Information for Healthcare Professionals
An outbreak of respiratory disease, COVID-19, caused by a novel (new) coronavirus (SARS-CoV-2) that was first detected in China in 2019 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, along with the vaccination of eligible individuals against 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.
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, along with needed follow up, please see CDPH guidance for antigen testing and CDC Interim Guidance for antigen testing. Currently, vaccination status does not change testing recommendations and individuals should continue to test as recommended after a close contact or exposure, if they have symptoms or concerns for COVID-19 infection, or if testing is recommended as screening for their work place.
Acceptable testing specimens for PCR and antigen test 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 and antigen 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.
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.
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.
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.
How to Report Results
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.
If a patient presents and is suspected of having COVID-19, a recent exposure, or is a confirmed case, proper infection control measures should be put in place immediately and includes:
- 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.
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.
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.
Multisystem inflammatory syndrome In Children (MIS-C)
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. Please visit: www.cdc.gov/mis-c/index.html for more information. 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.
The spectrum of medical therapies to treat coronavirus disease 2019 (COVID-19) is growing and evolving rapidly, including both drugs approved by U.S. Food and Drug Administration (FDA) and drugs made available under FDA emergency use authorization (EUA). Please visit guidance published by the National Institutes of Health (NIH) for treatment and management recommendations that are based on scientific evidence and expert opinion and are frequently updated COVID-19 Treatment Guidelinesexternal icon NIH COVID-19 Treatment Guidelines home page, and CDC Information for Clinicians on Therapeutic Options for COVID-19 Patients. For further information on registered trials in the U.S., see ClinicalTrials.gov.
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.
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:
- The PCR positive result is greater than 90 day from the previous PCR positive test result, regardless of symptoms, OR
- 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, the previous PCR positive specimen(s) and cycle time of those test will need to be obtained for further investigation of possible reinfection.
Post Vaccination Infection (Breakthrough Infection After Vaccination)
Some COVID-19 cases in vaccinated individuals, known as post vaccination cases (breakthrough cases), are expected. Currently, the California Department of Public Health (CDPH) and CDC are investigating breakthrough cases to identify trends or clustering in patient characteristics, the administered vaccine, or the infecting virus, and would like these cases to be reported to the local health department.
The California Department of Public Health and CDC defines COVID-19 post vaccination cases as an individual who has SARS-CoV-2 RNA or antigen detected on a respiratory specimen collected ≥14 days after completing the primary series (i.e., both doses of a two dose series or one dose of a single dose series) of an FDA-authorized COVID-19 vaccine. It is not required that the patient be symptomatic in order to meet this case definition, but CDPH reporting is focused on post vaccination cases of interest (VBCI)- (ie) post vaccine cases that are symptomatic.
If you have a case that meets the definition of VBCI- a case that has been fully vaccinated and their test date is 14 days or greater from completing their primary vaccine series AND they are symptomatic- please contact us at public health to report VBCI by emailing an ENCYPTED email to firstname.lastname@example.org (preferred method) or by calling public health at call 925-313-6740 7 days a week to reach the Communicable Disease Programs- this number is staffed 8AM-4:30PM. If you have a post vaccination case who is asymptomatic please also report these cases so potential follow up for whole genome sequencing (WGS) can take place, as capacity allows. Please see the WGS information below.
Individuals who have only received one dose of a two dose vaccine series or cases who tested positive for SARS-CoV-2 less than 14 days after finishing their vaccine series do not need to be reported in this manner.
When reporting post vaccination cases, please include the following information:
- Patient name
- Patient DOB
- If the case was symptomatic vs asymptomatic, and if symptomatic symptom onset date,
- If the case was hospitalized or admitted into the ICU
- The patient's test date
- Vaccine type
- Vaccine dates for both dose 1 and dose 2
- If available, the laboratory the specimen was sent to
Additionally, to learn more about post vaccination cases, further laboratory investigation, such as whole genome sequencing, may take place, as noted above, if the specimen is available. Please follow up with the testing lab to have them hold the specimen for possible further investigation, prioritizing VBCI (ie symptomatic cases). If the VBCI was identified by antigen testing, consider having the patient referred for confirmatory molecular testing, such as PCR, as soon as possible (within 48 hours from antigen test) and have the laboratory hold the specimen for possible further follow up. Asymptomatic vaccine breakthrough cases may also be reviewed for potential WGS, as noted above, but VBCI will be prioritized for further follow up. Please also see the section below on whole genome sequencing for further information.
Variants Of COVID-19
Viruses constantly change through mutation, and new variants of a virus are expected to occur over time. Sometimes new variants emerge and disappear. Other times, new variants emerge and persist. During this pandemic, multiple variants of the virus that causes COVID-19 have been documented in the United States and globally and a few have mutated to cause concerns for increase in transmission, potential increase in virulence, potential for immune escape, and potential decrease vaccine effectiveness. To understand COVID-19 variance and their prevalence in the community, CDC and CDPH is working on increasing efforts for whole genome sequencing and the capacity to report and monitor for variants of concern or variants of interest (variants with mutations that could cause concern but at this time have no data that suggests any concern). For more information on variants please visit www.cdc.gov and www.cdph.ca.gov
Whole Genome Sequencing (WGS)
If you have COVID-19 cases that you are interested in reviewing for possible WGS please:
- Contact the laboratory that preformed the testing and instruct them to hold the specimen for additional public health follow up.
- Contact Contra Costa Public Health at CICT-LabLiaison@cchealth.org or email@example.com to review the case for possible further work-up with WGS. Please send an secure email with "WGS case of Interest" in the subject line.
Contra Costa Public Health will follow up with the provider to review the case and with the laboratory that performed testing, as appropriate. The team will ask the laboratory for the cycle threshold (Ct) or Relative Light Units (RLU) , and if the specimen meets eligible specimen criteria- (ie) it has a Cycle threshold (Ct) value ≤30 (if Ct available) or RLU ≥1150, and is a nasal or NP swabs in viral transport medium (VTM), saline, or molecular transport medium, Hologic Aptima media, sputa. Please note that dry swabs, are not acceptable for WGS.)- the team will work to forward the specimen to the Contra Costa Public Health Laboratory for further testing and WGS as appropriate. At this time, cases that will be prioritized for WGS include:
- Concerns for reinfection and the current specimen and the specimen from previous positive result(s) are available
- Concerns for Variants:
- Outbreaks with high attack rate in a given outbreak or more cases then expected,
- Cases with concerns for variants due to drop in diagnostic assay target (ex: testing with a drop in the S target ((eg) ORF1ab target detected, N targe detected, and S target not detected), any marked differences in real-time RT PCR viral target(s) cycle threshold values, or other testing changes that may suggest a variant.
- Breakthrough infection after vaccinations, as noted above- Individuals who were fully vaccinated > 14 days from the test date. (ie received the second dose of vaccine in a two dose series or one dose in a one dose series > 14 days from test date). Symptomatic breakthrough cases (VBCI) will be prioritized for WGS, but asymptomatic vaccine breakthrough cases can be reviewed to see if potential follow up with WGS is appropriate.
- Hospitalized patients (or ICU patients)
- Concerning cases for possible variances due to clinical history (immunocompromised, prolonged infection, Cases who received Monoclonal Antibody but failed to improve, death, etc)
- Cases with recent travel (14 days from test date) or who is a close contact to someone that had a recent international travel. Cases with international travel or contacts with international travel will be prioritized for WGS, but cases with domestic travel maybe appropriate for WGS as well and can be reviewed for possible further follow up.
When contacting the Contra Costa Public Health about potential WGS, please include in the email the following information:
- Patient name
- Patient DOB
- Specimen collection date,
- Name of laboratory the preformed testing,
- Symptom onset date and symptoms,
- if applicable, reason for the WGS request, and appropriate information for reason for WGS is provided such as:
- breakthrough vaccine cases include vaccine dates (both vaccine #1 and Vaccine #2 date), vaccine manufacturer,
- travel cases include travel dates and locations (international and domestic, if appropriate),
- Reinfection cases, date or previous infection, if had symptoms during previous infection,
- Clinical information such as hospitalization status, if immunocompromised, etc
- And other appropriate information for WGS reason.
Please note WGS is not currently a validated assay and requesting providers or facilities will not receive laboratory reports from the Contra Costa Public Health Laboratory or California Department of Public Health (CDPH). However, the Contra Costa Public Health may reach out for purposes of Contact Tracing to control the spread of SARS-CoV-2 and certain variants.
For further information regarding process for COVID-19 Whole Genome Sequencing and reporting to local public health please review Provider and Laboratory Health Advisory COVID-19 Cases of Interest for Whole Genome Sequencing and review information on Contra Costa Public Health Laboratory website.
Quarantine for Close Contacts
CDC announced on 12/2/2020 options for quarantine. The full quarantine period for close contacts remains 14 days, but given resources and other considerations CDC has released options for reducing quarantine time.
Based on this guidance from the Centers for Disease Control and Prevention, Contra Costa Public Health has shortened the quarantine period for most individuals from 14 days to 10-days. Individuals should remain at home or another residence through 10 days from the last date that they were in contact to an person with COVID-19. Testing is recommended between day 7-10 after exposure, but individuals should still quarantine for the full 10 days even if they test negative. Symptoms can develop, even after testing negative, within 14 days after exposure, and individuals should continue to monitor their symptoms closely, and immediately isolate if they develop any symptoms. Additionally, close contacts should continue to strictly adhere to preventive measures such as social distancing and use of face masking/facial covering once out of the 10 day quarantine.
Because there is a small risk of virus transmission after the 10 day period, to lessen the risk of outbreaks in high-risk congregate settings such Long-Term Care facilities (residential care facilities for the elderly, board and cares, skilled nursing facilities, etc) and detention facilities individuals who have had close contact to a case and live in these settings should remain in quarantine for the 14-day period. Additionally, new admission to these facilities should continue to quarantine for 14 days from admission date or last date of potential exposure. Staff who work within these high-risk congregate settings should complete a 10 day home quarantine as described above, and also remain off of work for the full 14 day period, unless there are staffing needs as guided in home quarantine for Essential and Healthcare Workers.
Individuals who have tested positive for COVID-19 within the past 3 months, recovered from their infection, and remain asymptomatic do not have to quarantine after a close contact. Additionally, individuals should not test again if within 3 months of their infection, if no concerns, as noted above.
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. Facilities should also review CDC Mitigating Staffing Shortages.
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 and continue all other preventive measures. 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.
Quarantine for Fully Vaccinated Individuals
CDC continues to update guidance for fully vaccinated individuals including quarantine and infection control guidance as laid out on CDC guidance for fully vaccinated individuals and CDC infection control guidance after vaccination.
Fully vaccinated individuals who meet criteria will no longer be required to quarantine following an exposure to someone with COVID-19 if they meet ALL of the following criteria:
- They are fully vaccinated (it has been 2 weeks or more after getting the second dose in a 2-dose vaccine series, or 2 weeks or more after getting a single in a one-dose vaccine series) AND
- They are within 3 months of getting their last dose in the vaccine series AND
- They have not developed any symptoms since their close contact.
Exceptions to this quarantine criteria applies for fully vaccinated resident in Long-Term Care Facilities (Skilled Nursing Facilities (SNFs), Intermediate Care Facilities (ICF), Assisted Living Facilities (ALF), Board and Care, etc), non-healthcare congregate settings (e.g., correctional and detention facilities, group home), and patients in healthcare facilities as noted below.
Individuals who meet the criteria above and do not need to quarantine should still follow all preventive measures and watch for symptoms of COVID-19 for 14 days after their close contact. If they begin to develop any symptoms they should isolate immediately and follow up with their healthcare provider or with COVID-19 testing. If they go to a healthcare setting (clinic, hospital, dialysis center, etc) staff in these settings should continue to use appropriate transmission based precautions for patients with a close contact.
For asymptomatic fully vaccinated close contacts, testing is no longer recommended unless they are a resident/patient in a long-term care facility, healthcare facility, or non-healthcare congregate facility, a healthcare worker, a staff member in any congregate setting (long-term care facilities, detention facilities, shelters, group homes, etc), or work in other high-density workplaces (e.g., meat and poultry processing and manufacturing plants). Additionally, staff who are fully vaccinated should also continue to participate in staff testing for screening/surveillance.
Fully vaccinated patients in healthcare settings, and residents in both long-term care facilities and non-healthcare congregate settings should continue to follow quarantine and testing guidance in these settings, appropriate transmission based guidelines, and follow up testing after an exposure to someone with suspected or confirmed COVID-19. Healthcare settings includes outpatient clinical settings (clinic, dialysis, etc) and any hospital settings. Facilities should inform all healthcare settings when sending patients to these settings of any patient who has had close contact to a COVID-19 case, regardless of vaccination status, so staff in these settings can use the appropriate transmission-based precautions. New admissions into long-term care facilities do not need to quarantine on admission if they are fully vaccinated, unless there was an exposure to a case of COVID-19 I the last 14 days or are other concerns prior to admission. Facilities should also review new admission policies and procedures from their appropriate licensing body to ensure they are in adherence with these. New admissions who are fully vaccinated still need to follow all preventive measures. Facilities should also continue to monitor these residents for any symptoms and immediately isolate and test for COVID-19 if any concerns arise.
Fully vaccinated healthcare workers, and staff who work in any congregate setting (long-term care facilities, detention facilities, residential treatment facilities, shelters, group homes, etc) who meet the criteria above for a fully vaccinated person, and do not have COVID-19 like symptoms, do not need to quarantine after a high risk workplace exposure as defined in healthcare workers with potential exposure to COVID-19 or after a community exposure/close contact to someone with suspected or confirmed COVID-19, but should test following an exposure, with any outbreak or response testing, and continue their routine workplace screening programs. For more information and guidance on quarantine for healthcare workers and essential workers please visit Instructions for Healthcare and Essential Workers. Staff should monitor their symptoms closely and immediately isolate and test if they develop any COVID-19 symptoms.
Patient 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 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, discharges should be discussed between facility and hospital to ensure patient can be isolated safely in the facility. Public health approval is not needed, as long as facility can isolate safely and no questions or concerns arise. Public health should be notified of 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.
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).
Patients with severe disease hospitalized in the intensive care unit 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 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).
A very limited number of persons with severe illness who were not hospitalized in the intensive care unit, which includes Individuals who have respiratory frequency >30 breaths per minute, SpO2 <94% on room air at sea level (or, for patients with chronic hypoxemia, a decrease from baseline of >3%), ratio of arterial partial pressure of oxygen to fraction of inspired oxygen (PaO2/FiO2) <300 mmHg, or lung infiltrates >50% may warrant extending duration of isolation to up to 20 days after symptom onset.
As described in CDC Duration of Isolation and Precautions for adults with COVID, Decision Memo, an estimated 95% of severely or critically ill patients, no longer had replication-competent virus 15 days after onset of symptoms; no patients had replication-competent virus more than 20 days after onset of symptoms. The exact criteria that determine which patients will shed replication-competent virus for longer periods are not known. Disease severity factors and the presence of immunocompromising conditions should be considered in determining the appropriate duration for specific patient populations. For example, patients with characteristics of severe illness it may be appropriate for these patients least 15 days of isolation under Transmission-Based Precautions.
Patients who are severely immunocompromised could remain infectious more than 20 days after symptom onset. CDC defines severely immunocompromised as patients on chemotherapy for cancer, being within one year out from receiving a hematopoietic stem cell or solid organ transplant, untreated HIV infection with CD4 T lymphocyte count < 200, combined primary immunodeficiency disorder, and receipt of prednisone <20mg/day, but ultimately, notes that the degree of immunocompromise for the patient is determined by the treating provider, and preventive actions are tailored to each individual and situation. For patients who are considered severely immunocompromised, consultation with infectious diseases specialists is recommended for possible use of a test-based strategy for determining when to discontinue Transmission-Based Precautions could be considered. Please review CDC Discontinuation of Transmission Based Precautions and Disposition of Patients with SARS-COV2 Infection in healthcare settings for more details.
For patients who may remain infectious longer than 10 days, their symptoms, clinical presentation, and context should be reviewed by their healthcare provider or hospital team to determine if a longer isolation period is warranted. Additionally, consultation with local infectious disease experts can be considered when making decisions about discontinuing isolation for patients who maybe infectious longer than 10 days.
For patients who were asymptomatic at the time of testing 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.
Retesting, outside of instances that are recommended 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.
As the COVID-19 vaccine becomes more widely available in our community as a way to prevent and decrease severe outcomes from COVID-19, mitigation strategies such as social distancing, universal masking, isolation of ill individuals, and placing their close contacts in quarantine will continue to be most effective tool for containing the spread of COVID-19 as the vaccination efforts continue. Patients should be instructed to practice social distancing, wear mask if out, stay home if sick, wash hands frequently, avoid touching their faces, avoid crowded areas, as much as possible avoid poorly ventilated space, and to get vaccinated against COVID-19 as they become eligible for the vaccination.
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 provide PPE for staff and patients as needed, screen all patients for symptoms (fever, cough, shortness of breath) prior to them being seen, and reschedule any appointments with sick patients.
In Contra Costa County, vaccination efforts are taking place and will be an important aspect to prevention and mitigation strategies. Although the risk of COVID-19 is lower in vaccinated individuals, individuals who are vaccinated can still get COVID-19 and at this time they should continue to do all recommended preventive measures to protect themselves and others as noted in the CDC guidance for fully vaccinated individuals, including wearing a mask, staying at least 6 feet away from others, avoiding crowds, covering coughs and sneezes, washing hands often, following CDPH travel guidance, and following any applicable workplace or school guidance, including guidance related to personal protective equipment use or SARS-CoV-2 testing. Additionally, if vaccinated individuals are found to have COVID-19 they should still follow the same guidance for anyone with COVID-19 which includes isolation and contact tracing. Please visit CDC COVID-19 vaccine website and www.coronavirus.cchealth.org/vaccine for more information on COVID-19 vaccine and vaccination efforts.
Please also review CDC How to Protect Yourself and Others for Further Preventive Measures against COVID-19.
COVID-19 Vaccinations Adverse Reaction Reporting
COVID-19 vaccines are safe and effective, but clinicians should report any adverse reaction, including any serious and life-threatening adverse events, in patients following receipt of any COVID-19 vaccine to CDC/FDA Vaccine Adverse Event Reporting System (VAERS). These reported adverse events will be reviewed as part of vaccine safety monitoring, and if appropriate, follow up and further investigation may take place.
Due to reporting of adverse events, on April 13, 2021 CDC temporarily paused the use Johnson and Johnson vaccine to review the vaccine adverse reaction after receiving reports of a few cases of thrombosis with thrombocytopenia syndrome (TTS) following the Johnson and Johnson vaccine. The Johnson and Johnson vaccine was taken off of pause on 4/23/2021 after a thorough review by FDA and the CDC. TTS following Johnson and Jonson COVID-19 vaccine was deemed a rare event and added as a low risk associated health effect to patient education materials: CDPH Johnson and Johnson Fact Sheet. Although a rare reactions, clinicians should continue to monitor for these reactions and if a patient presents after receiving the Johnson and Johnson COVID-19 vaccine with concerns for thrombotic events or thrombocytopenia ((ie) severe headache, backache, new neurologic symptoms, severe abdominal pain, shortness of breath, leg swelling, petechiae, new or easy bruising have a high, or thrombocytopenia on CBC) TTS should be considered with appropriate follow up. Clinicians should also immediately report these adverse events to VEARS and save a copy of the report. In addition to promptly submitting a VEARS report, please also notify Contra Costa Public Health Department within one day regarding a case of TTS following receipt of Johnson and Johnson vaccine. Please contact Contra Costa Public health by sending an ENCYPTED email to email@example.com (preferred method) or by calling public health at call 925-313-6740 7 days a week to reach the Communicable Disease Programs- this number is staffed 8AM-4:30PM. Please include patient demographics (name, DOB), date received vaccine, symptoms onset and symptoms, VEARS number and attach the VEARS report if sending an email.
Please also review for further information regarding Johnson and Johnson Pause:
- 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