer standards: Improper calibration can lead to incorrect temperature readings.
Proper usage and reading of the thermometers: Non-contact infrared thermometers frequently used for health screening must be held at an established distance from the temporal artery in the forehead to take the temperature correctly. Holding the device too far from or too close to the temporal artery affects the reading.

Properly manage anyone with suspected or confirmed SARS-CoV-2 infection or who has had contact with someone with suspected or confirmed SARS-CoV-2 infection:
Healthcare personnel (HCP) should be excluded from work and should notify occupational health services to arrange for further evaluation.
Visitors should be restricted from entering the facility and be referred for proper evaluation.

Patients should be isolated in an examination room with the door closed.
If an examination room is not immediately available, such patients should not wait among other patients seeking care.
Identify a separate, well-ventilated space that allows waiting patients to be separated by 6 or more feet, with easy access to respiratory hygiene supplies.
In some settings, patients might opt to wait in a personal vehicle or outside the healthcare facility where they can be contacted by mobile phone when it is their turn to be evaluated.
Depending on the level of transmission in the community, facilities might also consider designating a separate area at the facility (e.g., an ancillary building or temporary structure) or nearby location as an evaluation area where patients with symptoms of COVID-19 can seek evaluation and care.

Re-evaluate admitted patients for signs and symptoms of COVID-19
Screening for fever and symptoms should also be incorporated into daily assessments of all admitted patients. All fevers and symptoms consistent with COVID-19 among admitted patients should be properly managed and evaluated (e.g., place any patient with unexplained fever or symptoms of COVID-19 on appropriate Transmission-Based Precautions and evaluate).
Implement Universal Source Control Measures
Source control refers to use of well-fitting cloth face masks or facemasks to cover a person’s mouth and nose to prevent spread of respiratory secretions when they are talking, sneezing, or coughing. Because of the potential for asymptomatic and pre-symptomatic transmission, source control measures are recommended for everyone in a healthcare facility, even if they do not have symptoms of COVID-19.
Patients and visitors should wear their own cloth mask (if tolerated) upon arrival to and throughout their stay in the facility. If they do not have a face covering, they should be offered a facemask or cloth mask
Patients may remove their cloth mask when in their rooms but should put it back on when around others (e.g., when visitors enter their room) or leaving their room.
Facemasks and cloth masks should not be placed on young children under age 2, anyone who has trouble breathing, or anyone who is unconscious, incapacitated or otherwise unable to remove the mask without assistance.
Visitors who are not able to wear a cloth mask or facemask should be encouraged to use alternatives to on-site visits with patients (e.g., telephone or internet communication), particularly if the patient is at increased risk for severe illness from SARS-CoV-2 infection.

HCP should wear a facemask at all times while they are in the healthcare facility, including in breakrooms or other spaces where they might encounter co-workers.
When available, facemasks are preferred over cloth face masks for HCP as facemasks offer both source control and protection for the wearer against exposure to splashes and sprays of infectious material from others.
Cloth masks should NOT be worn instead of a respirator or facemask if more than source control is needed.

To reduce the number of times HCP must touch their face and potential risk for self-contamination, HCP should consider continuing to wear the same respirator or facemask (extended use) throughout their entire work shift, instead of intermittently switching back to their cloth mask.
HCP should remove their respirator or facemask, perform hand hygiene, and put on their cloth mask when leaving the facility at the end of their shift.

Educate patients, visitors, and HCP about the importance of performing hand hygiene immediately before and after any contact with their facemask or cloth mask.
Encourage Physical Distancing
Healthcare delivery requires close physical contact between patients and HCP. However, when possible, physical distancing (maintaining at least 6 feet between people) is an important strategy to prevent SARS-CoV-2 transmission.
Examples of how physical distancing can be implemented for patients include:
Limiting visitors to the facility to those essential for the patient’s physical or emotional well-being and care (e.g., care partner, parent).
Encourage use of alternative mechanisms for patient and visitor interactions such as video-call applications on cell phones or tablets.

Scheduling appointments to limit the number of patients in waiting rooms, or creating a process so that patients can wait outside or in their vehicle while waiting for their appointment.
Arranging seating in waiting rooms so patients can sit at least 6 feet apart.
Modifying in-person group healthcare activities (e.g., group therapy, recreational activities) by implementing virtual methods (e.g., video format for group therapy) or scheduling smaller in-person group sessions while having patients sit at least 6 feet apart.
In some circumstances, such as higher levels of community transmission or numbers of patients with COVID-19 being cared for at the facility, and when healthcare-associated transmission is occurring, facilities might cancel in-person group activities in favor of an exclusively virtual format.

For HCP, the potential for exposure to SARS-CoV-2 is not limited to direct patient care interactions. Transmission can also occur through unprotected exposures to asymptomatic or pre-symptomatic co-workers in breakrooms or co-workers or visitors in other common areas. Examples of how physical distancing can be implemented for HCP include:
Reminding HCP that the potential for exposure to SARS-CoV-2 is not limited to direct patient care interactions.
Emphasizing the importance of source control and physical distancing in non-patient care areas.
Providing family meeting areas where all individuals (e.g., visitors, HCP) can remain at least 6 feet apart from each other.
Designating areas and staggered schedules for HCP to take breaks, eat, and drink that allow them to remain at least 6 feet apart from each other, especially when they must be unmasked.
Implement Universal Use of Personal Protective Equipment
HCP working in facilities located in areas with moderate to substantial community transmission are more likely to encounter asymptomatic or pre-symptomatic patients with SARS-CoV-2 infection. If SARS-CoV-2 infection is not suspected in a patient presenting for care (based on symptom and exposure history), HCP should follow Standard Precautions (and Transmission-Based Precautions if required based on the suspected diagnosis).They should also:
Wear eye protection in addition to their facemask to ensure the eyes, nose, and mouth are all protected from exposure to respiratory secretions during patient care encounters.
Wear an N95 or equivalent or higher-level respirator, instead of a facemask, for:

For HCP working in areas with minimal to no community transmission, HCP should continue to adhere to Standard and Transmission-Based Precautions based on anticipated exposures and suspected or confirmed diagnoses. This might include use of eye protection, an N95 or equivalent or higher-level respirator, as well as other personal protective equipment (PPE). In addition, universal use of a facemask for source control is recommended for HCP if not otherwise wearing a respirator.
Consider Performing Targeted SARS-CoV-2 Testing of Patients Without Signs or Symptoms of COVID-19
In addition to the use of universal PPE and source control in healthcare settings, targeted SARS-CoV-2 testing of patients without signs or symptoms of COVID-19 might be used to identify those with asymptomatic or pre-symptomatic SARS-CoV-2 infection and further reduce risk for exposures in some healthcare settings. Depending on guidance from local and state health departments, testing availability, and how rapidly results are available, facilities can consider implementing pre-admission or pre-procedure diagnostic testing with authorized nucleic acid or antigen detection assays for SARS-CoV-2.Testing results might inform decisions about rescheduling elective procedures or about the need for additional Transmission-Based Precautions when caring for the patient. Limitations of using this testing strategy include obtaining negative results in patients during their incubation period who later become infectious and false negative test results, depending on the test method used.
Consider if elective procedures, surgeries, and non-urgent outpatient visits should be postponed in certain circumstances.
Facilities must balance the need to provide necessary services while minimizing risk to patients and HCP. Facilities should consider the potential for patient harm if care is deferred when making decisions about providing elective procedures, surgeries, and non-urgent outpatient visits. Refer to the Framework for Healthcare Systems Providing Non-COVID-19 Clinical Care During the COVID-19 Pandemic for additional guidance.
Optimize the Use of Engineering Controls and Indoor Air Quality
Optimize the use of engineering controls to reduce or eliminate exposures by shielding HCP and other patients from infected individuals. Examples of engineering controls include:
Physical barriers and dedicated pathways to guide symptomatic patients through triage areas.
Remote triage facilities for patient intake areas.
If climate permits, outdoor assessment and triage stations for patients with respiratory symptoms.
Vacuum shrouds for surgical procedures likely to generate aerosols.
Reassess the use of open bay recovery areas.

Explore options, in consultation with facility engineers, to improve indoor air quality in all shared spaces.
Optimize air-handling systems (ensuring appropriate directionality, filtration, exchange rate, proper installation, and up to date maintenance).
Consider the addition of portable solutions (e.g., portable HEPA filtration units) to augment air quality in areas when permanent air-handling systems are not a feasible option.
Guidance on ensuring that ventilation systems are operating properly are available in the following resources:

Create a Process to Respond to SARS-CoV-2 Exposures Among HCP and Others
Healthcare facilities should have a process for notifying the health department about suspected or confirmed cases of SARS-CoV-2 infection, and should establish a plan, in consultation with local public health authorities, for how exposures in a healthcare facility will be investigated and managed and how contact tracing will be performed. The plan should address the following:
Who is responsible for identifying contacts (e.g., HCP, patients, visitors) and notifying potentially exposed individuals?
How will such notifications occur?
What actions and follow-up are recommended for those who were exposed?
Contact tracing should be carried out in a way that protects the confidentiality of affected individuals and is consistent with applicable laws and regulations. HCP and patients who are currently admitted to the facility or were transferred to another healthcare facility should be prioritized for notification. These groups, if infected, have the potential to expose a large number of individuals at higher risk for severe disease, or in the situation of admitted patients, are at higher risk for severe illness themselves.
Information about when HCP with suspected or confirmed SARS-CoV-2 infection may return to work is available in the Interim Guidance on Criteria for Return to Work for Healthcare Personnel with Confirmed or Suspected COVID-19.
Information about risk assessment and work restrictions for HCP exposed to SARS-CoV-2 is available in the Interim U.S. Guidance for Risk Assessment and Work Restrictions for Healthcare Personnel with Potential Exposure to Coronavirus Disease 2019 (COVID-19).
Healthcare facilities must be prepared for potential staffing shortages and have plans and processes in place to mitigate these, including providing resources to assist HCP with anxiety and stress. Strategies to mitigate staffing shortages are available.
2. Recommended infection prevention and control (IPC) practices when caring for a patient with suspected or confirmed SARS-CoV-2 infection
Establish Reporting within and between Healthcare Facilities and to Public Health Authorities
Implement mechanisms and policies that promote situational awareness for facility staff including infection control, healthcare epidemiology, facility leadership, occupational health, clinical laboratory, and frontline staff about patients with suspected or confirmed SARS-CoV-2 infection and facility plans for response.
Communicate and collaborate with public health authorities.
Facilities should designate specific persons within the healthcare facility who are responsible for communication with public health officials and dissemination of information to HCP.

Patient Placement
For patients with COVID-19 or other respiratory infections, evaluate need for hospitalization. If hospitalization is not medically necessary, home care is preferable if the individual’s situation allows.
If admitted, place a patient with suspected or confirmed SARS-CoV-2 infection in a single-person room with the door closed. The patient should have a dedicated bathroom.
Airborne Infection Isolation Rooms (AIIRs) (See definition of AIIR in appendix) should be prioritized for patients who will be undergoing aerosol generating procedures (See Aerosol Generating Procedures Section).

Personnel entering the room should use PPE as described below.
As a measure to limit HCP exposure and conserve PPE, facilities could consider designating entire units within the facility, with dedicated HCP, to care for patients with suspected or confirmed SARS-CoV-2 infection. Dedicated means that HCP are assigned to care only for these patients during their shifts.
Determine how staffing needs will be met as the number of patients with suspected or confirmed SARS-CoV-2 infection increases and if HCP become ill and are excluded from work.
It might not be possible to distinguish patients who have COVID-19 from patients with other respiratory viruses. As such, patients with different respiratory pathogens might be cohorted on the same unit. However, only patients with the same respiratory pathogen may be housed in the same room. For example, a patient with COVID-19 should not be housed in the same room as a patient with an undiagnosed respiratory infection or a respiratory infection caused by a different pathogen.

To the extent possible, patients with suspected or confirmed SARS-CoV-2 infection should be housed in the same room for the duration of their stay in the facility (i.e., minimize room transfers).
Limit transport and movement of the patient outside of the room to medically essential purposes.
Whenever possible, perform procedures/tests in the patient’s room.
Consider providing portable x-ray equipment in patient cohort areas to reduce the need for patient transport.

Communicate information about patients with suspected or confirmed SARS-CoV-2 infection to appropriate personnel before transferring them to other departments in the facility (e.g., radiology) and to other healthcare facilities.
Patients should wear a facemask or cloth mask to contain secretions during transport. If patients cannot tolerate a facemask or cloth mask or one is not available, they should use tissues to cover their mouth and nose while out of their room.
Once the patient has been discharged or transferred, HCP, including environmental services personnel, should refrain from entering the vacated room until sufficient time has elapsed for enough air changes to remove potentially infectious particles (more information on clearance rates under differing ventilation conditions is available). After this time has elapsed, the room should undergo appropriate cleaning and surface disinfection before it is returned to routine use.
Personal Protective Equipment

HCP who enter the room of a patient with suspected or confirmed SARS-CoV-2 infection should adhere to Standard Precautions and use a NIOSH-approved N95 or equivalent or higher-level respirator (or facemask if a respirator is not available), gown, gloves, and eye protection.
When available, respirators (instead of facemasks) are preferred; they should be prioritized for situations where respiratory protection is most important and the care of patients with pathogens requiring Airborne Precautions (e.g., tuberculosis, measles, varicella). Information about the recommended duration of Transmission-Based Precautions is available in the Interim Guidance for Discontinuation of Transmission-Based Precautions and Disposition of Hospitalized Patients with COVID-19.
Hand Hygiene
HCP should perform hand hygiene before and after all patient contact, contact with potentially infectious material, and before putting on and after removing PPE, including gloves. Hand hygiene after removing PPE is particularly important to remove any pathogens that might have been transferred to bare hands during the removal process.
HCP should perform hand hygiene by using ABHS with 60-95% alcohol or washing hands with soap and water for at least 20 seconds. If hands are visibly soiled, use soap and water before returning to ABHS.
Healthcare facilities should ensure that hand hygiene supplies are readily available to all personnel in every care location.

Personal Protective Equipment TrainingEmployers should select appropriate PPE and provide it to HCP in accordance with OSHA PPE standards (29 CFR 1910 Subpart I)external icon. HCP must receive training on and demonstrate an understanding of:
when to use PPE
what PPE is necessary
how to properly don, use, and doff PPE in a manner to prevent self-contamination
how to properly dispose of or disinfect and maintain PPE
the limitations of PPE.

Any reusable PPE must be properly cleaned, decontaminated, and maintained after and between uses. Facilities should have policies and procedures describing a recommended sequence for safely donning and doffing PPE.
The PPE recommended when caring for a patient with suspected or confirmed COVID-19 includes the following:
Respirator or Facemask (Cloth masks are NOT PPE and should not be worn for the care of patients with suspected or confirmed COVID-19 or other situations where use of a respirator or facemask is recommended.)
Put on an N95 respirator (or equivalent or higher-level respirator) or facemask (if a respirator is not available) before entry into the patient room or care area, if not already wearing one as part of extended use strategies to optimize PPE supply. Other respirators include other disposable filtering facepiece respirators, powered air purifying respirators (PAPRs), or elastomeric respirators.
N95 respirators or respirators that offer a higher level of protection should be used instead of a facemask when performing or present for an aerosol generating procedure. See appendix for respirator definition.
Disposable respirators and facemasks should be removed and discarded after exiting the patient’s room or care area and closing the door unless implementing extended use or reuse. Perform hand hygiene after removing the respirator or facemask.
If reusable respirators (e.g., powered air-purifying respirators [PAPRs] or elastomeric respirators) are used, they should also be removed after exiting the patient’s room or care area. They must be cleaned and disinfected according to manufacturer’s reprocessing instructions prior to re-use.

When the supply chain is restored, facilities with a respiratory protection program should return to use of respirators for patients with suspected or confirmed SARS-CoV-2 infection. Those that do not currently have a respiratory protection program, but care for patients with pathogens for which a respirator is recommended, should implement a respiratory protection program.

Eye Protection
Put on eye protection (i.e., goggles or a face shield that covers the front and sides of the face) upon entry to the patient room or care area, if not already wearing as part of extended use strategies to optimize PPE supply.
Protective eyewear (e.g., safety glasses, trauma glasses) with gaps between glasses and the face likely do not protect eyes from all splashes and sprays.

Ensure that eye protection is compatible with the respirator so there is not interference with proper positioning of the eye protection or with the fit or seal of the respirator.
Remove eye protection after leaving the patient room or care area, unless implementing extended use.
Reusable eye protection (e.g., goggles) must be cleaned and disinfected according to manufacturer’s reprocessing instructions prior to re-use. Disposable eye protection should be discarded after use unless following protocols for extended use or reuse.

Gloves
Put on clean, non-sterile gloves upon entry into the patient room or care area.
Change gloves if they become torn or heavily contaminated.

Remove and discard gloves before leaving the patient room or care area, and immediately perform hand hygiene.

Gowns
Put on a clean isolation gown upon entry into the patient room or area. Change the gown if it becomes soiled. Remove and discard the gown in a dedicated container for waste or linen before leaving the patient room or care area. Disposable gowns should be discarded after use. Reusable (i.e., washable or cloth) gowns should be laundered after each use.

Additional information is available at Personal Protective Equipment: Questions and Answers.Facilities should work with their health department and healthcare coalitionexternal icon to address shortages of PPE.
Aerosol Generating Procedures (AGPs)
Some procedures performed on patients with suspected or confirmed SARS-CoV-2 infection could generate infectious aerosols. Procedures that pose such risk should be performed cautiously and avoided if possible.
If performed, the following should occur:
HCP in the room should wear an N95 or equivalent or higher-level respirator, eye protection, gloves, and a gown.
The number of HCP present during the procedure should be limited to only those essential for patient care and procedure support. Visitors should not be present for the procedure.
AGPs should take place in an AIIR, if possible.
Clean and disinfect procedure room surfaces promptly as described in the section on environmental infection control below.

Collection of Diagnostic Respiratory Specimens
When collecting diagnostic respiratory specimens (e.g., nasopharyngeal or nasal swab) from a patient with possible SARS-CoV-2 infection, the following should occur:
Specimen collection should be performed in a normal examination room with the door closed.
HCP in the room should wear an N95 or equivalent or higher-level respirator (or facemask if a respirator is not available), eye protection, gloves, and a gown.
If respirators are not readily available, they should be prioritized for other procedures at higher risk for producing infectious aerosols (e.g., intubation), instead of for collecting diagnostic respiratory specimens. The number of HCP present during the procedure should be limited to only those essential for patient care and procedure support. Visitors should not be present for specimen collection.
Clean and disinfect procedure room surfaces promptly as described in the section on environmental infection control below.

Manage Visitor Access and Movement Within the Facility
Limit visitors to the facility to only those essential for the patient’s physical or emotional well-being and care (e.g., care partner, parent).
Encourage use of alternative mechanisms for patient and visitor interactions such as video-call applications on cell phones or tablets.
If visitation to patients with SARS-CoV-2 infection occurs, visits should be scheduled and controlled to allow for the following:
Facilities should evaluate risk to the health of the visitor (e.g., visitor might have underlying illness putting them at higher risk for COVID-19) and ability to comply with precautions.
Facilities should provide instruction, before visitors enter patients’ rooms, on hand hygiene, limiting surfaces touched, and use of PPE according to current facility policy while in the patient’s room.
Visitors should not be present during AGPs or other procedures.
Visitors should be instructed to only visit the patient room. They should not go to other locations in the facility.

Environmental Infection Control
Dedicated medical equipment should be used when caring for patients with suspected or confirmed SARS-CoV-2 infection.
All non-dedicated, non-disposable medical equipment used for patient care should be cleaned and disinfected according to manufacturer’s instructions and facility policies.

Ensure that environmental cleaning and disinfection procedures are followed consistently and correctly.
Routine cleaning and disinfection procedures (e.g., using cleaners and water to pre-clean surfaces prior to applying an EPA-registered, hospital-grade disinfectant to frequently touched surfaces or objects for appropriate contact times as indicated on the product’s label) are appropriate for SARS-CoV-2 in healthcare settings, including those patient-care areas in which aerosol generating procedures are performed.
Refer to List Nexternal icon on the EPA website for EPA-registered disinfectants that have qualified under EPA’s emerging viral pathogens program for use against SARS-CoV-2.

Management of laundry, food service utensils, and medical waste should also be performed in accordance with routine procedures.
Additional information about recommended practices for terminal cleaning of rooms and PPE to be worn by environmental services personnel is available in the Healthcare Infection Prevention and Control FAQs for COVID-19
Appendix: Additional Information about Airborne Infection Isolation Rooms, Respirators and Facemasks
Information about Airborne Infection Isolation Rooms (AIIRs):
AIIRs are single-patient rooms at negative pressure relative to the surrounding areas, and with a minimum of 6 air changes per hour (12 air changes per hour are recommended for new construction or renovation).
Air from these rooms should be exhausted directly to the outside or be filtered through a high-efficiency particulate air (HEPA) filter directly before recirculation.
Room doors should be kept closed except when entering or leaving the room, and entry and exit should be minimized.
Facilities should monitor and document the proper negative-pressure function of these rooms.
Information about Respirators:
A respirator is a personal protective device that is worn on the face, covers at least the nose and mouth, and is used to reduce the wearer’s risk of inhaling hazardous airborne particles (including dust particles and infectious agents), gases, or vapors. Respirators are certified by the CDC/NIOSH, including those intended for use in healthcare.
Respirator use must be in the context of a complete respiratory protection program in accordance with OSHA Respiratory Protection standard (29 CFR 1910.134external icon). HCP should be medically cleared and fit tested if using respirators with tight-fitting facepieces (e.g., a NIOSH-approved N95 respirator) and trained in the proper use of respirators, safe removal and disposal, and medical contraindications to respirator use.
NIOSH information about respirators
OSHA Respiratory Protection eTooexternal icon
Strategies for Optimizing the Supply of N-95 Respirators
Filtering Facepiece Respirators (FFR) including N95 Respirators
Elastomeric Respirators
NIOSH-certified reusable elastomeric particulate respirators provide at least the same level of protection as N95 FFRs, and some types of elastomeric respirators can offer higher assigned protection factors than N95 FFRs.
Elastomeric respirators, such as half facepiece or full facepiece tight-fitting respirators where the facepieces are made of synthetic or natural rubber material, can be repeatedly used, cleaned, disinfected, stored and re-used. They are available as alternatives to disposable half mask filtering facepiece respirators (FFRs), such as N95 FFRs, for augmenting the total supply of respirators available for use by HCP.
Elastomeric respirators have the same basic requirements for an OSHA-approved respiratory protection program as filtering facepiece respirators, including medical evaluation, training, and fit testing. However, they have additional maintenance requirements which include cleaning and disinfection of the facepiece components such as straps, valves, and valve covers.
Additional information about elastomeric respirators, including strategies during conventional and surge demand situation is available.
Powered Air Purifying Respirators (PAPRs)
PAPRs have a battery-powered blower that pulls air through attached filters, canisters, or cartridges. They provide protection against gases, vapors, or particles, when equipped with the appropriate cartridge, canister, or filter.
Depending on the design of the tight-fitting (full facepiece or half) or loose fitting PAPR, air is directed differently, which may have an impact on effectiveness of source control.
Loose-fitting PAPRs do not require fit testing and can be used with facial hair.
A list of NIOSH-approved PAPRs is located on the NIOSH Certified Equipment List.
Considerations for Optimizing the Supply of PAPRs
Information about Facemasks:
If worn properly, a facemask helps block respiratory secretions produced by the wearer from contaminating other persons and surfaces (often called source control).
Surgical facemasks are cleared by the U.S. Food and Drug Administration (FDA) for use as medical devices. Facemasks should be used once and then thrown away in the trash.
Definitions:
Healthcare Personnel (HCP): HCP refers to all paid and unpaid persons serving in healthcare settings who have the potential for direct or indirect exposure to patients or infectious materials, including body substances (e.g., blood, tissue, and specific body fluids); contaminated medical supplies, devices, and equipment; contaminated environmental surfaces; or contaminated air. HCP include, but are not limited to, emergency medical service personnel, nurses, nursing assistants, home healthcare personnel, physicians, technicians, therapists, phlebotomists, pharmacists, students and trainees, contractual staff not employed by the healthcare facility, and persons not directly involved in patient care, but who could be exposed to infectious agents that can be transmitted in the healthcare setting (e.g., clerical, dietary, environmental services, laundry, security, engineering and facilities management, administrative, billing, and volunteer personnel).
Healthcare settings refers 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 and assisted living facilities, home healthcare, vehicles where healthcare is delivered (e.g., mobile clinics), and outpatient facilities, such as dialysis centers, physician offices, and others.
Source Control: Use of cloth masks or facemasks to cover a person’s mouth and nose to prevent spread of respiratory secretions when they are talking, sneezing, or coughing. Facemasks and cloth masks should not be placed on children under age 2, anyone who has trouble breathing, or anyone who is unconscious, incapacitated, or otherwise unable to remove the mask without assistance.
Cloth mask: Textile (cloth) covers that are intended for source control. They are not personal protective equipment (PPE) and it is uncertain whether cloth face coverings protect the wearer. Guidance on design, use, and maintenance of cloth masks is available.
Facemask: Facemasks are PPE and are often referred to as surgical masks or procedure masks. Use facemasks according to product labeling and local, state, and federal requirements. FDA-cleared surgical masks are designed to protect against splashes and sprays and are prioritized for use when such exposures are anticipated, including surgical procedures. Facemasks that are not regulated by FDA, such as some procedure masks, which are typically used for isolation purposes, may not provide protection against splashes and sprays.
Respirator: A respirator is a personal protective device that is worn on the face, covers at least the nose and mouth, and is used to reduce the wearer’s risk of inhaling hazardous airborne particles (including dust particles and infectious agents), gases, or vapors. Respirators are certified by the CDC/NIOSH, including those intended for use in healthcare. Refer to the Appendix for a summary of different types of respirators.
Substantial community transmission: Large scale community transmission, including communal settings (e.g., schools, workplaces)
Minimal to moderate community transmission: Sustained transmission with high likelihood or confirmed exposure within communal settings and potential for rapid increase in cases
No to minimal community transmission: Evidence of isolated cases or limited community transmission, case investigations underway; no evidence of exposure in large communal setting

State, tribal, territorial, and local jurisdictions: CDC is working with state, tribal, territorial, and local jurisdictions on the development of COVID-19 vaccination plans for their respective areas. CDC released a playbook on September 16, 2020, to provide specific information to consider during vaccination plan development. The playbookpdf icon was updated on October 30, 2020.
Private partners and federal agencies: CDC has also worked with private partners, such as chain and networks of independent pharmacies, and other federal agencies (e.g., the Indian Health Service) on plans to more widely distribute COVID-19 vaccines. For example, CDC is working with pharmacies to offer on-site COVID-19 vaccination services for residents in long-term care settings, including skilled nursing facilities, nursing homes, and assisted living facilities where most individuals are over 65 years of age.

Revisions made on October 21, 2020
Added links to the updated close contact definition.
Updated language to align with updated definition.

1. Background
While new discoveries continue to be made about COVID-19, early reports indicate that person-to-person transmission most often occurs during close contact with an individual infected with SARS-CoV-2, the virus that causes COVID-19. Healthcare workers (HCWs) are not only at higher risk of infection but can also amplify outbreaks within healthcare facilities if they become ill. Identifying and managing HCWs who have been exposed to a patient with COVID-19 is of great importance in preventing healthcare transmission and protecting staff and vulnerable patients in healthcare settings.
2. Target Audience
These operational considerations are intended to be used by healthcare facilities and public health authorities in non-U.S. healthcare settings, particularly focusing on low- and middle-income countries, assisting with the management of HCWs exposed to a person with suspected or confirmed COVID-19.
This includes but is not limited to:
Healthcare facility leadership
Infection prevention and control (IPC) staff
Occupational health and worker safety staff
Public health staff at the national and sub-national level
3. Objectives
The goals of HCW risk assessment, work restriction, and monitoring are to:
Allow for early identification of HCWs at high risk of exposure to COVID-19;
Reinforce the need for HCWs to self-monitor for fever and other symptoms, and avoid work when ill;
Limit introduction and spread of COVID-19 within healthcare facilities by healthcare personnel;
This document is only intended to advise on the management of HCWs regarding their work within healthcare facilities. Guidance on management of exposed HCWs outside of healthcare facilities (e.g., quarantine, travel-restriction) is beyond the scope of this document. Recommendations are made based on currently available data and subject to change when new information becomes available.
4. Definitions
Healthcare worker – all paid and unpaid persons serving in healthcare settings who have the potential for direct or indirect exposure to patients or their infectious secretions and materials (e.g., doctors, nurses, laboratory workers, facility or maintenance workers, clinical trainees, volunteers).
High risk exposure –
Close contact (being within 2 meters for a total of 15 minutes or more with a person with COVID-19 ) with a person with COVID-19 in the community[1]; OR
Providing direct patient care for a patient with COVID-19 (e.g., physical exam, nursing care, performing aerosol-generating procedures, specimen collection, radiologic testing) without using proper personal protective equipment (PPE)[2] or not performing appropriate hand hygiene after these interactions; OR
Having contact with the infectious secretions from a patient with COVID-19 or contaminated patient care environment, without using proper personal protective equipment (PPE) or not performing appropriate hand hygiene
Low risk exposure – contact with a person with COVID-19 having not met criteria for high-risk exposure (e.g., brief interactions with COVID-19 patients in the hospital or in the community).
Active monitoring – healthcare facility or public health authority establishes a minimum of daily communication with exposed HCWs to assess for the presence of fever or symptoms consistent with COVID-19[3]. Monitoring could involve in-person temperature and symptom checks or remote contact (e.g., telephone or electronic-based communication).
Self-monitoring – HCWs monitor themselves for fever by taking their temperature twice a day and remaining alert for respiratory and other symptoms that may be compatible with COVID-19. HCWs are provided a plan for whom to contact if they develop fever or even mild symptoms during the self-monitoring period to determine whether medical evaluation and testing is needed.

5. Considerations when Managing HCWs Exposed to Individuals with COVID-19
Healthcare facilities may choose to manage exposed HCWs in a variety of ways and may consider multiple factors when deciding on a management strategy for exposed HCWs, including:
Epidemiology of COVID-19 in the surrounding community;
Ability to maintain staffing levels to provide adequate care to all patients in the facility;
Availability of IPC, employee/occupational health, or other chosen personnel to carry out HCW risk assessment and monitoring activities;
Access to resources that can limit the burden of HCW active monitoring (e.g., electronic tools)
All healthcare facilities should have an established communication plan for notifying appropriate public health authorities of any HCW who requires testing for COVID-19 during the monitoring period. Staff should be aware of the established procedures for HCWs who have been exposed to a person with COVID-19, and facilities should develop paid sick leave policies and contract extensions that support the ability for staff to avoid work when ill.
Risk Assessment, Work Restriction, and Monitoring
The accompanying flowchart [see Figure] describes possible scenarios for risk assessment of exposed HCWs. Any HCW exposed to a person with COVID-19 in a healthcare facility or in the community should be quickly identified and assessed for fever or symptoms of COVID-19. If found to be symptomatic, they should be immediately restricted from work until a medical evaluation can be completed and testing for COVID-19 considered. If the exposed worker is not symptomatic, an assessment can be done to determine the risk category of exposure, necessary work restriction, and monitoring for 14 days [see Appendix 1pdf icon].
Ideally, HCWs who had a high-risk exposure should be restricted from work and remain quarantined with active monitoring for COVID-19 symptoms for 14 days after the date of last exposure. If at any time the worker develops fever or symptoms, they should undergo medical evaluation and COVID-19 testing, if indicated. Those who test negative should continue to be restricted from work, actively monitored, and may return to work at the end of the monitoring period if symptoms are resolved. Those HCWs who remain asymptomatic over the monitoring period may likewise return to work after 14 days. See below Considerations When Resources are Limited for alternative strategies if staffing shortages prevent the ability to restrict HCWs from work.
HCWs who had a low-risk exposure and are considered essential staff may continue to work during the 14 days after their last exposure to a patient with COVID-19. These HCWs should preferably be assigned to care for patients with COVID-19 and should perform self-monitoring twice a day. If the worker is scheduled for a shift, they should take their temperature and self-evaluate for symptoms before reporting to work. Healthcare facilities can consider establishing protocols in which HCWs under self-monitoring report their temperature and symptom status to IPC staff, employee/occupational health, or a designated supervisor prior to beginning a shift. If the HCW develops fever or symptoms, they should:
Not report to work (or should immediately stop patient care if symptoms begin during a work shift);
Alert their designated point of contact (POC);
Be restricted from work until medical evaluation and COVID-19 testing can be performed.
If testing is negative and symptoms are resolved, they may return to work while observing standard precautions and continuing to self-monitor for the remainder of the 14 days. Some facilities have instructed any exposed staff that continue working during the 14 days post-exposure (e.g., asymptomatic low-risk exposure or staff who had symptoms, tested negative and returned to work within the exposure period) to wear a medical mask at all times in the facility to reduce the risk of asymptomatic or pre-symptomatic transmission.
Any HCW who tests positive for COVID-19, either in the course of monitoring after an exposure or otherwise, should be immediately restricted from work and public health notified for further case management.
Considerations When Resources are Limited
There may be situations in which healthcare facilities are unable to perform contact tracing of all HCWs exposed to a patient with confirmed COVID-19 or to carry out an individual risk assessment for all exposed HCWs. Some of these scenarios include:
Inability to perform contact tracingHealthcare delivery and traffic flow in a healthcare facility can be dynamic, and documentation of staffing assignments may not be routine practice. This has made it challenging for some healthcare facilities to identify all HCWs who had contact with a case. In situations where identifying all exposed HCWs is not possible, facilities have sent a general communication to all facility staff informing them of:
Exposure risk;
Associated facility location(s);
Date(s) and time(s) for potential exposure;
Instructions for staff to self-identify any known exposures and to notify the designated POC so that risk assessment and public health recommendations can be made;
Instructions for staff to self-monitor for fever or respiratory symptoms for a chosen period of time and to notify the POC if they become ill.

Inability to perform individual HCW risk assessmentsIf many HCWs were exposed to a case or there are limited IPC, employee/occupational health, or public health staff available to assist with public health management, some facilities have found it impractical or impossible to perform individual risk assessments on all exposed HCWs. Efforts have instead focused on identifying staff at highest risk of exposure to COVID-19, including those who were exposed in the setting of an aerosol-generating procedure[4] without the use of appropriate PPE, since this would pose the highest risk of transmission to the HCW. These staff have been designated as potential high-risk exposures, with the remaining exposed staff as potentially exposed. Facilities and public health authorities then determined whether they will manage these staff as low-risk or high-risk while weighing the risks and benefits of each strategy (e.g., available resources, ability to work restrict HCWs, etc.).
Limited Testing Availability
When overall testing capacity has been limited and must be rationed, facilities and public health authorities have prioritized symptomatic HCWs for testing over low-risk groups in the community (e.g., young healthy individuals). If no testing is available, for the purposes of returning to work, these HCWs have been managed as if potentially infected with SARS-CoV-2 and can return to work based on the strategies described below.
6. Management Considerations of HCWs with Suspected or Confirmed COVID-19
Previous U.S. CDC and WHO recommendations included a symptom-based strategy and a test-based strategy for returning HCWs with suspected or confirmed COVID-19 to work or discontinue isolation. As described in a Decision Memo, U.S. CDC no longer recommends a test-based strategy based on current evidence. This is consistent with a WHO Scientific Briefexternal icon on discontinuation of isolation for COVID-19. Replication-competent virus has not been recovered after 10 days following symptom onset among individuals with mild to moderate COVID-19 illness. In severely or critically ill patients, including some with severely immunocompromising conditions, an estimated 95% no longer have replication-competent virus 15 days after onset of symptoms. While individuals may continue to shed detectable SARS-CoV-2 RNA beyond these time points, a test-based strategy is no longer recommended, with rare exception, because in the majority of cases it results in excluding from work HCWs who continue to shed virus but are no longer infectious.
U.S. CDC recommendations for a symptom-based strategy to determine when HCWs can return to work:
HCWs with mild to moderate illness [5] who are not severely immunocompromised [6]:
At least 10 days have passed since symptoms first appeared and
At least 24 hours have passed since last fever without the use of fever-reducing medications and
Symptoms (e.g., cough, shortness of breath) have improved
Note: HCWs who are not severely immunocompromised and were asymptomatic throughout their infection may return to work when at least 10 days have passed since the date of their first positive viral diagnostic test.
HCW with severe to critical illness5 or who are severely immunocompromised:
At least 10 days and up to 20 days have passed since symptoms first appeared and
At least 24 hours have passed since last fever without the use of fever-reducing medications and
Symptoms (e.g., cough, shortness of breath) have improved
Consider consultation with infection control experts
Note: HCWs who are severely immunocompromised but who were asymptomatic throughout their infection may return to work when at least 10 days and up to 20 days have passed since the date of their first positive viral diagnostic test.
The exact criteria that determine which HCWs will shed replication-competent virus for longer periods are not known. Disease severity factors and the presence of immunocompromising conditions should be considered in determining the appropriate duration of isolation (see footnotes 5 and 6). Consultation with infection control experts should be considered to determine the optimal time for an individual HCW to return to work.
Per the WHO Scientific Briefexternal icon, countries can choose to continue to use a laboratory testing algorithm as part of the criteria for releasing infected individuals from isolation. Countries that decide to adopt a test-based strategy for returning HCWs to work should take into consideration the limitations of this approach, including HCWs who continue to shed virus but are no longer infectious and strain on testing resources.
CDC and WHO recommend all HCWs wear a medical mask for universal source control if there is SARS-CoV-2 transmission in the community. For countries that are not using medical masks for universal source control, HCWs returning to work after SARS-CoV-2 infection should wear a medical mask at all times while in the healthcare facility until all symptoms are completely resolved or at baseline. After returning to work, HCWs should continue to adhere to hand hygiene, respiratory hygiene, and cough etiquette at all times, and continue to self-monitor for symptoms, seeking medical evaluation if fever or respiratory symptoms worsen or recur.
CDC testing and return to work guidance is based upon currently available evidence and is subject to change as more information becomes available. Please see CDC Criteria for Return to Work for Healthcare Personnel with Suspected or Confirmed COVID-19 (Interim Guidance) for further updates to these recommendations.

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Cruise lines that have ships operating or planning to operate in U.S. waters during the period of the No Sail Order extension
Parent Company
Cruise Line
No Sail Order Response Plan Status
Ship Name
Ship Status
Commercial Travel Allowed¥
Bahamas Paradise Cruise Line
Bahamas Paradise Cruise Line
Complete and accurate with signed acknowledgement
Grand Celebration
Green
Yes
Grand Classica
Green
Yes
Walt Disney Company
Disney Cruise Line
Complete and accurate with signed acknowledgement
Disney Wonder
Green
Yes
MSC Cruise Management (UK) Limited
MSC Cruises
Complete and accurate with signed acknowledgement
MSC Armonia
Green
Yes
MSC Meraviglia
Green
Yes
MSC Preziosa
Green
Yes
MSC Seaside
Green
Yes
Norwegian
Cruise Line Holdings

NorwegianCruise Line
Complete and accurate with signed acknowledgement
Norwegian Gem
Green
Yes
Norwegian Jewel
Green
Yes
Pride of America
Green
Yes
Oceania Cruises
Complete and accurate with signed acknowledgement
Oceania Regatta
Green
Yes
Royal Caribbean Group
Celebrity Cruises
Complete and accurate with signed acknowledgement
Celebrity Apex
Green
Yes
Celebrity Eclipse
Green
Yes
Celebrity Edge
Green
Yes
Celebrity Equinox
Green
Yes
Celebrity Millennium
Green
Yes
Celebrity Reflection
Green
Yes
Celebrity Silhouette
Green
Yes
Celebrity Summit
Green
Yes
Royal Caribbean International
Complete and accurate with signed acknowledgement
Adventure of the Seas
Green
Yes
Brilliance of the Seas
Green
Yes
Enchantment of the Seas
Green
Yes
Freedom of the Seas
Green
Yes
Grandeur of the Seas
Red
No
Harmony of the Seas
Green
Yes
Independence of the Seas
Green
Yes
Liberty of the Seas
Green
Yes
Mariner of the Seas
Green
Yes
Navigator of the Seas
Green
Yes
Oasis of the Seas
Green
Yes
Rhapsody of the Seas
Green
Yes
Serenade of the Seas
Green
Yes
Symphony of the Seas
Green
Yes
Vision of the Seas
Green
Yes

*Provisionally Green: Ship meets the surveillance criteria for “Green” status, but the following have not been completed:
Review and revision of the cruise line’s No Sail Order response plan, or
Cruise line’s signed acknowledgement of a complete and accurate plan, or
Ship’s submission of a signed attestation to CDC for crew to travel commercially.
ⱽProvisionally Yellow: Ship meets the surveillance criteria for “Yellow” status, but the following have not been completed:
Review and revision of the cruise line’s No Sail Order response plan, or
Cruise line’s signed acknowledgement of a complete and accurate plan, or
Ship’s submission of a signed attestation to CDC for crew to travel commercially.
^Provisionally Red: Ship meets the surveillance criteria for “Red” status, but the following have not been completed:
Review and revision of the cruise line’s No Sail Order response plan, or
Cruise line’s signed acknowledgement of a complete and accurate plan.
¥Commercial Travel Allowed: Allowed for ships that are “Green” and have submitted a signed attestation to CDC for crew to travel commercially.
Note: The above list includes cruise ships operating in U.S. waters or seeking to operate in U.S. waters during the period of the No Sail Order extension.
Frequently Asked Questions
What does it mean for a cruise ship operator to have a plan that is complete and accurate?
A complete and accurate plan adequately addresses every element of the No Sail Order. A cruise ship operator must be in compliance with the No Sail Order, the operator’s No Sail Order response plan, and CDC’s Interim Guidance for Mitigation of COVID-19 Among Cruise Ship Crew During the Period of the No Sail Order. CDC assesses compliance through implementation checks on a sample of ships covered under a cruise ship operator’s plan. There must be no evidence of noncompliance.
What steps is CDC taking to make sure ships stay in compliance with the criteria for commercial transport of crew?
CDC will review weekly surveillance data provided by ships, and only those ships that continue to report no cases of COVID-19 or COVID-like illness will maintain this status.
What other changes can cruise ships make if they meet these criteria?
CDC is committed to helping cruise lines provide for the safety and well-being of their crew members onboard. As cruise ships are able to show they have no cases of confirmed COVID-19 or COVID-like illnesses on board, crew members will be able to resume some of their daily interactions with fellow crew members.
Some examples of decreased restrictions on cruise ships if they meet these criteria include resuming in-person meetings, events, and social gatherings; reopening bars, gyms, or other group settings onboard for crew member use; and removing requirements to wear face coverings.
What does it mean if a ship that was previously on the commercial travel list is no longer listed?
Ships may come off this list for a number of reasons, including if there are new cases of COVID-19 or COVID-like illness detected on the ship, if the ship engages in an unauthorized transfer of crew members, if the ship stops reporting weekly surveillance data, if the ship embarks passengers, or if the ship decides to leave U.S. waters for the remainder of the period of the No Sail Order.
What happens to cruise ships that have commercial travel planned if they are no longer on the list?
Ships that are not currently on the list are not permitted to make future bookings for commercial travel and are required to cancel any existing commercial travel tickets or itineraries.
What is the difference between the two attestations CDC requires under the No Sail Order?
Under the No Sail Order, cruise lines are required to develop and implement comprehensive plans to prevent, detect, respond to, and contain COVID-19 among crew members onboard. While these response plans have been under review, CDC has allowed cruise lines to disembark crew members if they submit a signed attestation stating they have complied with the requirements to safely disembark crew members. This attestation included a requirement that crew members only use noncommercial travel to disembark and reach their final destinations and do not interact with the public during travel.
Cruise lines that have a complete and accurate No Sail Order response plan may disembark crew members without a signed attestation if they use noncommercial travel and follow CDC requirements. Cruise company officials must sign an acknowledgment of the completeness and accuracy of their response plan. Cruise ships that want to use commercial travel for crew members must meet additional requirements, which include demonstrating there are no confirmed cases of COVID-19 or COVID-like illness on board and submitting a signed attestation for commercial travel.
What does it mean if a cruise line is not listed on the table above?
If a cruise line is not listed, it means the cruise line is not operating and does not plan to operate any of its ships in U.S. waters during the period of the No Sail Order.
What does it mean if a cruise ship is not listed on the table above?
If a cruise ship is not listed, it means the ship is not operating in U.S. waters and does not plan to operate in U.S. waters during the period of the No Sail Order.

Summary of Recent Changes
Below are changes to the guidance as of May 28, 2020:

This guidance applies to all pharmacy staff to minimize their risk of exposure to SARS-CoV-2 and reduce the risk for patients during the COVID-19 pandemic. As a vital part of the healthcare system, pharmacies play an important role in providing medicines, therapeutics, vaccines, and critical health services to the public. Ensuring continuous function of pharmacies during the COVID-19 pandemic is important. During the pandemic, pharmacy staff can minimize their risk of exposure to the virus that causes COVID-19 and reduce the risk for patients by using the principles of infection prevention and control and social distancing.
Implement universal use of face coverings
Individuals without coronavirus symptoms (“asymptomatic”) and those who eventually develop symptoms (“pre-symptomatic”) can transmit the virus to others before showing symptoms.  This means that the virus can spread between people interacting in close proximity—for example, speaking, coughing, or sneezing—even if those people are not exhibiting symptoms.
Everyone entering the pharmacy should wear a face covering for source control (i.e., to protect other people in case the person is infected), regardless of symptoms. CDC recommends persons entering public settings where other social distancing measures are difficult to maintain wear a cloth face covering, especially in areas of substantial community-based transmission. Cloth face coverings should not be placed on young children under age 2, anyone who has trouble breathing, or is unconscious, incapacitated or otherwise unable to remove the mask without assistance.
Pharmacists and pharmacy technicians should always wear a facemask while they are in the pharmacy for source control.
Medical or surgical facemasks are generally preferred over cloth face coverings for healthcare professionals (HCP) for source control. If there are shortages of facemasks, facemasks should be prioritized for HCP who need them for PPE. Cloth face coverings should NOT be worn instead of a respirator or facemask if more than source control is required.
Advise staff who are sick to stay home
Make sure that pharmacy staff who have fever or symptoms that may be due to COVID-19 stay home and away from the workplace until they have recovered. Ensure that sick leave policies are flexible, nonpunitive, and consistent with public health guidance and that employees are aware of and understand these policies.
Filling prescriptions
Although the actual process of preparing medications for dispensing is not a direct patient care activity, the other components of medication dispensing such as prescription intake, patient counseling, or patient education should be conducted in ways that maintain social distancing and minimize the risk of exposure for pharmacy staff and patients. In addition to following workplace guidance, pharmacy staff should:
Provide hand sanitizer containing at least 60% alcohol on counters for use by patients and have sufficient and easy access to soap and water or hand sanitizer for staff.
Encourage all prescribers to submit prescription orders via telephone or electronically. The pharmacy should develop procedures to avoid handling paper prescriptions, in accordance with appropriate state laws, regulations, or executive orders.
After a prescription has been prepared, the packaged medication can be placed on a counter for the patient to retrieve, instead of being directly handed to the patient. Other strategies to limit direct contact with patients include:
Avoid handling insurance or benefit cards. Instead, have the patient take a picture of the card for processing or read aloud the information that is needed (in a private location so other patients cannot hear).
Avoid touching objects that have been handled by patients. If transfer of items must occur, pharmacy staff should wash their hands afterwards with soap and water for at least 20 seconds or use an alcohol-based hand sanitizer containing at least 60% alcohol. They should always avoid touching their eyes, nose, or mouth with unwashed hands.

Encourage patients, especially those at increased risk of severe illness, to use alternate methods to pick-up medication. To decrease risk of exposure, patients who have an increased risk for severe illness due to COVID-19 may consider using:
Home delivery of medications
Curbside pickup
Drive-through services
Having someone else who is not at higher risk of severe illness pick up medications for them

Use strategies to minimize close contact between pharmacy staff and patients and between patients:
Use engineering controls where the patient and pharmacy staff interact, such as at the pharmacy counter, to minimize close contact:
Minimize physical contact with patients and between patients. Maintain social distancing (6 feet between individuals) for people entering the pharmacy as much as possible. Use signage/barriers and floor markers to instruct waiting patients to remain 6 feet back from the counter, from other patient interfaces, and from other patients and pharmacy staff.
To shield against droplets from coughs or sneezes, install a section of clear plastic at the patient contact area to provide barrier protection (e.g., plexiglass type material or clear plastic sheet). Configure with a pass-through opening at the bottom of the barrier for people to speak through or to provide pharmacy items.
For hard non-porous surfaces, clean with detergent or soap and water if the surfaces are visibly dirty prior to disinfectant application. Frequently clean and disinfect all patient service counters and patient contact areas. Clean and disinfect frequently touched objects and surfaces such as workstations, keyboards, telephones, and doorknobs.

Clean and disinfect self-serve blood pressure units between customers. These devices should be used in accordance with the manufacturer’s instructions.
Routine cleaning with soap and water will decrease how much of the virus is on surfaces, which reduces the risk of exposure.
Disinfection using EPA-approved disinfectants against COVID-19external icon can also help reduce the risk when used in accordance with the manufacturer’s instructions.
Post signage advising customers to wear masks during use and to wash their hands or use a hand sanitizer that contains at least 60% alcohol, both before and after using the blood pressure unit.

Discontinue the use of magazines and other shared items in pharmacy waiting areas. Ensure that the waiting area is cleaned regularly.
Promote the use of self-serve checkout registers and clean and disinfect them frequently. Encourage the use of and have hand sanitizer and disinfectant wipes available at register locations for use by patients.

Use administrative controls— such as protocols or changes to work practices, policies, or procedures — to keep staff and patients separated:
Promote social distancing by diverting as many patients as possible to drive-through windows, curbside pick-up, or home delivery, where feasible.
Large, outdoor signage asking pharmacy patients to use the drive-through window or call for curbside pick-up can be useful.
Include text or automated telephone messages that specifically ask sick patients to stay home and request home delivery or send a well family member or friend to pick up their medicine.

Limit the number of patients in the pharmacy at any given time to prevent crowding at the pharmacy counter or checkout areas beyond what can be managed by 6 ft distancing.
Pharmacists who are providing patients with chronic disease management services, medication management services, and other services that do not require face-to-face encounters should make every effort to use telephone, telehealth, or tele-pharmacy strategies.

Reduce risk during COVID-19 testing and other close-contact pharmacy care services
Pharmacies that are participating in public health testing for COVID-19 should communicate with local and state public health staff to determine how to operationalize and prioritize client testing. State and local health departments will inform pharmacies about procedures to collect, store, and ship specimens appropriately, including during afterhours or on weekends/holidays. Some pharmacies are including self-collection options.
In the “CDC Infection Prevention and Control Recommendations for Patients with Suspected or Confirmed Coronavirus Disease 2019 (COVID-19) in Healthcare Settings,” there is guidance for collecting respiratory specimens.
Pharmacy staff conducting COVID-19 testing and other close-contact patient care procedures that will likely elicit coughs or sneezes (e.g., influenza and strep testing) should be provided with appropriate PPE. Staff who use respirators must be familiar with proper use and follow a complete respiratory protection program that complies with OSHA Respiratory Protection standard (29 CFR 1910.134). Staff should receive training on the appropriate donning and doffing of PPE. Cloth face coverings should NOT be worn by staff instead of a respirator or facemask if more than source control is required.
Provide adult vaccinations based on local conditions
Evaluate provision of routine clinical preventive services, including adult vaccinations, that require face-to-face encounters. Based on local conditions, evaluate the risk of an in-person encounter versus the benefit using the Framework for Healthcare Systems Providing Non-COVID-19 Clinical Care During the COVID-19 Pandemic.
Adult vaccination should be considered if the service can be delivered during a visit with no additional risk to the patient or the health care provider.
Consideration should be given to prioritizing older adults or adults with underlying conditions for vaccination due to their increased risk of disease and complications if vaccination is deferred.
Pharmacies should develop a strategy for screening patients for fever and symptoms of COVID-19 prior to providing vaccinations.
Health care providers should follow standard precautions and adhere to additional PPE recommendations, including use of a facemask at all times while in the facility. Use of eye protection is recommended in areas with moderate to substantial community transmission. For areas with minimal to no community transmission, eye protection is considered optional, unless otherwise indicated as part of standard precautions.
Hand hygiene should be performed before and after vaccine administration. If gloves are worn, they should be changed and hand hygiene should be performed between patients.

For Clinics: Special considerations when co-located in pharmacies
Post signs at the door instructing clinic patients with fever, respiratory symptoms, or other symptoms of COVID-19 to return to their vehicles (or remain outside if pedestrians) and call the telephone number for the clinic so that triage can be performed before they enter the store.
It may be possible to manage patients with mild symptoms telephonically and send them home with instructions for care.

Facemasks or cloth face coverings should be provided for all clinic patients if they are not already wearing one, ideally prior to entering the clinic.
Where possible, provide separate entrances for all clinic patients. Otherwise create a clear path from the main door to the clinic, with partitions or other physical barriers (if feasible), to minimize contact with other customers.

The Centers for Disease Control and Prevention (CDC) is working closely with international partners to respond to the coronavirus disease (COVID-19) pandemic. CDC provides technical assistance to help other countries increase their ability to prevent, detect, and respond to health threats, including COVID-19.
This document is provided by CDC and is intended for use in non-U.S. healthcare settings.

If washing the body, shrouding, or other important religious or cultural practices are observed in a specific tribal community, families are encouraged to consider this guidance and work with their cultural and religious leaders and funeral home staff on how to reduce their exposure as much as possible.
If you participate in these activities, wear disposable gloves (nitrile, latex, or rubber). And you may need additional equipment (called personal protective equipment, or PPE). For example, you may need the following:
Disposable, waterproof isolation gown
Face shield or goggles
Facemask
Following preparation of the body remove PPE and throw away. Immediately wash your hands with soap and water for at least 20 seconds. If soap and water are not available, use a hand sanitizer that contains at least 60% alcohol.
Shower after completing body preparation activities. If you did not wear any personal protective equipment while preparing the body, wash your clothes in the warmest setting possible and dry them completely.
For more information see CDC resources on Cleaning and Disinfecting Your Facility or Cleaning and Disinfecting Your Home.