Isolation Guidance: COVID-19 Rebound

CDC Advisory (May 24, 2022)

Click Here for the Full CDC Advisory

The full CDC advisory contains detailed background information, clinical observations and data, and guidance for the general public, public health officials, and healthcare providers.

Background

• Individuals who have taken Paxlovid for treatment of COVID-19 are reporting recurrence of symptoms following completion of treatment
• It is unclear if this is attributed to the treatment and if it differs from the normal course of infection, which has been observed to ebb and flow in some cases since the beginning of the pandemic
• Based on available data, COVID-19 rebound is not thought to represent a reinfection with SARS-CoV-2
• Based on available data, it is not yet clear if the risk of infecting others is as high during the rebound period as it is during the initial infection period.
• Paxlovid is still the recommended treatment for mild-to-moderate COVID infection in individuals at high risk for severe disease
• Regardless of whether the individual has received Paxlovid treatment, people with COVID-19 rebound should restart isolation as directed below, in Guidance for the General Public

Guidance for General Public

What Does Rebound Look and Feel Like?

• COVID-19 rebound is characterized by:
  • Recurrence of symptoms and/or a new positive test after having tested negative
  • Rebound occurs between 2 and 8 days after initial recovery
• You may experience COVID-19 rebound even if you have not received Paxlovid or other treatment. Symptom recurrence and COVID-19 rebound have been observed since the beginning of the pandemic, and may be part of the natural course of infection for some individuals.

What Should I Do if I Experience COVID-19 Rebound?

• If you experience COVID-19 rebound, you should isolate again and restart the 5-day strict isolation period at the time of the recurrence in symptoms or new positive COVID-19 test result
• You may end the re-isolation if:
  • It has been at least 5 days since the recurrence of symptoms or new positive test
  • Your symptoms are resolving and you have not had a fever for at least 24 hours (without the use of fever-reducing medications such as Tylenol)
• You should wear a mask for 10 days after rebound
• If your rebound symptoms persist or worsen, you should contact your health care provider

Guidance for Health Care Providers

For Patients with COVID-19 Rebound:

• There is currently no evidence that additional treatment for COVID-19 is needed for COVID-19 rebound. Based on data available at this time, patient monitoring continues to be the most appropriate management for patients with recurrence of symptoms after completion of a treatment course of Paxlovid. 
• Advise people with COVID-19 rebound to follow CDC’s guidance on isolation and take precautions to prevent further transmission. Patients should re-isolate for at least 5 days. Per CDC guidance, they can end their re-isolation period after 5 full days if fever has resolved for 24 hours (without the use of fever-reducing medication) and symptoms are improving. The patient should wear a mask for a total of 10 days after rebound symptoms started.
• Consider clinical evaluation of patients who have COVID-19 rebound and symptoms that persist or worsen. 
• Healthcare providers are encouraged to report cases of COVID-19 rebound to Pfizer after Paxlovid treatment using the following online tool: Pfizer Safety Reporting and to FDA MedWatch. Complete and submit a MedWatch form, or complete and submit FDA Form 3500 (health professional) by fax (1-800-FDA-0178). Call 1-800-FDA-1088 for questions. For patients just diagnosed with COVID-19 
• Healthcare providers should counsel patients on available COVID-19 treatment options, particularly for those patients at increased risk of developing severe COVID-19. 
• Paxlovid should be considered for any patient who meets the eligibility criteria. For information on Paxlovid eligibility, refer to FDA’s Fact Sheet for Healthcare Providers. 
• Due to the potential for severe drug-drug interactions with the ritonavir component of Paxlovid, it is strongly suggested that healthcare providers not experienced in prescribing this drug refer to the Fact Sheet for Healthcare Providers, the Paxlovid Patient Eligibility Screening Checklist Tool for Prescribers, and the NIH Statement on Paxlovid Drug-Drug Interactions | COVID-19 Treatment Guidelines. Healthcare providers can also contact a local clinical pharmacist or infectious disease specialist for advice. 
• For further information on the use of Paxlovid, CDC recommends healthcare providers continue to closely follow NIH’s COVID-19 Treatment Guidelines, the Assistant Secretary for Preparedness and Response Public Health Emergency COVID-19 Therapeutics site, and IDSA’s Guidelines on the Management of Patients with COVID-19.