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Coronavirus (COVID-19)

Information for Healthcare Professionals



General Information

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.

Laboratory Testing

Acceptable testing specimens include a nasopharyngeal (NP) or oropharyngeal (OP) swab collected by a healthcare provider, OR a nasal mid-turbinate or anterior nares swab collected by a healthcare provider or by the patient through a supervised onsite self-collection. There are many PCR test available to detect COVID-19 and the source, collection method, and swabs may differ based on the platform being used. Providers should consult with their submitting laboratory to ensure they are using the proper collection method and swab for the testing platform in place.

Retesting of patients who were previously diagnosed with COVID-19 is NOT recommended within 3 months. This includes NOT retesting after an infection for clearance. Patients who tested positive and have cleared their infection based on the ending isolation criteria below do not need a negative test for work, being transferred back to facilities, or other housing programs. If it has been longer than 3 months since the patients' COVID-19 infection, retesting would be recommended for surveillance testing or other concerns. For patients, who develop new symptoms consistent with COVID-19 during the 3 months after the date of initial test or symptom onset, if an alternative etiology cannot be identified by a provider, then retesting may be warranted and consultation with infectious disease or infection control experts is recommended for guidance.

Serological testing for SARS COV 2 is also available through the FDA Emergency Use Authorization (EUA). Along with the FDA EUA serological test there is also several unauthorized serology tests that have become available and being used. Please be aware given the uncertainty of serological testing and immunity, that at this time, serology testing must not be used for the diagnosis of acute COVID-19 infection, isolation or transmission-based precautions decisions, or management of contacts to cases. Currently, the only tests which are authorized for use in the diagnosis of COVID-19 are nucleic acid amplification tests, such as PCR and antigen tests with an FDA EUA approval. For more information about testing please visit CDC Testing for SARS-COV-2 and for more information and guidance on antigen testing please see CDPH guidance for antigen testing.

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:

  1. 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;
  2. HOMELESS PERSONS regardless of current status of shelter;
  3. HEALTH CARE WORKERS and FIRST RESPONDERS;
  4. Persons who receive DIALYSIS or CHEMOTHERAPY in clinic settings;
  5. Persons who are HOSPITALIZED.

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.

For further guidance on testing and testing priorities when experiencing limited testing capacity please also review CDPH Testing Guidance.

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 as described in Title 17 California Code of Regulations for Reportable Disease and Conditions. Please fax a completed COVID-19 CMR to 925-313-6465.

Additionally, laboratories, which include clinics and facilities doing point-of-care testing, must report test results as described in 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.

COVID-19 testing which includes COVID-19 Point of Care antigen testing, should be reported through the CalRedie electronic lab reporting (ELR) system. If your clinic or facility does not have ELR capacity lab results can be reported using the CalRedie Reporting module. Please review CalRedie Manual Lab Reporting module for further information on enrollment.

Infection Control

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.

Clinical Management

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.

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 and report any suspected cases of MIS- C to public health to Contra Costa Public Health by calling the Communicable Disease Program at 925-313-6740 during regular business hours (M-F, 8am to 5pm) or by submitting a completed COVID-19 CMR form, indicating MIS-C in the “Disease being reported” field, by FAX to Contra Costa Public Health at (925) 313-6465.

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.

Reinfection

Currently there have been a few case studies suggestive of reinfection. Reinfection seems to be a rare occurrence, but the scope COVID-19 infection is still being explored. Given the questions around reinfection, Contra Costa Public Health Department would like to know about cases of possible reinfection if:

  1. The PCR positive result is greater than 90 day from the previous PCR positive test result, regardless of symptoms, OR
  2. 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 and evaluate the concern for reinfection, retain the current positive PCR specimen and obtain the cycle time of the test. Additionally, if possible, try and locate the previous PCR positive specimen(s) and cycle time of those test, and if still available retain any previous specimen for potential further investigation.

Management of Healthcare Workers and Essential Workers

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 to continue operations. 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 to determine staffing needs and if there is a need for them to report to work to continue operations. As noted in the guidance, if an asymptomatic healthcare worker or essential worker is needed to continue to work, they should be instructed to monitor their symptoms closely. If they develop any symptoms, they should immediately inform their supervisor and remain home. Symptomatic workers or those who are diagnosed with COVID-19 will need to remain at home and isolate per guidance below.

Notification of Results

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 are considered infections for 15 minutes or longer (cumulative total of 15 minutes or more over a 24-hour period). 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- to determine close contacts or testing plan for asymptomatic patients who live or work in a high-risk setting, such as a Long Term Care Facility, a more conservative infectious period of 10 days from the test date maybe more appropriate for these settings) 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 cocohelp@cchealth.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.

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).

Retesting, outside of rare instances in consultation with infectious disease, is NOT recommended to determine if the patient has cleared their infection. Patients who tested positive and have cleared their infection based on the ending isolation criteria above do not need a negative test for work, being transferred back to facilities, or other housing programs.

Treatment

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.

Preventive Measures

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 as appropriate and 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 if appropriate when there is increasing or substantial community prevalence. 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, if increasing or substantial community prevalence, 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.

Additional Resources