Question: My toddler busted her chin getting out of the tub the other day, prompting us to visit the emergency room. A couple of stitches later, she’s fine and was happy with the whole experience because she got lollipops and juice from the doctor — an extra special treat since she never gets those at home. Anyway, while we were sitting in the emergency room, we were around people coughing, people there for COVID tests, and just a general sea of humanity. Yes, they were wearing masks, but still, it was very disconcerting. Do we need to worry about exposure to COVID? Do we need to self-isolate?

Answer: I’m glad baby girl is fine and took it all in stride. I’m sorry that you had to go through that experience . Honestly, I’m shocked that the emergency room has everyone sitting together. I would have hoped (and expected!) they would have people with COVID-like symptoms and people wanting a COVID test to wait in a different area! Indeed, if the emergency room were following CDC guidelines for infection control, they would be screening and triaging everyone coming into the facility and separating anyone with COVID symptoms. Since that didn’t happen, I think you may have to consider yourself exposed and self-isolate. 🙁 Here’s more background on why I’m suggesting that you may need to self-isolate:

1. There are a few differences in how CDC and other public health groups define “close contact.” I’m quoting the close contact definition that New Jersey uses because it directly addresses hospital waiting rooms: “A close contact is defined as being within approximately 6 feet (2meters) of a COVID-19 case for a prolonged period of time (approximately 10 minutes or longer); close contact can occur while caring for, living with, visiting, or sharing a health care waiting area or room with a COVID-19 case OR Having direct contact with infectious secretions of a COVID-19 case (for example, being coughed on).” Based on the waiting room experience you described, it sounds like you meet the criteria of being a “close contact.” Of course, I was not there and I do not know what your experience truly was, so please use your own best judgement.
2. While I have not found any direct evidence of COVID-19 infection resulting from exposure in a hospital waiting room, we do have some reason for concern based on evidence from other diseases (though like most things in science, it’s not clear cut). Here are a few pieces of related evidence that unfortunately do not offer much clarity. From what I’m reading, I think that if everyone was wearing masks, sitting far apart, and not playing with common toys or reading from a shared pile of magazines or the like, your risk is quite low.

• This article from June 2020, “Minimizing intra-hospital transmission of COVID-19: the role of social distancing” describes Singapore General Hospital’s recent experience of caring for COVID patients. Of the 75 cases they cared for in the first months of the pandemic, 1 case was not initially isolated and potentially exposed 18 other patients and 8 health care workers. None of the exposed patients or health care workers became infected. The authors believe this happy outcome was the result of social distancing + mask wearing by the infected patient.
• This article from 2018, “Infection prevention and control in paediatric office settings”, offers an informative synthesis of the evidence:
  • Measles has been transmitted in paediatricians’ offices.
  • There are reports of transmission of tuberculosis from physicians to patients in paediatricians’ offices.
  • Pertussis has been transmitted to healthcare workers in paediatric ambulatory settings.
  • In-office spread of common viral and gastrointestinal infections has not been reported, but is nonetheless probable if offices don’t take precautions.
  • One study showed no increased risk of influenza-like illness while another study reported an increased risk of influenza-like illness in a family member in the 2 weeks following a well-child visit.
• This 2010 modeling study, “Potential for airborne transmission of infection in the waiting areas of healthcare premises” concluded, “Under normal circumstances the risk of acquiring a TB infection during a visit to a hospital waiting area is minimal. Likewise the risks associated with the transmission of influenza, although an order of magnitude greater than those for TB, are relatively small. By comparison, the risks associated with measles are high.”
• This 2012 cohort study, “Extremely low risk for acquisition of a respiratory viral infection in the emergency room of a large pediatric hospital during the winter season” followed 615 children in Athens, Greece who visited the emergency room, finding that only 22 (3·6%) children developed at least one symptom compatible with a respiratory viral infection within 1–7 days after the visit, and only 3 children (0·5%) developed an influenza‐like illness.