In response to the COVID-19 pandemic in the United States, in March, 2020, CDC recommended that dental settings should prioritize urgent and emergency visits* and delay elective visits and procedures to protect staff and preserve personal protective equipment and patient care supplies, as well as expand available hospital capacity. However, as the pandemic continues to evolve, and healthcare settings are responding to unique situations in their communities, CDC recognizes that dental settings may also need to deliver non-emergency dental care. Dental settings should balance the need to provide necessary services while minimizing risk to patients and dental healthcare personnel (DHCP)†. CDC has developed a framework for healthcare personnel and healthcare systems for delivery of non-emergent care during the COVID-19 pandemic. DHCP should regularly consult their state dental boards and state or local health departments for current local information for requirements specific to their jurisdictions, including recognizing the degree of community transmission and impact, and their region-specific recommendations.
Transmission: SARS-CoV-2, the virus that causes COVID-19, is thought to be spread primarily through respiratory droplets when an infected person coughs, sneezes, or talks. Airborne transmission from person-to-person over long distances is unlikely. However, COVID-19 is a new disease, and we are still learning about how it spreads and the severity of illness it causes. The virus has been shown to persist in aerosols for hours, and on some surfaces for days under laboratory conditions. COVID-19 may be spread by people who are not showing symptoms.
Risk: The practice of dentistry involves the use of rotary dental and surgical instruments, such as handpieces or ultrasonic scalers and air-water syringes. These instruments create a visible spray that can contain particle droplets of water, saliva, blood, microorganisms, and other debris. Surgical masks protect mucous membranes of the mouth and nose from droplet spatter, but they do not provide complete protection against inhalation of airborne infectious agents. There are currently no data available to assess the risk of SARS-CoV-2 transmission during dental practice. To date in the United States, clusters of healthcare personnel who have tested positive for COVID-19 have been identified in hospital settings and long-term care facilities, but no clusters have yet been reported in dental settings or among DHCP.1,2
*The urgency of a procedure is a decision based on clinical judgement and should be made on a case-by-case basis. See the American Dental Association: What Constitutes a Dental Emergencypdf iconexternal icon.
†Dental healthcare personnel (DHCP) refers to all paid and unpaid persons serving in dental healthcare settings who have the potential for direct or indirect exposure to patients or infectious materials, including:
- body substances
- contaminated medical supplies, devices, and equipment
- contaminated environmental surfaces
- contaminated air
DHCP should apply the guidance found in the Framework for Healthcare Systems Providing Non-COVID-19 Clinical Care During the COVID-19 Pandemic to determine how and when to resume non-emergency dental care. DHCP should stay informed and regularly consult with the state or local health department for region-specific information and recommendations. Monitor trends in local case counts and deaths, especially for populations at higher risk for severe illness.
Regardless of the degree of community spread, continue to practice universal source control and actively screen for fever and symptoms of COVID-19 for all people who enter the dental facility. If patients do not exhibit symptoms consistent with COVID-19, provide dental treatment only after you have assessed the patient and considered both the risk to the patient of deferring care and the risk to DHCP of healthcare-associated disease transmission. Ensure that you have the appropriate amount of personal protective equipment (PPE) and supplies to support your patient volume. If PPE and supplies are limited, prioritize dental care for the highest need, most vulnerable patients first.
If your community is experiencing no transmission or minimal community transmission*, dental care can be provided to patients without suspected or confirmed COVID-19 using strict adherence to Standard Precautions. However, given that patients may be able to spread the virus while pre-symptomatic or asymptomatic, it is recommended that DHCP practice according to the below considerations whenever feasible. Because transmission patterns can change, DHCP should stay updated about local transmission trends.
If your community is experiencing minimal to moderate† or substantial transmission‡, dental care can be provided to patients without suspected or confirmed COVID-19 using the below considerations to protect both DHCP and patients and prevent the spread of COVID-19 in dental facilities.
Considerations for additional precautions or strategies for treating patients with suspected or confirmed COVID-19 are also included below.
*No to minimal community transmission is defined as evidence of isolated cases or limited community transmission, case investigations underway; no evidence of exposure in large communal setting.
†Minimal to moderate community transmission is defined as sustained transmission with high likelihood or confirmed exposure within communal settings and potential for rapid increase in cases.
‡Substantial community transmission is defined as large scale community transmission, including communal settings (e.g., schools, workplaces).
- Contact all patients prior to dental treatment.
- Telephone screen all patients for symptoms consistent with COVID-19. If the patient reports symptoms of COVID-19, avoid non-emergent dental care. If possible, delay dental care until the patient has recovered.
- Telephone triage all patients in need of dental care. Assess the patient’s dental condition and determine whether the patient needs to be seen in the dental setting. Use teledentistry options as alternatives to in-office care.
- Request that the patient limit the number of visitors accompanying the patient to the dental appointment to only those people who are necessary.
- Advise patients that they, and anyone accompanying them to the appointment, will be requested to wear a face covering when entering the facility and will undergo screening for fever and symptoms consistent with COVID-19.
- Systematically assess all patients and visitors upon arrival.
- Ensure that the patient and visitors have donned their own face covering, or provide a surgical mask if supplies are adequate.
- Ask about the presence of fever or other symptoms consistent with COVID-19.
- Actively take the patient’s temperature.
- If the patient is afebrile (temperature < 100.4˚F)* and otherwise without symptoms consistent with COVID-19, then dental care may be provided using appropriate engineering and administrative controls, work practices, and infection control considerations (described below).
- Ask patient to re-don their face covering at the completion of their clinical dental care when they leave the treatment area.
- Even when DHCP screen patients for respiratory infections, inadvertent treatment of a dental patient who is later confirmed to have COVID-19 may occur. To address this, DHCP should request that the patient inform the dental clinic if they develop symptoms or are diagnosed with COVID-19 within 14 days following the dental appointment.
*For the general population, fever is measured as a temperature ≥100.4˚F. Fever may be subjective or confirmed. If the patient has a fever strongly associated with a dental diagnosis (e.g., pulpal and periapical dental pain and intraoral swelling is present), but no other symptoms consistent with COVID-19 are present, care can be provided with appropriate protocols.
- Take steps to ensure patients and staff adhere to respiratory hygiene and cough etiquette, as well as hand hygiene, and all patients follow triage procedures throughout the duration of the visit.
- Post visual alertspdf icon (e.g., signs, posters) at the entrance and in strategic places (e.g., waiting areas, elevators, break rooms) to provide instructions (in appropriate languages) about hand hygiene and respiratory hygiene and cough etiquette. Instructions should include 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 rub (ABHR) with 60– 95% alcohol, tissues, and no-touch receptacles for disposal, at healthcare facility entrances, waiting rooms, and patient check-ins.
- Install physical barriers (e.g., glass or plastic windows) at reception areas to limit close contact between triage personnel and potentially infectious patients.
- Place chairs in the waiting room at least six feet apart.
- Remove toys, magazines, and other frequently touched objects that cannot be regularly cleaned or disinfected from waiting areas.
- Minimize the number of persons waiting in the waiting room.
- Patients may opt to wait in a personal vehicle or outside the dental facility where they can be contacted by mobile phone when it is their turn for dental care.
- Minimize overlapping dental appointments.
- After a period of non-use, dental equipment may require maintenance and/or repair. Review the manufacturer’s instructions for use (IFU) for office closure, period of non-use, and reopening for all equipment and devices. Some considerations include:
- Dental unit waterlines (DUWL):
- Test water quality to ensure it meets standards for safe drinking water as established by the Environmental Protection Agency (< 500 CFU/mL) prior to expanding dental care practices.
- Confer with the manufacturer regarding recommendations for need to shock DUWL of any devices and products that deliver water used for dental procedures.
- Continue standard maintenance and monitoring of DUWL according to the IFUs of the dental operatory unit and the DUWL treatment products.
- Autoclaves and instrument cleaning equipment
- Ensure that all routine cleaning and maintenance has been performed according to the schedule recommended per manufacturer’s IFU.
- Test sterilizers using a biological indicator with a matching control (i.e., biological indicator and control from same lot number) after a period of non-use prior to reopening per manufacturer’s IFU.
- Air compressor, vacuum and suction lines, radiography equipment, high-tech equipment, amalgam separators, and other dental equipment: Follow protocol for storage and recommended maintenance per manufacturer IFU.
- Dental unit waterlines (DUWL):
- For additional guidance on reopening buildings, see CDC’s Guidance for Reopening Buildings After Prolonged Shutdown or Reduced Operation.
Administrative Controls and Work Practices
- DHCP should limit clinical care to one patient at a time whenever possible.
- Set up operatories so that only the clean or sterile supplies and instruments needed for the dental procedure are readily accessible. All other supplies and instruments should be in covered storage, such as drawers and cabinets, and away from potential contamination. Any supplies and equipment that are exposed but not used during the procedure should be considered contaminated and should be disposed of or reprocessed properly after completion of the procedure.
- Avoid aerosol-generating procedures whenever possible. Avoid the use of dental handpieces and the air/water syringe. Use of ultrasonic scalers is not recommended. Prioritize minimally invasive/atraumatic restorative techniques (hand instruments only).
- If aerosol-generating procedures are necessary for dental care, use four-handed dentistry, high evacuation suction and dental dams to minimize droplet spatter and aerosols. The number of DHCP present during the procedure should be limited to only those essential for patient care and procedure support.
- Preprocedural mouth rinses (PPMR)
- There is no published evidence regarding the clinical effectiveness of PPMRs to reduce SARS-CoV-2 viral loads or to prevent transmission. Although COVID-19 was not studied, PPMRs with an antimicrobial product (chlorhexidine gluconate, essential oils, povidone-iodine or cetylpyridinium chloride) may reduce the level of oral microorganisms in aerosols and spatter generated during dental procedures.
- Properly maintain ventilation systems.
- Ventilation systems that provide air movement from a clean (DHCP workstation or area) to contaminated (clinical patient care area) flow direction should be installed and properly maintained. Providing supply air only in the receptionist area with return air louvers positioned in the waiting area will help to achieve this effect.
- Consult a heating, ventilation and air conditioning (HVAC) professional to investigate increasing filtration efficiency to the highest level compatible with the HVAC system without significant deviation from designed airflow.
- Consult a HVAC professional to investigate the ability to safely increase the percentage of outdoor air supplied through the HVAC system (requires compatibility with equipment capacity and environmental conditions).
- Limit the use of demand-controlled ventilation (triggered by temperature setpoint and/or by occupancy controls) during occupied hours and when feasible, up to two hours post occupancy to assure that ventilation does not automatically change. Run bathroom exhaust fans continuously during business hours.
- Consider the use of a portable HEPA air filtration unit while the patient is actively undergoing, and immediately following, an aerosol-generating procedure.
- The use of these units will reduce particle count (including droplets) in the room and will reduce the amount of turnover time, rather than just relying on the building HVAC system capacity.
- Place HEPA unit within vicinity of patient’s chair, but not behind DHCP. Ensure DHCP are not positioned between the unit and the patient’s mouth. Position the unit to ensure that it does not pull air into or past the breathing zone of the DHCP.
- Consider the use of upper-room ultraviolet germicidal irradiation (UVGI) as an adjunct to higher ventilation and air cleaning rates.
- Patient placement
- Ideally, dental treatment should be provided in individual patient rooms whenever possible.
- For dental facilities with open floor plans, to prevent the spread of pathogens there should be:
- At least 6 feet of space between patient chairs.
- Physical barriers between patient chairs. Easy-to-clean floor-to-ceiling barriers will enhance effectiveness of portable HEPA air filtration systems (check to make sure extending barriers to ceiling will not interfere with fire sprinkler systems).
- Operatories should be oriented parallel to the direction of airflow if possible.
- Where feasible, consider patient orientation carefully, placing the patient’s head near the return air vents, away from pedestrian corridors, and towards the rear wall when using vestibule-type office layouts.
- Patient volume
- Determine the maximum number of patients who can safely receive care at the same time in the dental facility, based on the number of rooms, the layout of the facility, and the time needed to clean and disinfect patient operatories*.
*To allow time for droplets to sufficiently fall from the air after a dental procedure, DHCP should wait at least 15 minutes after the completion of dental treatment and departure of the patient to begin the room cleaning and disinfection process.3
Ensure DHCP practice strict adherence to hand hygiene, including
- Before and after all patient contact, contact with potentially infectious material, and before putting on and after removing personal protective equipment (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.
- Use ABHR with 60-95% alcohol or wash hands with soap and water for at least 20 seconds. If hands are visibly soiled, use soap and water before returning to ABHR.
- Dental healthcare facilities should ensure that hand hygiene supplies are readily available to all DHCP in every care location.
Universal Source Control
As part of source control efforts, DHCP should wear a facemask at all times while they are in the dental setting.
- When available, surgical masks are preferred over cloth face coverings for DHCP; surgical masks offer both source control and protection for the wearer against exposure to splashes and sprays of infectious material from others.
- Cloth face coverings should NOT be worn instead of a respirator or facemask if more than source control is required, as cloth face coverings are not PPE.
- Some DHCP whose job duties do not require PPE (such as clerical personnel) may continue to wear their cloth face covering for source control while in the dental setting.
- Other DHCP (such as dentists, dental hygienists, dental assistants) may wear their cloth face covering when they are not engaged in direct patient care activities, and then switch to a respirator or a surgical mask when PPE is required.
- DHCP should remove their respirator or surgical mask and put on their cloth face covering when leaving the facility at the end of their shift.
- DHCP should also be instructed that if they must touch or adjust their mask or cloth face covering, they should perform hand hygiene immediately before and after.
Because facemasks and cloth face coverings can become saturated with respiratory secretions, DHCP should take steps to prevent self-contamination:
- DHCP should change facemasks and coverings if they become soiled, damp, or hard to breathe through.
- Cloth face coverings should be laundered daily and when soiled.
- DHCP should perform hand hygiene immediately before and after any contact with the facemask or cloth face covering.
- Dental facilities should provide DHCP with training about when, how, and where cloth face coverings can be used, including frequency of laundering, guidance on when to replace them, circumstances when they can be worn in the facility, and the importance of hand hygiene to prevent contamination.
Using Personal Protective Equipment (PPE)
Employers should select appropriate PPE and provide it to DHCP in accordance with Occupational Safety and Health Administration PPE standards (29 CFR 1910 Subpart I)external icon. DHCP 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.
Dental facilities must ensure that any reusable PPE is properly cleaned, decontaminated, and maintained after and between uses. Dental settings also should have policies and procedures describing a recommended sequence for safely donning and doffing PPE.
DHCP should wear a surgical mask, eye protection (goggles, protective eyewear with solid side shields, or a full-face shield), and a gown or protective clothing during procedures likely to generate splashing or spattering of blood or other body fluids.
During aerosol-generating procedures conducted on patients assumed to be non-contagious, consider the use of an N95 respirator* or a respirator that offers a higher level of protection such as other disposable filtering facepiece respirators, PAPRs, or elastomeric respirators, if available. Respirators should be used in the context of a respiratory protection program, which includes medical evaluations, training, and fit testing. Of note, it is uncertain if respirators with exhalation valves provide source control. If a respirator is not available for an aerosol-generating procedure, use both a surgical mask and a full-face shield. Ensure that the mask is cleared by the US Food and Drug Administration (FDA) as a surgical maskexternal icon. Use the highest level of surgical maskpdf iconexternal icon available. If a surgical mask and a full-face shield are not available, do not perform any aerosol-generating procedures.
There are multiple sequences recommended for donning and doffing PPE. One suggested sequence for DHCP includes:
- Before entering a patient room or care area:
- Perform hand hygiene.
- Put on a clean gown or protective clothing that covers personal clothing and skin (e.g., forearms) likely to be soiled with blood, saliva, or other potentially infectious materials.
- Gowns and protective clothing should be changed if they become soiled.
- Put on a surgical mask or respirator.
- Mask ties should be secured on the crown of the head (top tie) and the base of the neck (bottom tie). If mask has loops, hook them appropriately around your ears.
- Respirator straps should be placed on the crown of the head (top strap) and the base of the neck (bottom strap). Perform a user seal check each time you put on the respirator.
- Put on eye protection.
- Personal eyeglasses and contact lenses are NOT considered adequate eye protection.
- Perform hand hygiene.
- Put on clean non-sterile gloves.
- Gloves should be changed if they become torn or heavily contaminated.
- Enter the patient room.
- After completion of dental care:
- Remove gloves.
- Remove gown or protective clothing and discard the gown in a dedicated container for waste or linen.
- Discard disposable gowns after each use.
- Launder cloth gowns or protective clothing after each use.
- Exit the patient room or care area.
- Perform hand hygiene.
- Remove eye protection.
- Carefully remove eye protection by grabbing the strap and pulling upwards and away from head. Do not touch the front of the eye protection.
- Clean and disinfect reusable eye protection according to manufacturer’s reprocessing instructions prior to reuse.
- Discard disposable eye protection after use.
- Remove and discard surgical mask or respirator†.
- Do not touch the front of the respirator or mask.
- Surgical mask: Carefully untie the mask (or unhook from the ears) and pull it away from the face without touching the front.
- Respirator: Remove the bottom strap by touching only the strap and bring it carefully over the head. Grasp the top strap and bring it carefully over the head, and then pull the respirator away from the face without touching the front of the respirator.
- Perform hand hygiene.
PPE Optimization Strategies
Major distributors in the United States have reported shortages of PPE, especially surgical masks and respirators. The anticipated timeline for return to routine levels of PPE is not yet known. CDC has developed a series of strategies or options to optimize supplies of PPE in healthcare settings when there is limited supply, and a burn rate calculator that provides information for healthcare facilities to plan and optimize the use of PPE for response to the COVID-19 pandemic. Optimization strategies are provided for gloves, gowns, facemasks, eye protection, and respirators.
These policies are only intended to remain in effect during times of shortages during the COVID-19 pandemic. DHCP should review this guidance carefully, as it is based on a set of tiered recommendations. Strategies should be implemented sequentially. Decisions by facilities to move to contingency and crisis capacity strategies are based on the following assumptions:
- Facilities understand their current PPE inventory and supply chain;
- Facilities understand their PPE utilization rate;
- Facilities are in communication with local healthcare coalitions and federal, state, and local public health partners (e.g., public health emergency preparedness and response staff) regarding identification of additional supplies;
- Facilities have already implemented engineering and administrative control measures;
- Facilities have provided DHCP with required education and training, including having them demonstrate competency with donning and doffing, with any PPE ensemble that is used to perform job responsibilities, such as provision of patient care.
For example, extended use of facemasks and respirators should only be undertaken when the facility is at contingency or crisis capacity and has reasonably implemented all applicable administrative and engineering controls. Such controls include selectively canceling elective and non-urgent procedures and appointments for which PPE is typically used by DHCP. Extended use of PPE is not intended to encourage dental facilities to practice at a normal patient volume during a PPE shortage, but only to be implemented in the short term when other controls have been exhausted. Once the supply of PPE has increased, facilities should return to standard procedures.
Respirators that comply with international standards may be considered during times of known shortages. CDC has guidance entitled Factors to Consider When Planning to Purchase Respirators from Another Country which includes a webinar, and Assessments of International 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 CDC/National Institute for Occupational Safety and Health (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). DHCP 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.
†Facilities implementing reuse or extended use of PPE will need to adjust their donning and doffing procedures to accommodate those practices (see PPE Optimization Strategies).
Environmental Infection Control
- DHCP should ensure that environmental cleaning and disinfection procedures are followed consistently and correctly after each patient (however, it is not necessary that DHCP should attempt to sterilize a dental operatory between patients).
- To clean and disinfect the dental operatory after a patient without suspected or confirmed COVID-19, wait 15 minutes after completion of clinical care and exit of each patient to begin to clean and disinfect room surfaces. This time will allow for droplets to sufficiently fall from the air after a dental procedure, and then be disinfected properly.3
- Routine cleaning and disinfection procedures (e.g., using cleaners and water to clean surfaces before applying an Environmental Protection Agency-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.
- Alternative disinfection methods
- The efficacy of alternative disinfection methods, such as ultrasonic waves, high intensity UV radiation, and LED blue light against COVID-19 virus is not known. EPA does not routinely review the safety or efficacy of pesticidal devices, such as UV lights, LED lights, or ultrasonic devices. Therefore, EPA cannot confirm whether, or under what circumstances, such products might be effective against the spread of COVID-19.
- CDC does not recommend the use of sanitizing tunnels. There is no evidence that they are effective in reducing the spread of COVID-19. Chemicals used in sanitizing tunnels could cause skin, eye, or respiratory irritation or damage.
- EPA only recommends use of the surface disinfectants identified on List Nexternal icon against the virus that causes COVID-19.
- Manage laundry and medical waste in accordance with routine policies and procedures.
Sterilization and Disinfection of Patient-Care Items
- Sterilization protocols do not vary for respiratory pathogens. DHCP should perform routine cleaning, disinfection, and sterilization protocols, and follow the recommendations for Sterilization and Disinfection of Patient-Care Items present in the Guidelines for Infection Control in Dental Health Care Settings – 2003pdf icon.
- DHCP should follow the manufacturer’s instructions for times and temperatures recommended for sterilization of specific dental devices.
Considerations for Additional Precautions or Strategies for Treating Patients with Suspected or Confirmed COVID-19
- If a patient arrives at your facility and is suspected or confirmed to have COVID-19, defer dental treatment and take the following actions:
- If the patient is not already wearing a mask, give the patient a mask to cover his or her nose and mouth.
- If the patient is not acutely sick, send the patient home, and instruct the patient to call their primary care provider.
- If the patient is acutely sick (for example, has trouble breathing), refer the patient to a medical facility, or call 911 as needed and inform them that the patient may have COVID-19.
- If emergency dental care is medically necessary for a patient who has, or is suspected of having, COVID-19, DHCP should follow CDC’s Interim Infection Prevention and Control Recommendations for Patients with Suspected or Confirmed Coronavirus Disease 2019 (COVID-19) in Healthcare Settings, including the use of PPE.
- Dental treatment should be provided in an individual patient room with a closed door.
- Avoid aerosol-generating procedures (e.g., use of dental handpieces, air/water syringe, ultrasonic scalers) if possible.
- If aerosol-generating procedures must be performed, take precautions.
- DHCP in the room should wear an N95 or higher-level respirator, such as disposable filtering facepiece respirator, powered air-purifying respirator (PAPR), or elastomeric respirator, as well as eye protection (goggles or a full-face shield), gloves, and a gown.
- The number of DHCP 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.
- Aerosol-generating procedures should ideally take place in an airborne infection isolation room.
- Consider scheduling the patient at the end of the day.
- Do not schedule any other patients at that time.
- People with COVID-19 who have ended home isolation can receive dental care following Standard Precautions.
Considerations for Use of Test-Based Strategies to Inform Patient Care
In the context of COVID-19, some infected individuals might not be identified based on clinical signs and symptoms.
Facilities could consider using a tiered approach to universal PPE based on the level of transmission in the community. In areas where there is moderate to substantial community transmission, this includes consideration for DHCP for wearing an N95 or higher-level respirator for patients undergoing procedures that might pose higher risk (e.g., those generating potentially infectious aerosols or involving anatomic regions where viral loads might be higher).
Depending on testing availability and how rapidly results are available, facilities can also consider implementing pre-admission or pre-procedure testing for COVID-19, which might inform implementation of PPE use as described above, especially in the situation of PPE shortages. However, limitations of this approach should be considered, including negative results from patients during their incubation period who could become infectious later, and false negative tests depending on the test method used.
Monitor and Manage Dental Health Care Personnel
- Implement sick leave policies for DHCP that are flexible, non-punitive, and consistent with public health guidance.
- As part of routine practice, DHCP should be asked to regularly monitor themselves for fever and symptoms consistent with COVID-19.
- DHCP should be reminded to stay home when they are ill and should receive no penalties when needing to stay home when ill or under quarantine.
- If DHCP develop fever (T≥100.0˚F) or symptoms consistent with COVID-19 while at work, they should keep their cloth face covering or facemask on, inform their supervisor, and leave the workplace.
- Screen all DHCP at the beginning of their shift for fever and symptoms consistent with COVID-19*.
- Actively measure their temperature and document absence of symptoms consistent with COVID-19.
- Clinical judgement should be used to guide testing of individuals in such situations.
- Medical evaluation may be warranted for lower temperatures (<100.0˚F) or other symptoms based on assessment by occupational health personnel. Additional information about clinical presentation of patients with COVID-19 is available.
- If DHCP experience a potential work exposure to COVID-19, follow CDC’s Healthcare Personnel with Potential Exposure Guidance.
- If DHCP suspect they have COVID-19:
- For information on work restrictions for health care personnel with underlying health conditions who may care for COVID-19 patients, see CDC’s FAQ.
*For DHCP, fever is either measured temperature ≥100.0˚F or subjective fever. Note that fever may be intermittent or may not be present in some individuals, such as those who are elderly, immunosuppressed, or taking certain medications (e.g., NSAIDs).
Education and Training
- Provide DHCP with job- or task-specific education and training on preventing transmission of infectious agents, including refresher training.
- Ensure that DHCP are educated, trained, and have practiced the appropriate use of PPE prior to caring for a patient, including attention to correct use of PPE and prevention of contamination of clothing, skin, and the environment during the process of removing such equipment.
Global COVID-19 Deaths Top 3 Million
Global deaths from COVID-19 has surpassed 3 million, according to the latest data from John Hopkins University.
Leading in those deaths are the United States, with more than 566,000, and Brazil, with more than 368,000. They are followed by Mexico, India and the United Kingdom.
The global death toll reached 1 million in September 2020 and 2 million in January.
The grim milestone comes after health officials in the U.S. paused rollout of the single-dose Johnson & Johnson vaccine after six women experienced rare but severe blood clots a week or two after receiving it.
Overall, more than 129 million people in the U.S. have received at least one dose of COVID-19 vaccine, including 7.8 million doses of the J&J vaccine. More than 82 million Americans — nearly 25% of the population — have been fully vaccinated.
In Brazil, deaths have topped 3,000 per day as the country is ravaged by the virus. Mexico has recorded more than 211,000 deaths. India has had more than 175,000 deaths and deaths in the United Kingdom have topped 127,000.
COVID-19 variants are spreading throughout the U.S., with the more contagious U.K. variant, B.1.1.7, now dominant. On Friday, the Biden administration announced plans to spend $1.7 billion on combating and tracking variants.
KFF COVID-19 Vaccine Monitor: What We’ve Learned
The KFF COVID-19 Vaccine Monitor is an ongoing research project tracking the public’s attitudes and experiences with COVID-19 vaccinations. Using a combination of surveys and qualitative research, this project tracks the dynamic nature of public opinion as vaccine development and distribution unfold, including vaccine confidence and acceptance, information needs, trusted messengers and messages, as well as the public’s experiences with vaccination.
KFF launched the COVID-19 Vaccine Monitor in December 2020 to track the dynamic nature of the U.S. public’s attitudes and experiences with COVID-19 vaccination as distribution efforts unfold across the country. As many states have opened up eligibility to everyone ages 16 and over and the remainder of states are poised to do so soon, this brief summarizes some of the key findings and themes from this research based on interviews with more than 11,000 adults across the nation to date.
- Broadly, the COVID-19 Vaccine Monitor has found that vaccine confidence in the U.S. has increased as more and more people have seen their friends and family members get vaccinated, and now a majority of the public has either already gotten vaccinated or is ready to get the vaccine as soon as they can. Yet with a small but persistent group opposed to getting the vaccine and many others still on the fence, the U.S. may soon hit a point where vaccine supply exceeds demand, a situation that is already the case in certain communities.
- While some media narratives have focused on which groups are most “vaccine hesitant,” our research finds that no group is monolithic in their vaccine attitudes, and in every demographic segment there are large shares of people who are ready to get the vaccine, others who are in “wait and see” mode, and some who are more resistant. Even though certain demographics (for example, Republicans) have a higher share than other groups saying they don’t intend to get vaccinated and others (for example, Black adults) have a higher share saying they want to “wait and see,” we’ve found that majorities across all demographic groups are at least somewhat open to getting the vaccine.
- Those who are not ready to get vaccinated for COVID-19 right away have a range of questions and concerns about the vaccine that require different strategies to address. The top concern across groups has been the potential side effects of the vaccine, including a substantial share who are worried about missing work due to side effects. Other concerns reflect a lack of access to accurate information; for example, many are concerned that they might get COVID-19 from the vaccine (which is not possible) or that they will have to pay out-of-pocket costs to get vaccinated (when in fact, vaccination is free). And other concerns reflect issues with vaccine access, including needing to take time off work to get vaccinated, issues with transportation, or concern about not being able to get the vaccine from a trusted place. Rather than a single messaging strategy, these concerns point to the need for a combination of information, outreach, and policies to both bolster confidence in COVID-19 vaccines and make vaccination accessible across communities.
- Individual health care providers are the most trusted messengers when it comes to information about the COVID-19 vaccines. With trust in national public health messengers eroding and becoming increasingly partisan over the past year, local doctors, nurses, health care providers, and other trusted community figures have an important role to play in supplementing any national campaigns to increase COVID-19 vaccine confidence and uptake.
- It is too early to know what effect the recent announcement about the pause in distribution of the Johnson & Johnson vaccine will have on COVID-19 vaccine confidence. Prior to this announcement, our research found that the one-shot vaccine was an appealing option for a large share of those in the “wait and see” group. However, the potential side effects of the vaccine are a top concern for those who have not yet been vaccinated, so if the public perceives blood clots as a potential side effect (regardless of whether a link is proven), this news does have the potential to increase concerns about getting the Johnson & Johnson vaccine. In the meantime, messages about the effectiveness of the existing vaccine options at preventing serious illness and death from COVID-19 are likely to be the most effective at bolstering confidence among those who are on the fence about getting the vaccine.
Vaccination intentions: trends and demographics
- The share of the public that is eager to get the COVID-19 vaccine has been increasing over time, including across subgroups by race/ethnicity, partisanship, and urbanicity. As of March, six in ten adults said they had already gotten at least one dose of the vaccine (32%) or would get it as soon as it was available to them (30%), a share that has increased steadily since December, when 34% said they would get the vaccine as soon as possible. The share saying they want to “wait a while and see how it’s working for others” before getting vaccinated themselves declined steadily from 39% in December to 17% in March. Where we have not yet seen much movement is in the shares saying they definitely won’t get the vaccine (13% in March) or will do so only if required for work, school, or other activities (7%).
- People at higher risk for serious complications and death from COVID-19 tend to be more enthusiastic about getting the vaccine. For example, in March, 82% of adults ages 65 and older and 70% of individuals with a serious health condition say they’ve already been vaccinated or will get the vaccine as soon as they can, compared to smaller shares of younger adults and those without serious health conditions. This at least partially reflects early access these groups had to the vaccine compared to others, but also the fact that larger shares of younger and healthier adults say they want to wait and see, will get the vaccine only if required, or will definitely not get vaccinated.
- While enthusiasm for getting the vaccine increased dramatically among Black adults between February and March (from 41% to 55% saying they’d already gotten vaccinated or intended to do so as soon as possible), Black adults remain somewhat more likely than White adults to say they want to “wait and see” (24% vs. 16%). In earlier months, Hispanic adults were also somewhat more likely to say they wanted to “wait and see,” but by March the share among Hispanic adults decreased to 18%.
- Education is also a dividing factor in vaccination intentions, with college-educated adults more likely than those without college degrees to say they’ve already gotten vaccinated or will do so as soon as they can (73% vs. 56% in March).
- Vaccination intentions have also divided along party lines since December, reflecting the broader partisan dialogue about the pandemic over the past year. About eight in ten Democrats (79%) are eager to get the vaccine or say they have done so already, compared to nearly six in ten independents (57%) and just under half of Republicans (46%). About three in ten Republicans (29%) say they will “definitely not” get vaccinated, a share that has not changed substantially over time.
- In addition, 28% of White Evangelical Christians say they will definitely not get the vaccine, reflecting the fact that two-thirds (66%) of this group either identifies as Republican or leans towards the Republican party. One in five rural residents also say they will definitely not get vaccinated, about twice the share as in urban areas, a gap largely explained by the concentration of Republicans and White Evangelical Christians who live there.
Challenges and opportunities that cross demographic groups
Concerns and messages
- The potential side effects and the newness of the vaccine seem to be driving a lot of the concern among people who have not yet been vaccinated. Among the 37% of adults in March who were not yet convinced to get the vaccine as soon as possible, seven in ten said they were concerned they might experience serious side effects from the vaccine, and over six in ten were concerned the effects of the vaccine might be worse than getting COVID-19. In addition, when those who say they will definitely not get the vaccine are asked to state their main reason in their own words, the most common response is that the vaccine is too new and/or that not enough is known about the long-term effects.
- Different groups respond to messaging and information at different levels, but of the messages we’ve tested, emphasizing the effectiveness of the vaccine at preventing serious illness and death is the most effective across groups (two-thirds of those in the “wait and see” group and four in ten in the “only if required” group say they’d be more likely to get vaccinated after hearing the vaccines are nearly 100% effective at preventing hospitalizations and death from COVID-19).
- The “wait and see” group is an important target for outreach and messaging, since they express some concerns about getting vaccinated, but will likely be much easier to convert from vaccine-hesitant to vaccine-acceptant than those who say they will “definitely not” get the vaccine or will get it “only if required” to do so. Other messages/information that are effective at persuading many in the “wait and see group” include that scientists have been working on the technology used in the new COVID-19 vaccines for 20 years; that more than 100,000 people from diverse backgrounds took part in the vaccine trials; that the vast majority of doctors who have been offered the vaccine have taken it; and that there is no cost to get the vaccine.
- Separate from concerns about the effects of the vaccine itself, about six in ten of those who are not yet convinced to get the vaccine right away are concerned that they might be required to get the vaccine even if they don’t want to.
Information and misinformation
- Reaching people with information about how to access vaccines is an ongoing challenge. As of March, many people say they still don’t have enough information about when (46%) and where (33%) they’ll be able to get the vaccine, and three in ten are not sure if they are currently eligible in their state (rising to four in ten among Hispanics, young adults, and those with lower incomes).
- Many are unaware of some basic facts about the vaccines and how they work. As of January, 34% of all those who had not been vaccinated had heard and believed or were unsure about several common “myths” about the vaccine (that it contains the live virus that causes COVID-19, that it causes infertility, or that one must pay out-of-pocket to get vaccinated), rising to 41% among the “wait and see” group and 53% among those who say they will “definitely not” get vaccinated. Around four in ten of those who are not yet convinced to get the vaccine right away (rising to half among Black and Hispanic adults) are concerned that they might get COVID-19 from the vaccine.
- Health care providers are the top source people say they will turn to for information when making decisions about whether to get vaccinated (79%, far outranking other sources in January). However, just one-quarter of those who had not yet been vaccinated said they have asked a provider about the vaccine as of February. Regardless of the sources they trust or say they will turn to, the media is a more prominent source where people are actually getting information. Asked where they have gotten information about the vaccine in recent weeks, cable (43%), network (41%), and local TV news (40%) are top sources, along with family and friends (40%). However, social media, most notably Facebook, is among the most prominent sources of information for those who want to “wait and see” about the vaccine (37%) as well as those who say they “definitely won’t” get vaccinated (40%).
Vaccine access and experiences
- While most of those who were vaccinated as of February say they were able to find or schedule a vaccine appointment on their own, about four in ten say someone else helped them, including larger shares of those with lower incomes and without college degrees. Among those who believe they are eligible but had not yet been vaccinated as of March, about a third have tried to schedule a vaccination appointment including 16% who did so successfully and 17% who say they tried but were unable to make an appointment.
- Making access to vaccines more convenient may improve uptake among some groups. Among the “wait and see” group, half say they’d be more likely to get vaccinated if their doctor offered it during a routine appointment, and four in ten of those with jobs say they’d be more likely to get it if their employer arranged for them to get vaccinated at work. Employer incentives could also play a role (38% of the employed “wait and see” say they’ be more likely to get vaccinated if their employer paid them $200), as could airline travel requirements (almost half in both the “wait and see” and “only if required” groups say they’d be more likely to get vaccinated if it was required to fly).
Challenges and opportunities for key subgroups
Despite the demographic differences in vaccination intentions noted above, no group is monolithic in their attitudes towards the COVID-19 vaccines. In each demographic group, there are many who are eager to get the vaccine right away and some who say they won’t get it under any circumstances. Importantly, across all the groups we’ve analyzed, a large majority is at least somewhat open to getting the vaccine and no more than one-third say they will “definitely not” get it. Still, our in-depth survey work has revealed some insights that may be helpful for those looking to understand vaccine attitudes and increase confidence in specific populations, and those are outlined in the sections below.
Black and Hispanic adults
- Concern about getting sick with COVID-19 is high among Black and Hispanic adults who want to wait and see before getting vaccinated, but concern about experiencing serious side effects of the vaccine is also high. Given this, messages focused on protecting individuals and families from illness, while also acknowledging and/or addressing concerns about serious side effects may be most successful.
- People express a range of other concerns about the vaccine that can be addressed with better access to information and policies that make it easier for people to get the vaccine from trusted places, and many of these concerns are expressed at higher rates among people of color. In particular, among those who are not convinced to get the vaccine as soon as possible, at least half of Black and Hispanic adults are concerned that they might get COVID from the vaccine or that they might have to miss work if they have side effects. Addressing these misperceptions in conversations and outreach may be helpful.
- For Black adults in particular, reluctance to get vaccinated may be related to mistrust of the health care system that reflects both historical mistreatment and personal experiences with racism and discrimination. In fact, 38% of Black adults and 27% of Hispanic adults who are not yet convinced to get the vaccine are worried they won’t be able to get it from a place they trust.
- Black and Hispanic adults say they will turn to a wide range of information sources when making vaccine-related decisions, including individual health care providers, pharmacists, friends and family, and government health agencies. While religious leaders rank lower on the list of overall sources of information, among those who want to “wait and see,” Black adults (35%) and Hispanic adults (28%) are more likely than white adults (14%) to say they’ll turn to them for information, indicating a possible effective messenger to reach some the Black and Hispanic communities.
- While about a third of Republicans say they will “definitely not” get the vaccine or will get it “only if required,” another 19% are in “wait and see” mode and may be receptive to messages and information aimed at increasing vaccine uptake. However, even within the “wait and see” group, partisan differences emerge that suggest different messaging strategies will be required. For example, two-thirds (67%) of Republicans and Republican-leaning independents in the “wait and see” group view vaccination as a personal choice, and half (51%) believe the seriousness of COVID-19 is being exaggerated in the news, according to the January Monitor. This suggests that messages focused on helping people make the right choice to protect their own health are more likely to resonate with Republican audiences than those that emphasize the seriousness of the pandemic or the need to get vaccinated for the collective good.
- Government sources of information (including the CDC and state and local health departments) are less trusted by Republicans than by Democrats in the “wait and see” group, so individual health care providers, pharmacists, and friends and family are a better conduit for messaging/information to Republicans.
- Republicans – who tend to be particularly concerned about personal liberty – are more likely to be concerned about being required to get vaccinated against their will. Among those who are not convinced to get vaccinated right away, a larger share of Republicans (71%) compared to independents (57%) and Democrats (53%) say they are concerned that they might be required to get the vaccine even if they don’t want to.
- Two-thirds (66%) of White Evangelical Protestants identify as Republicans or independents who lean toward the Republican Party, so there is a lot of overlap between their attitudes toward the COVID-19 vaccine and the attitudes of Republicans in general.
- In a large survey of over 1,000 adults living in rural areas, we found signs of strong early uptake and access to vaccines in rural areas. A slightly larger share of adults in rural areas compared to urban and suburban areas reported having received at least one dose of the vaccine (39% vs. 31%), and an additional 16% of rural residents want to get the vaccine as soon as they can. In addition, most adults living in rural areas feel their community has enough vaccination locations and vaccine supply to serve local residents. However, Black adults living in rural areas are less likely than White or Hispanic adults to say their community has adequate supply of these things.
- While one in five rural residents say they will “definitely not” get vaccinated, this is largely due to the disproportionate share of Republicans and White Evangelical Christians living in these areas. The concerns that rural residents have about the vaccine and the messages that resonate most to convince them to get vaccinated mirror the concerns and effective messages for the public at large.
The “definitely nots”
- Those who say they will “definitely not” get the vaccine (13% of the overall public) have a very different view of the overall pandemic compared to the rest of the population. For example, 75% of this group believes the seriousness of coronavirus has been exaggerated by the media (compared to 32% of the public overall), and 82% are not worried about themselves or a family member getting sick from COVID-19 (compared to 50% of the public overall).
- This group not only views the vaccine differently, but they also hold different views on other protective measures. For example, 96% of those in the “definitely not” group say getting vaccinated for COVID-19 is a personal choice rather than part of everyone’s responsibility to protect others (compared to 46% of the public overall who say this), and 65% believe that wearing a mask does not prevent the spread of coronavirus (compared with 20% of the public overall).
- This group is highly distrustful of government sources of information; 83% say they trust the U.S. government “not too much” or “not at all” to look out for the interests of people like them, and 71% say they do not trust the CDC for reliable information about COVID-19 vaccines.
- Of the messages and incentives we’ve tested to see what might make people more likely to get the vaccine, none are effective at moving more than a very small share of the “definitely not” group. For example, fewer than one in ten among this group say they’d be more likely to get vaccinated after hearing the vaccines are nearly 100% effective at preventing hospitalization and death from COVID-19 or that scientists have been working on the technology used in the vaccines for 20 years. A similarly small share say they’d be more likely to get vaccinated if airlines required it or if it was offered to them during a routine medical visit.
Frontline health care workers
- A KFF/Washington Post survey of frontline health care workers, including those who work in various functions such as treating patients, performing administrative duties, or assisting with patient’s daily activities and housekeeping, found that half (52%) of all frontline health workers reported receiving at least one dose of a COVID-19 vaccine as of early March and another one in five (19%) had scheduled or were planning to receive the vaccine. Another nearly one in five (18%) said they did not plan to get vaccinated and 12% had not made up their mind.
- As among the general public, COVID-19 vaccination intention among health care workers divides by race/ethnicity and education, as well as by work location and type of job duties. For example, while the large majority of those working in hospitals have been gotten the vaccine or intend to do so, almost half of those working in patients’ homes say they won’t get vaccinated or are undecided. And among physicians (and nurses with graduate degrees), nearly nine in ten report either already being vaccinated or plan to get a vaccine.
- Health care employers have a role to play in making sure their employees can get vaccinated. The share of health care workers who were offered a COVID-19 vaccine from their employer was much lower among those working in patients’ homes compared to those working hospitals and other settings.
- The potential side effects of the vaccine – a top concern among the public – are also a top concern for health care workers who have not yet been vaccinated; 82% say worry about possible side effects is a major factor in their decision about whether to get vaccinated.
Vaccine Monitor: What We’ve Learned
With nearly all states poised to allow anyone at least 16 years old to get a COVID-19 vaccine, this week’s announcement pausing the distribution of the Johnson & Johnson vaccine to investigate a rare side effect is raising questions about whether and how it will affect the public’s eagerness to get vaccinated.
A new report summarizes key insights about vaccine confidence, messages and messengers from the KFF COVID-19 Vaccine Monitor project, which has interviewed more than 11,000 adults nationally since December to track the public’s shifting attitudes and experiences with COVID-19 vaccinations.
Among its key takeaways:
- Among those who are not ready to get a COVID-19 vaccination right away, their top concern consistently has been the potential side effects, including many who worry they will have to miss work due to side effects. The news about the Johnson & Johnson vaccine could heighten those worries for people on the fence about getting vaccinated.
- Prior to the pause in the Johnson & Johnson vaccine, it was an appealing option for a large share of those in the “wait and see” group because it requires only a single shot, while the other available vaccines (Moderna and Pfizer) require two shots several weeks apart.
- Some people’s concerns about vaccination are based on lack of access to accurate information. For example, many are concerned that they might get COVID-19 from a vaccine, which is not possible, or that they will have to pay out-of-pocket even though the COVID-19 vaccinations are free.
- No group is monolithic in their vaccine attitudes. While some demographics such as Republicans have a higher share saying they don’t intend to get vaccinated, and others such as Black adults have a higher share saying they want to “wait and see,” majorities across all demographic groups are at least somewhat open to getting a vaccine.
- Individual health care providers are the most trusted messengers when it comes to information about the COVID-19 vaccines.
Available through the Monitor’s online dashboard, the report looks at common messages and messengers that apply across demographic groups, as well as challenges and opportunities related to the views of specific groups such as Black and Hispanic adults, Republicans, rural residents, frontline health workers and those who say they will “definitely not” get vaccinated.
The KFF COVID-19 Vaccine Monitor is an ongoing research project tracking the public’s attitudes and experiences with COVID-19 vaccinations. Using a combination of surveys and qualitative research, this project tracks the dynamic nature of public opinion as vaccine development and distribution unfolds, including vaccine confidence and acceptance, trusted messengers and messages, as well as the public’s experiences with vaccination.
Recommendation to Pause Use of Johnson & Johnson’s Janssen COVID-19 Vaccine
Safety Is a Top Priority
COVID-19 vaccine safety is a top priority for the federal government, and all reports of health problems following COVID-19 vaccination are taken very seriously. This potential safety issue was caught early, and this pause reflects the federal government’s commitment to transparency as CDC and FDA review these data. COVID-19 vaccines have undergone and will continue to undergo the most intensive safety monitoring in U.S. history.
What to Do If You Received the J&J/Janssen COVID-19 Vaccine
If you received the vaccine more than three weeks ago, the risk of developing a blood clot is likely very low at this time.
If you received the vaccine within the last three weeks, your risk of developing a blood clot is also very low and that risk will decrease over time.
Contact your healthcare provider and seek medical treatment urgently if you develop any of the following symptoms:
- severe headache,
- new neurologic symptoms,
- severe abdominal pain,
- shortness of breath,
- leg swelling,
- tiny red spots on the skin (petechiae), or
- new or easy bruising
If you are scheduled to get the J&J/Janssen COVID-19 Vaccine, please work with your vaccine provider to reschedule your appointment to receive another authorized and recommended COVID-19 vaccine. There are two other COVID-19 vaccines authorized and recommended for use in the United States: Pfizer-BioNTech and Moderna.
If you experience any adverse events after vaccination, report them to v-safe and the Vaccine Adverse Event Reporting Systemexternal icon.
For Healthcare Providers
Healthcare providers are recommended to pause the use of the J&J/Janssen COVID-19 Vaccine. Maintain acute clinical awareness of symptoms that might represent serious thrombotic events or thrombocytopenia in patients who have recently received the J&J/Janssen COVID-19 Vaccine, including:
- severe headache,
- new neurologic symptoms,
- severe abdominal pain,
- shortness of breath,
- leg swelling,
- petechiae, or
- new or easy bruising.
Read the official CDC health alert, Cases of Cerebral Venous Sinus Thrombosis with Thrombocytopenia after Receipt of the Johnson & Johnson COVID-19 Vaccine, which includes details about how to handle a patient that presents with thrombosis or thrombocytopenia.
Report adverse events to the Vaccine Adverse Event Reporting Systemexternal icon.
For Vaccine Providers
Please work with individuals who were scheduled to receive the J&J/Janssen COVID-19 Vaccine in the days ahead to reschedule their appointments to receive another authorized and recommended COVID-19 vaccine (i.e., Pfizer-BioNTech, Moderna).
hand holding medical light icon
For Healthcare Workers
Clinical Resources: Toolkits and resources for handling, storing and administering the vaccine.
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