Routine Observation Periods during Movement Protocols
Routine observation periods can be used as part of intake, transfer, and/or release processes to minimize potential transmission to/from other facilities or the community during movement. These observation periods are sometimes referred to as “routine intake/transfer/release quarantine” but are not related to a potential exposure to someone with COVID-19 and should not be combined with post-exposure quarantine cohorts. Rather, they are periods where residents are housed separately from the rest of the facility’s population (ideally individually, or as small cohorts if individual housing is not possible or is not advisable due to mental health concerns).
As a strategy for everyday operations, correctional and detention facilities should implement screening testing OR a routine observation period for all residents at intake. The routine observation period option should only be used under the following scenarios: a) Residents under intake observation are housed individually, OR b) Residents under intake observation are housed in small cohorts due to mental health concerns associated with individual housing, and all cohort members begin the observation period on the same day and will be tested at the end of the observation period. Routine observation periods during transfer and/or release (or during intake if not already in place) can be added as enhanced prevention strategies.
Observation periods should be 7-10 days if the residents under observation are not tested at the end of the observation period. A shorter period (minimum of 5 days) could be used if combined with testing at the end of the observation period.
Medication to Prevent Severe Disease
As a strategy for everyday operations, correctional and detention facilities should maintain awareness of how to access medications to prevent severe COVID-19 in the resident population. Facilities without onsite healthcare capacity should maintain a plan to assess residents’ risk for severe health outcomes and to ensure timely access to treatment outside the facility.
The FDA has expanded EUAs for use of some investigational monoclonal antibody medications to prevent SARS-CoV-2 infection and severe health outcomes, including in correctional populations, under certain conditions. Refer to the National Institutes of Health website on Characteristics of SARS-CoV-2 Antibody-Based Products for details related to specific medications, including when they are recommended for use.
In addition, antiviral medications are available that are effective in preventing severe health outcomes in persons with COVID-19. The National Institute of Health COVID-19 Treatment Guidelines provide information about these medications and describe what is known about their effectiveness.
These medications can be ordered at no cost through the office of the Assistant Secretary for Preparedness and Response (ASPR) within the Department of Health and Human Services, from the manufacturer, or in some cases through facilities’ usual medication procurement mechanisms.
Medications are not a substitute for vaccination. Vaccination remains the best tool to prevent severe illness and death from COVID-19.
Medical Isolation and Quarantine
Isolation (for persons with suspected or confirmed COVID-19) and quarantine (for persons who have been exposed to someone with COVID-19) are strategies for everyday operations in correctional and detention facilities. The guidance below includes recommendations for modified isolation protocols during short-term periods of crisis-level operations, as well as modified quarantine approaches that can be considered based on a combination of factors including current COVID-19 Community Level, facility-level factors, and residents’ mental health.
Managing medical isolation and quarantine spaces
Have a plan in place to ensure that separate physical locations (dedicated housing areas and bathrooms) have been identified to:
- Medically isolate residents with suspected COVID-19 (ideally individually for short periods while awaiting test results)
- Medically isolate residents with confirmed COVID-19 (individually or as a cohort)
- Quarantine residents identified as close contacts of those with confirmed or suspected COVID-19 (ideally individually, but as a cohort if necessary. Note that when traditional contact tracing is not feasible, close contacts can be identified through location-based contact tracing.)
Note that facilities may determine that individual housing is not advisable in some situations due to mental health concerns. If close contacts are quarantined as a cohort, keep the number housed together as small as possible to minimize the risk of further transmission.
Manage medical isolation and quarantine units as follows to prevent further transmission:
- Keep residents’ movement outside the medical isolation/quarantine space to a minimum.
- Serve meals inside the medical isolation/quarantine space.
- Provide medical care inside the medical isolation/quarantine space, unless it is not physically possible to do so or if a resident needs to be transferred to a healthcare facility.
- Minimize shared air between medical isolation/quarantine spaces and other spaces within a building. Ventilation to/from the medical isolation/quarantine space should be separate from ventilation to other spaces within the same building. Air should flow from clean to less clean areas.
- Where possible, restrict medically isolated/quarantined residents from leaving the facility (including transfers to other facilities) during the medical isolation/quarantine period, unless released from custody or a transfer is necessary for medical care, infection control, lack of medical isolation/quarantine space, or extenuating correctional, judicial, or security concerns.
- Staff assignments to medical isolation/quarantine spaces should remain as consistent as possible, and these staff members should limit their movements to other parts of the facility. These staff members should wear recommended PPE appropriate for their level of contact with people under medical isolation/quarantine. See PPE section and Table 2.
- Clean and disinfect areas used by people with COVID-19 and their close contacts on an ongoing basis during medical isolation/quarantine.
Ensure that medical isolation and quarantine are operationally distinct from punitive segregation.
Because of limited individual housing spaces within many correctional and detention facilities, infected or exposed people are often placed in the same housing spaces that are used for administrative or disciplinary segregation. To encourage prompt reporting of COVID-19 symptoms and support mental health, ensure that medical isolation and quarantine are operationally distinct from administrative or disciplinary segregation, even if the same housing spaces are used for both. For example:
- As much as possible, provide similar access to radio, TV, reading materials, personal property, commissary, showers, and other resources as would be available in individuals’ regular housing units.
- As much as possible, allow residents to return to their previously assigned housing spaces after medical isolation/quarantine ends, if that is their preference.
- Ensure that staff understand that the same restrictions placed on residents in segregated housing when used for disciplinary reasons should not be applied to residents housed in the same spaces for COVID-19 related reasons.
- To support mental health, consider allowing increased telephone time or other opportunities to communicate with others outside the facility during the medical isolation or quarantine period.
- Communicate regularly with residents in medical isolation or quarantine about the duration and purpose.
Medical isolation during routine operations
Medical isolation for residents with suspected or confirmed COVID-19
Regardless of their vaccination and booster status, residents showing symptoms of COVID-19 (suspected COVID-19) or testing positive for SARS-CoV-2 (confirmed COVID-19) should wear a well-fitting cloth or disposable procedure mask or respirator and should be immediately placed under medical isolation and medically evaluated (including eligibility for COVID-19 therapeutics). Facilities without onsite healthcare capacity to medically evaluate and/or treat residents should have a plan in place to ensure that timely evaluation and treatment take place through an offsite medical facility, additional healthcare providers, or other means.
Clinical staff evaluating and providing care for people with confirmed or suspected COVID-19 should follow the CDC Interim Clinical Guidance for Management of Patients with Confirmed Coronavirus Disease (COVID-19), including wearing recommended PPE, and should monitor the guidance website regularly for updates to these recommendations.
Residents with suspected or confirmed COVID-19 should wear a well-fitting cloth or disposable procedure mask or respirator under the following circumstances:
- Immediately upon identification of symptoms or positive test, until placed in medical isolation
- Once in the medical isolation space, whenever another individual enters (unless the person entering a medical isolation space for confirmed COVID-19 also has confirmed COVID-19)
- If they leave the medical isolation space for any reason
Residents with suspected COVID-19 should be tested for SARS-CoV-2 and should ideally be housed individually while waiting for test results. If the resident’s SARS-CoV-2 test result is positive, they can be moved to cohorted medical isolation with other residents with confirmed COVID-19. If the resident’s test result is negative, they can return to their prior housing assignment unless they require further medical assessment or care or if they need to be quarantined as a close contact of someone with COVID-19.
Residents with confirmed COVID-19 may be housed in medical isolation as a cohort (rather than in single cells), even if they tested positive on different dates. Cohorting residents during medical isolation can mitigate some mental health concerns associated with individual medical isolation and can increase capacity for medical isolation during case surges. Considerations for cohorted medical isolation include:
- Only residents with a positive SARS-CoV-2 test result should be housed together as a cohort. Do not cohort those with confirmed COVID-19 together with those with suspected COVID-19, with close contacts of people with confirmed or suspected COVID-19, or with those with other illnesses.
- When choosing a space to cohort groups of residents with confirmed COVID-19, use a single, large, well-ventilated room with solid walls and a solid door that closes fully. Using a single room will conserve PPE and reduce the chance of cross-contamination across different parts of the facility.
Medical isolation can be discontinued based on the following criteria:
- Residents with asymptomatic infection – Medical isolation can end 10 days after the first positive test result (with Day 0 being the date their specimen was collected).
- Residents with mild or moderate, symptomatic illness – Medical isolation can end 10 days after symptom onset and after resolution of fever for at least 24 hours, without the use of fever-reducing medications, and with improvement of other symptoms. Loss of taste and smell can persist for weeks or months after recovery and need not delay end of isolation.
- Residents with severe illness – Medical isolation can end 10 days after symptom onset and after resolution of fever for at least 24 hours, without the use of fever-reducing medications, and with improvement of other symptoms. Extending duration to up to 20 days may be warranted.
- Residents who are moderately or severely immunocompromised – Medical isolation should extend to 20 or more days because these people can have a longer infectious period. Use a test-based strategy to end isolation, and consult with an infectious disease specialist to determine the appropriate duration.
See section below on recommended duration of medical isolation during short-term periods of crisis-level operations (e.g., severe staffing or space shortages).
Isolation for staff with COVID-19 symptoms or a positive test
Staff with COVID-19 symptoms should be excluded from work and advised to seek testing, regardless of their COVID-19 vaccination and booster status. Staff members with a positive test result (with or without symptoms) should be excluded from work for 10 days from the date when symptoms started, or from the date of the positive test if they do not have symptoms (with Day 0 being the date their specimen was collected). (However, staff may use CDC guidance for the general public for duration of isolation when they are not at work.) See section below on isolation duration for staff during crisis-level operations.
The same recommendations apply for access to the facility by visitors, vendors, and volunteers.
Because of the potential for rapid, widespread transmission of SARS-CoV-2 in congregate environments and evidence that infected people who are up to date on their COVID-19 vaccines can transmit the virus to others, CDC recommends maintaining 10-day isolation periods as much as possible for all infected residents and staff in correctional and detention facilities, regardless of their vaccination and booster status. (However, staff may use CDC guidance for the general public for duration of isolation when they are not at work.)
During crisis-level operations (examples below), facilities may need to consider short-term alternatives to the recommended 10-day isolation periods for staff and/or residents. Facilities should consult their state, local, tribal, or territorial department to discuss approaches that would meet their needs while maximizing infection control during these short-term periods.
Examples of crisis-level operation scenarios:
- Staffing shortages threaten to compromise the safety and security of the facility or the continuity of essential operations.
- There is insufficient space to medically isolate all residents who have been infected for the full 10-day period, and other options to increase space have been exhausted.
Once the period of crisis-level operations has passed, facilities should return to the recommendations for periods of routine operations (10 days for isolation for residents and staff). Facilities should ensure that both residents and staff understand that reduced isolation protocols are short-term, crisis-management tools and that the facility will return to the full 10-day isolation recommendations.
The following are guiding principles for reducing isolation periods during crisis-level operations:
- Reductions in isolation duration should be as minimal as possible to mitigate the crisis scenario.
- Decisions to shorten isolation duration should be made independently for staff and for residents, based on the specific resources that are constrained at the time.
- Before reducing isolation duration, consider alternatives (e.g., shifting from individual to cohorted medical isolation units for residents or reducing the resident population).
- Take into consideration the risk of transmission within the facility (e.g., layout) and the risk profile of the facility’s population and access to COVID-19 therapeutics to prevent severe illness.
- If crisis-level protocols allow infected staff to return to work before 10 days of isolation, the risk of transmission can be reduced by assigning them to work exclusively in medical isolation units or in assignments where they have minimal contact with others until day 10.
- If a facility shortens isolation duration, it is possible to incorporate a negative test result into these protocols (i.e., “test-out” strategies). The following factors are necessary for facilities to incorporate test-out strategies without compromising essential functions:
- Sufficient testing supplies and staff capacity to maintain recommended diagnostic testing and screening testing at intake (see section above on testing)
- Fast test turn-around time to inform timely decision-making
- Sufficient staff capacity to continue to prioritize care and treatment for residents at high risk for severe COVID-19
Standard quarantine approach
Quarantine for close contacts of those with confirmed or suspected COVID-19
The most stringent form of quarantine, with the lowest risk of transmission, is to individually quarantine all residents who have been in close contact with someone with confirmed or suspected COVID-19 for 10 days from the date of the last exposure, regardless of their vaccination and booster status. Note that when traditional contact tracing is not feasible, close contacts can be determined through location-based contact tracing.
Movement outside the quarantine space should be kept to a minimum. All quarantined residents should receive an initial diagnostic test as soon as possible after identification as a close contact (but not within the first 24 hours after a known exposure, because a test is unlikely to be positive that quickly) and should be monitored for symptoms once per day. Residents who are more likely to get very sick from COVID-19 should also be evaluated for eligibility for COVID-19 therapeutics to prevent severe outcomes. If a resident develops symptoms, follow procedures detailed above for medical isolation of people with suspected COVID-19.
If the initial test result is negative, the resident should receive a second diagnostic test at least 5 days after the close contact in order to facilitate early identification of a potential infection to prevent severe outcomes. (If the initial test was performed at least 5 days after the close contact, a second test is not needed.) Day 0 is the date of last exposure/close contact.
Quarantined residents can be released from quarantine restrictions if they remain asymptomatic and have not tested positive for SARS-CoV-2 during the 10 days since their last potential exposure or known close contact with someone with confirmed or suspected COVID-19.
Residents who have been exposed to someone with COVID-19 should wear a well-fitting cloth or disposable procedure mask or respirator under the following circumstances:
- Immediately upon identification as a close contact of someone with COVID-19 (if not already in a quarantine space)
- When another individual enters a quarantine space that is occupied by a single resident
- When quarantined residents are housed as a cohort
- If a resident under quarantine leaves the quarantine space for any reason
Considerations for Cohorted Quarantine
Ideally, facilities should individually quarantine close contacts of persons with confirmed or suspected COVID-19, unless mental health concerns preclude individual housing. Cohorting multiple quarantined close contacts could result in further transmission. If cohorted quarantine is necessary, reduce transmission risk by selecting housing spaces for quarantine that:
- Are well ventilated
- Minimize the number of residents sharing the housing space
- Maximize the physical distance between residents sharing the housing space
- Are physically separated (i.e., solid walls and solid doors) from non-quarantine spaces
If cohorting close contacts is necessary, be especially mindful of those who are more likely to get very sick from COVID-19. Ideally, they would not be cohorted with other quarantined residents, to reduce their chance of infection. If cohorting is unavoidable, make all possible accommodations to reduce exposure for residents who are more likely to get very sick from COVID-19.
In addition, consider possible co-infection with other respiratory illnesses, such as influenza, in quarantine decisions. Individual quarantine is recommended for residents with co-infection.
Serial testing for cohorted quarantine. If quarantine cohorts are used, transmission may continue if some members of the cohort have an unrecognized infection. Serial testing of the entire quarantined cohort, regardless of their vaccination and booster status, can identify additional infections early and prevent continued transmission. When the transmissibility of circulating SARS-CoV-2 variant(s) is high, serial testing may be challenging to implement because of reduced staffing levels and/or large numbers of residents in cohorted quarantine. In such situations, facilities may choose to prioritize serial testing primarily when the circulating SARS-CoV-2 variant(s) also causes high rates of severe illness, with a focus on identifying infections early to prevent severe health outcomes. Facilities with a low risk tolerance may consider using serial testing in quarantine cohorts more routinely.
- To implement serial testing, re-test people quarantined as a cohort every 3–7 days until testing identifies no new cases in the cohort for 10 days since the most recent positive result. The testing interval should be based on the stage of an ongoing outbreak (i.e., testing every 3 days can allow for faster outbreak control in the context of an escalating outbreak; testing every 5–7 days may be sufficient when transmission has slowed). In addition, continue diagnostic testing for residents with symptoms.
- Anyone testing positive should be removed from the cohort, placed in medical isolation, and the 10-day quarantine period should re-start for the remainder of the cohort.
Quarantine for staff members
All staff members who have been potentially exposed or identified as a close contact to someone with COVID-19 should be advised to seek testing. If the test result is positive, staff members should be excluded from work for 10 days from the date when symptoms began, or from the date of the positive test if they do not have symptoms (with Day 0 being the date their specimen was collected).
Staff members should quarantine if their test result is negative. The quarantine approach with the lowest risk of transmission to residents and staff in the facility is to exclude exposed staff from work for 10 days after their last exposure, regardless of their vaccination and booster status. (However, staff may use the CDC guidance for the general public for duration of quarantine when they are not at work.) See section below on modified quarantine approaches that could be applied to staff.
The same recommendations apply for access to the facility by visitors, vendors, and volunteers.
Modified quarantine approaches
Because of the potential for rapid, widespread transmission of SARS-CoV-2 in congregate environments and evidence that infected people who are up to date on their COVID-19 vaccines can transmit the virus to others, CDC recommends maintaining 10-day quarantine periods as much as possible for all residents and staff in correctional and detention facilities who have been potentially exposed or come into close contact with someone with COVID-19, regardless of their vaccination and booster status. However, quarantine protocols for residents and/or staff may need to be modified in some facilities to balance the risks of severe disease from COVID-19 and the impact of prolonged quarantine on residents’ mental health, or to adapt to changes in disease severity and transmissibility from different SARS-CoV-2 variants. Quarantine protocols for staff may also need to be modified during case surges to ensure adequate staff coverage to maintain safety, security, and essential services in the facility.
Quarantine can be very disruptive to the daily lives of residents because of the limitations it places on access to programming, recreation, in-person visitation, in-person learning, and other services. These challenges are especially pronounced when residents must be quarantined as cohorts, because quarantine periods can become prolonged due to continued transmission. In addition, recommended serial testing every 3–7 days during cohorted quarantine has been difficult for facilities to accomplish during large outbreaks when testing and staffing resources have been strained.
Table 3 presents a range of modified quarantine approaches that can be considered for residents and/or staff, with variations in duration, testing, movement, and monitoring strategies. When choosing among these approaches, facilities should consider the current COVID-19 Community Level (which incorporates both transmission and disease severity for currently circulating variants) in combination with facility-level factors and what is known about the incubation period of the variants circulating at the time. During times when risk tolerance is low (e.g., when disease severity is high), facilities should choose lower risk strategies.