Information for Healthcare Professionals
How to Report
An outbreak of respiratory disease, COVID-19, caused by a novel (new) coronavirus (SARS-CoV-2) that was first detected in China has spread globally including to all continents and all states in the US. Community spread of COVID-19 has been established in Contra Costa County, and mitigation strategies such as social distancing, universal masking, and isolation of ill individuals and quarantine of their close contacts continue to be most effective measures to control the spread of COVID-19.
Based on what is currently known about COVID-19, spread occurs mostly from person-to-person via respiratory droplets. The most common symptoms seen with COVID-19 include fever (may be subjective) or symptoms of acute lower respiratory illness such as cough and shortness of breath. Patients have also presented with other symptoms such as fatigue, chills, myalgias, headache, sore throat, new loss of taste or smell, vomiting, nausea, nasal congestion, rhinorrheas, or diarrhea. In addition to these symptoms, elderly patients may present with weakness, confusion, dizziness, or a subtle change from their baseline. Although the complete clinical picture of COVID-19 continues to evolve, reported illnesses have ranged from no symptoms to mild symptoms to severe illness and death. Older people and people with underlying health conditions are at the highest risk of developing serious COVID-19 illness.
Acceptable testing specimens include a nasopharyngeal (NP) or oropharyngeal (OP) swab collected by a healthcare provider OR nasal mid-turbinate or anterior nares swab collected by a healthcare provider or by a supervised onsite self-collection. Providers should consult with their submitting laboratory to ensure proper collection and swab are being used for testing platform in place. Serological testing for SARS COV 2 is available through the FDA Emergency Use Authorization (EUA), along with several other unauthorized serology tests. Please be aware that at this time, serology testing must not be used for the diagnosis of acute COVID-19 infection or management of contacts to cases. The only tests which are authorized for use in the diagnosis of COVID-19 are nucleic acid amplification tests, such as PCR, and also antigen testing for diagnosis of probable cases. For more information about testing please visit CDC Testing for SARS-COV-2 and for more information and guidance regarding antigen testing please see CDPH guidance for antigen testing.
Currently there have been a few case studies suggestive of reinfection. Reinfection seems to be a rare occurrence, but we are still learning about COVID-19 infection and its scope. Gven this and the questions around reinfection, Contra Costa Public Health Department would like to know about cases of possible reinfection if the PCR positive result is greater than 90 day from the previous PCR positive test result, regardless of symptoms OR if the PCR positive is greater than 45 days from the previous positive PCR test result, the patient has symptoms consistent with COVID-19, they had previously met the criteria to end isolation, and there was no other etiology found for their current symptoms. These cases will be reviewed with Contra Costa Public Health Department for possible further investigation with California Department of Public Health. To aid in these investigations, if there is a concern for reinfection, retain the current positive PCR specimen and the cycle time of this test. Additionally, to aid in the investigation, if possible, try and locate the previous PCR positive specimen and cycle time of that test.
The Contra Costa Public Health Lab will continue to accept specimens for high priority patients. High priority patients are those who are at risk for poor outcomes or may expose vulnerable people, such as:
- Persons who LIVE or WORK in CONGREGATE FACILITIES (skilled nursing facilities, board and care, assisted living and other congregate senior living facilities, shelters, group homes, residential treatment programs and facilities, jails) presenting in any setting - hospital or ambulatory;
- HOMELESS PERSONS regardless of current status of shelter;
- HEALTH CARE WORKERS and FIRST RESPONDERS;
- Persons who receive DIALYSIS or CHEMOTHERAPY in clinic settings;
- Persons who are HOSPITALIZED.
Please also see CDPH Testing Guidance for the most current information on testing and testing priorities when experiencing limited testing capacity.
When laboratories, which include clinics and facilities doing point-of-care testing, are reporting test results they must follow Title 17 section 2505 of the California code of Regulations and the current Contra Costa Health officer order directing all laboratories conducting COVID-19 Diagnostic test to report COVID-19 test information to local and state public health authorities for all testing results. If your facility or lab is running COVID-19 Point of Care antigen testing, or doing other COVID testing, and has not been reporting results through the CalRedie electronic lab reporting (ELR) system or is not able to report through the ELR system, please review CalRedie Manual Lab Reporting module to enroll in CalRedie for reporting these test results.
When submitting a specimen to the Contra Costa Public health lab you must also submit a Lab Requisition Form with the indication of the priority group for public health testing noted on the lab requisition form.
If a patient presents and is suspected of having COVID-19, or is a confirmed case, proper infection control measures should be put in place immediately:
- Place surgical mask on patient and place patient in private room with door closed (optimally, a negative-pressure, airborne isolation room).
- Implement all of the infection control procedures listed below for healthcare workers:
- Standard precautions AND
- Contact precautions (gloves, gown) AND
- Airborne precautions (N95 mask or PAPR) AND
- Eye protection (face shield or goggles)
- Additionally, universal masking of all staff and visitors should be implemented within the facility.
Surfaces should also be cleaned frequently using appropriate disinfectants: List of disinfectants for use for COVID-19 cleaning.
For additional infection control guidance please review CDC Infection Control Recommendations.
How to Report
When some is diagnosed with COVID with a positive test result submit, a COVID-19 Confidential Morbidity Report (COVID-19 CMR, formerly PUI Form) to Contra Costa Public Health. Please fax a completed COVID-19 CMR to 925-313-6465.
If a patient has mild symptoms not requiring medical care, healthcare providers may instruct the patient to stay at home in isolation and only seek medical attention if symptoms worsen. If a patient is tested for COVID-19, but does not require hospitalization, he/she may be discharged home with instructions to isolate at home while awaiting results along with quarantine instructions for close contacts. Please provide patients with Home Isolation Instructions for Person under investigation, Home Isolation instructions for confirmed cases, home quarantine instructions for close contacts, found on: www.coronavirus.cchealth.org/for-covid-19-patients along with isolation and quarantine health officer order found on www.coronavirus.cchealth.org/health-orders.
CDC provides guidance for the management of healthcare workers with potential exposure to COVID-19. Decisions on work exclusion or re-assignment can be made by healthcare facilities depending on staffing needs. If there are no staffing needs, healthcare workers who are considered close contacts to a case or exposed should be instructed to stay at home to quarantine. Healthcare workers with close or household contacts to a COVID-19 case should review healthcare workers with close contact to a COVID-19 case and follow up with their employer.
Note, if a healthcare worker is diagnosed with COVID-19, they will have to isolate at home for at least 10 days from their symptom onset (or test date if asymptomatic) with at least 24 hours have passed since last fever without using a fever-reducing medication like Tylenol or ibuprofen and symptoms like cough, body aches, sore throat have improved. Please also review CDC criteria to return to work for healthcare personnel.
It is the responsibility of the ordering provider to inform patients of their test results and to give instruction regarding home isolation to patients and home quarantine to close contacts. For patients who test positive, please provide patients with Home isolation instructions for themselves, and Home Quarantine Instructions for their close contacts found on www.coronavirus.cchealth.org/for-covid-19-patients. A close contact is defined as anyone who was within 6 feet of a person with COVID-19, while they were considered infectious, for 15 minutes or longer. A person is considered infectious from 48 hours before his or her symptoms began (or, in the absence of symptoms, from 48 hours before the date of the test) and until the patient is cleared of their infection as noted in the clearance section below. Patients who had a recent COVID-19 infection in the past 3 months do not need to be quarantined after a close contact with a COVID-19 patient. Patients should also be given a copy of the Health Officer order for Isolation and the Health Officer order for quarantine for their close contacts found on www.coronavirus.cchealth.org/health-orders when testing is taking place and results are given.
If a hospitalized patient has confirmed COVID-19, but no longer requires inpatient care and is still considered infectious, they may be discharged to home under home isolation. Public health does not need to be notified of discharges home if the patient can safely isolate at home. On discharge give the patient home isolation instruction and quarantine instructions, along with the orders, as noted above. If the patient is unable to isolate at home safely or is homeless public health can be contacted for possible PUI hotel placement. Please review provider guidance for placing person experiencing homelessness or unable to isolate safely. You may also fill out a Case discharge notification form if the patient is unable to isolate safely 48-24 hours prior to planned discharge. For patients with planned discharge to a congregate setting please review Guidance for Hospitals Receiving and Discharge a Patient from Long Term Care Facility. As noted on this guidance, public health should be notified 24-48 hours prior to planned discharges into a Long Term Care Facility of patients who need continued isolation precautions. Notifications should take place filling out and emailing (the preferred method) the Case Discharge Form to firstname.lastname@example.org, ensuring that the email in ENCRYPTED, or by calling public health at 925-313-6740.
If a patient is moving to another facility, including congregate care facilities, please complete Interfacility Transfer form (Comprehensive Form or Abbreviated Form) and have form transfer with the patient. If patient had COVID testing attach lab results to form for transfer.
On May 14, 2020, the U.S. Centers for Disease Control and Prevention (CDC) issued a health alert regarding children with signs and symptoms of a severe multisystem inflammatory syndrome (MIS-C) potentially associated with SARS-CoV-2 infection. Cases presenting with features resembling Kawasaki disease or toxic shock syndrome have been reported in Italy, the United Kingdom, New York City and other locations in the United States, including California. Please see the Provider Alert Multi-System Inflammatory Syndrome.
For more additional guidance for the care of patients with COVID-19, including care of newborns, children, pregnant and breastfeeding women please visit CDC Clinical Care Guidance for Healthcare Professionals.
Ending Isolation for Patients with Confirmed or Suspected Infection
For most patients with confirmed or suspected COVID-19, including patients returning to long-term care facilities with mild or moderate illness, isolation can be discontinued after at least 10 days after symptoms onset, and at least 24 hours after fever has resolved (fever has gone away without using a fever-reducing medication like Tylenol or ibuprofen AND their symptoms like cough, body aches, sore throat, have improved).
For patients who were asymptomatic at the time of testing, they should remain in isolation for at least 10 days from the date the test was performed. Patients should also monitor themselves for symptoms. If any symptoms develop during this time, they should remain isolated until 10 days after symptom onset plus 24 hours after symptom resolution, as noted above.
Patients with severe disease hospitalized in the intensive care unit or who are severely immune-comprised may have longer periods of SARS-CoV-2 RNA shedding compared to patients with mild or moderate disease. Given this, patients who were hospitalized in the intensive care unit with COVID-19 or are severely immune-compromised should be instructed to remain isolated for at least 20 days and at least 24 hours after their fever has resolved (fever has gone away without using a fever-reducing medication like Tylenol or ibuprofen AND their symptoms like cough, body aches, sore throat, have improved).
Any patient who has been diagnosed with COVID-19 and admitted to a healthcare facility maybe discharged to a skilled nursing facility even if they have not cleared their infection based on the criteria above. They may only be discharged to a skilled nursing facility that has a COVID unit, and appropriate transmission based precautions in place, after clearance from the Local Public Health Department.
Note: Patients with a COVID-19 diagnosis prior to admission into the healthcare facility may return to their prior Skilled Nursing Facility bed without obtaining public health approval, if they were previous residents of the facility within the last 14 days. If the patient is a resident of Residential Care Facility for the Elderly, and a known positive who had been isolating at the facility with appropriate transmission based precautions in place prior to the hospital admission, they may also be readmitted to their facility without public health approval as described above.
There is no current FDA approved treatment for COVID-19 outside of supportive care. For other management and treatment guidelines please visit the NIH COVID-19 Treatment Guidelines.
The use of investigational therapies for treatment of COVID-19 should ideally be done in the context of enrollment in randomized controlled trials. For the latest information, see Information for Clinicians on Therapeutic Options for COVID-19 Patients. For the information on registered trials in the U.S., see ClinicalTrials.gov.
Mitigation strategies such as social distancing, universal masking, isolation of ill individuals, and placing their close contacts in quarantine will be most effective for containing the spread of COVID-19. Patients should be instructed to practice social distancing, wear mask if out, stay home if sick, wash hands frequently, and to avoid touching their faces.
Additionally, individuals such as older adults (age ≥ 65 years) and those with chronic medical conditions and/or an immunocompromised state that may put them at higher risk for poor outcomes (e.g., diabetes, heart disease, receiving immunosuppressive medications, chronic lung disease, chronic kidney disease), should be advised to stock up on supplies and prescriptions, avoid large crowds as much as possible, avoid contact with ill persons, avoid non-essential air travel and cruises, and stay home as much as possible to reduce the risk of being exposed.
Preventive measures should also be taken for all clinical settings, including dental clinics, to decrease the chance of spread. Staff should be monitored for symptoms, and be instructed to stay home if sick. Additionally, practices should implement alternatives to face-to-face triage and visits; consider designating an area of the facility (e.g. an ancillary building or temporary structure) as a location for initial evaluation of patients who present with fever or respiratory symptoms; cancel group healthcare activities (e.g., group therapy, recreational activities); and postpone elective procedures, surgeries, and non-urgent outpatient visits. See more information on actions that can be taken for healthcare facilities.
For dental practices, it is also important that measures are taken to decrease the spread of COVID-19. Patients should be allowed to access dental care, if needed, but considerations should be taken to reschedule non-urgent appointments such as dental cleaning. Additionally, it is up to dental practices to monitor staff for any symptoms, and to have staff who are sick remain home. Practices should also screen all patients for symptoms (fever, cough, shortness of breath) prior to them being seen, and reschedule any appointments with sick patients.
- Coronavirus 2019 (COVID-2019)- CDC
- Coronavirus Disease 2019- Information for Health Professionals
- Current Health officer orders
- How to Get Tested Through Contra Costa Health Services