Health Advisory: Update #8 & Interim Guidance On Outbreak Of COVID-19

| April 4, 2020
close up of microscope with blue background

This is an evolving situation. The guidance is subject to change frequently. Please ensure you are reviewing the information as it comes out.

Contact: Melissa Sixberry, Director of Disease Control  509-249-6509

Requested Action:

Background:

COVID-19 disease should be considered in patients with lower respiratory infection symptoms such as fever, cough, or shortness of breath, without other explanation. It may also manifest with milder symptoms such as sore throat, coryza, body aches and fatigue.

As the COVID-19 outbreak continues to rapidly evolve, it is important to ensure local health jurisdictions and clinical partners are aware of current operational guidance on: testing, personal protective equipment, isolation, and quarantine. A summary of current recommendations is provided below. In addition, links are provided to documents for more detailed guidance on each topic. For the most up-to-date reports of cases in Yakima County, visit the Yakima Health District COVID-19 website.

At this point in time, providers must contact YHD when:

  1. Reporting confirmed cases, hospitalizations and deaths related to COVID-19
    1. Fax lab and demographics to 509-249-6628
  2. Requesting testing at the WA DOH PHL
    1. If testing at a commercial lab, YHD does not need to be notified. Follow guidelines outlined in “Testing”
    2. During business hours call 509-249-6541. After hours 509-575-4040 Option 2

1. Limit Risk of Exposure at Healthcare Facilities 4/3/20

Healthcare facilities must be implementing measures to minimize the possibility of exposure in lobbies, potential exposure to the healthcare workforce as well as to free up room space.

  • Healthcare facilities are encouraged to implement telehealth options as available.
  • Healthcare facilities are encouraged to cancel and/or reschedule all non-emergent procedures.
  • Hospitals must implement visitor restrictions and it is recommended that permitted visitors are screened for symptoms and fever. For Patients with COVID-19, the Yakima Health District recommends allowing one asymptomatic close contact visitor with PPE and that the visitor is restricted to the unit.
  • To further reduce the volume of patients coming into its facilities, healthcare facilities should reschedule non-essential visits unless clinically necessary for the next 4-6 weeks.
  • Limit movement of staff and patients within facility to help decrease transmission. This includes, HCWs, dietary, environmental services and other support staff. 4/3/20

2. PPE: Universal masking in healthcare settings 4/3/20

Given local evidence of multiple cases of asymptomatic COVID-19 infection in healthcare staff, and emerging evidence around the role of transmission from asymptomatic and pre-symptomatic individuals, we recommend that until further notice all individuals employed in healthcare settings and congregate care settings (such as group homes, jails, skilled nursing and assisted living) take a universal masking approach when at work. This includes:

  • Donning a mask prior to entry to work and leaving a mask on at all times in the workplace except for eating, drinking, or changing a mask, during which time social distancing of >6 feet must be observed.
  • If local supplies of PPE do not support universal masking with surgical masks at all times, we recommend use of cloth/homemade masks for all activities beyond direct care of patients with known or suspected COVID-19 infection.
  • Avoid touching mask except for eating, drinking, replacing masks, or changing mask as necessary for specific tasks (surgical mask for suspect or confirmed COVID-19 patients, N-95 for procedures anticipated to generate aerosolized droplets
  • Performing proper hand hygiene after any handling of mask (touching or adjusting, donning/doffing)
  • Launder cloth masks daily, replace surgical masks and N-95’s per CDC guidelines (when soiled, damaged, hard to breath through: https://www.cdc.gov/coronavirus/2019-ncov/hcp/ppestrategy/face-masks.html )

Patients with known or suspected COVID-19 who are critically ill as well as those requiring aerosol generating procedures are recommended to be placed in standard/airborne/contact precautions with eye protection. For other patients with known or suspected COVID-19, the Department of Health recommends using standard/droplet/contact precautions with eye protection.

Use of PPE when caring for confirmed or suspected COVID 19 with proper donning and doffing instructions. 4/3/20 https://www.cdc.gov/coronavirus/2019-ncov/downloads/A_FS_HCP_COVID19_PPE.pdf

Follow recommendations for extended use and limited reuse of N95 filtering facemask respirators in healthcare settings.

Guidance document for PPE: https://www.doh.wa.gov/Portals/1/Documents/1600/coronavirus/ppeCOVID-19confirmed.pdf

3. Returning to Work (RTW) after a COVID-19 positive test or household exposure to COVID-19 4/3/20

As we identify more healthcare workers (HCW) and first responders (FR) with symptomatic and asymptomatic COVID-19 infection, our community will have increasingly scarce resources to staff our healthcare facilities. In light of this we have developed these additional recommendations for returning to work safely after COVID-19 positive testing for HCW/FR in Yakima County.

SYMPTOMATIC COVID-19 INFECTION IN HCW/FR

As staffing permits, follow CDC and WA DOH guidelines for returning to work (RTW): https://www.cdc.gov/coronavirus/2019-ncov/healthcare-facilities/hcp-return-work.html

https://www.doh.wa.gov/Portals/1/Documents/1600/coronavirus/HealthCareworkerReturn2Work.pdf

For confirmed or suspected symptomatic COVID+ HCW/FR:

  • exclude from work until 3 days/72 hours after resolution of fever (without fever-reducing medications) AND improvement in respiratory symptoms AND at least 7 days since symptom onset. If testing is used to confirm resolution, employees may RTW after two consecutive negative tests collected >24 hours apart. YHD does not recommend this strategy at this time due to ongoing effort to conserve testing supplies.
  • Wear a surgical facemask at all times for 7 days after return to work, or 14 days after symptom onset, whichever is longer.
  • Self-monitor for symptoms and exclude from work for return/worsening of symptoms.
  • Follow proper hand and cough hygiene.
  • Avoid contact with patients with severe immune compromise (e.g. transplant, oncology, HIV)
  • Pair recovered COVID+ staff with COVID+ patients as is possible.

ASYMPTOMATIC COVID-19 INFECTION IN HCW/FR

COVID-19 is most transmissible when individuals are most symptomatic but can be spread by asymptomatic (and presymptomatic) individuals as well. Every effort should be taken to exclude asymptomatic individuals with positive COVID-19 test results for at least 7 days after the test was obtained. If there are severe staffing shortages, it may be necessary for COVID+ asymptomatic staff to RTW before 7 days have passed since testing. For asymptomatic COVID+ HCW/FR:

  • Only return as many asymptomatic COVID+ staff (“positive staff” for remaining recommendations) as is absolutely necessary.
  • Wear a surgical facemask at all times for 14 days after positive test results.
  • Perform temperature screening at arrival to work/shift change at minimum and consider screening before returning from breaks as well. Exclude for temperature >100.4F.
  • Self-monitor symptoms and exclude from work for development of symptoms
  • Follow proper hand and cough hygiene.
  • Exclude positive staff from work with patients with severe immune compromise (e.g. transplant, oncology, HIV) until at least 14 days have passed since testing.
  • Pair recovered COVID+ staff with COVID+ patients as is possible. Cohort COVID-19+ staff as is possible (breaks, meals, workspace together) until 14 days have passed since testing, and ensure frequent sanitizing of common surfaces in these areas.

ASYMPTOMATIC HCW/FR WITH COVID-19 EXPOSURE

For occupational exposures, follow Washington DOH and CDC guidelines for returning to work (RTW) based on exposure risk category:

https://www.doh.wa.gov/Portals/1/Documents/1600/coronavirus/HealthCareWorkerReturn2Work.pdf https://www.cdc.gov/coronavirus/2019-ncov/healthcare-facilities/hcp-return-work.html

For HCW/FR with household exposure, current recommendations are:

https://www.cdc.gov/coronavirus/2019-ncov/php/public-health-recommendations.html

  • Stay at home until 14 days after most recent exposure, maintain 6 feet from others at all times
  • Self-monitor for symptoms (twice daily temperature checks, observe for cough, shortness of breath, etc)
  • Avoid contact with high risk individuals (patients older than 60 years, patients with underlying medical conditions, pregnant women)

If the HCW/FR works in a setting where staffing is critically low (as determined by institutional leadership) and early RTW after household or occupational exposure is necessary, we recommend the following:

  • Delay return to work as long as is feasible to attain maximum number of recommended days quarantine
  • Wear a surgical facemask at all times until 14 days after most recent exposure to ill household member.
  • Perform temperature screening at arrival to work/shift change and before returning from breaks (at least every 4 hours). Exclude for temperature >100.4F.
  • Self-monitor symptoms and exclude from work for development of symptoms.
  • Follow proper hand and cough hygiene.
  • Exclude COVID-19-exposed staff from work with patients with severe immune compromise (e.g. transplant, oncology, HIV) until at least 14 days have passed since most recent exposure.

4. Isolation – General Public

Consistent with CDC guidelines, WA DOH recommends persons with COVID-19 who have symptoms and were directed to care for themselves at home may discontinue home isolation under the following conditions:

  • At least 3 days (72 hours) have passed since recovery defined as resolution of fever without the use of fever-reducing medications and improvement in respiratory symptoms (e.g., cough, shortness of breath); and,
  • At least 7 days have passed since symptoms first appeared. Guidance document for general public:

https://www.doh.wa.gov/Portals/1/Documents/1600/coronavirus/COVIDcasepositive.pdf

5. Quarantine – General Public

Individuals who have been in close contact with someone with COVID-19 should monitor their health for fever, cough and shortness of breath during the 14 days after the last day they were in close contact with the sick person with COVID-19. They should not go to work or school, and should avoid public places for 14 days.

Guidance document: https://www.doh.wa.gov/Portals/1/Documents/1600/coronavirus/COVIDexposed.pdf

6. Testing 4/3/20 

WHERE TO TEST

As additional resources for testing become available, more testing sites have been established. Please see YHD Provider Resources webpage for current testing options for High-risk Yakima County residents with COVID-19 symptoms, including those who work in healthcare, public safety or critical infrastructure.

https://www.yakimacounty.us/2389/DRIVE-THRU-COVID-19-TESTING

 

WHO TO TEST

There are currently no restrictions on who can be tested for COVID-19 and commercial testing is becoming more available. Healthcare providers are encouraged to test any patient with symptoms consistent with COVID-19 (e.g., fever, cough, shortness of breath). We will continue to closely monitor available testing supplies and lab capacity and will notify you of any changes to these recommendations. If testing capacity is at any time limited, we will request that providers resume prioritization of testing for COVID-19 as follows:

The following patients with COVID-19 symptoms should be tested for COVID-19:

  • Patients hospitalized with severe lower respiratory illness
  • Patients who work in any setting where healthcare services are delivered (including hospital, department of corrections, juvenile detention centers, mental/behavioral health clinics, longterm care facilities, and similar)
  • Patients working in other public safety occupations (e.g., law enforcement, fire fighter, EMS)
  • Patients who live or work in an institutional or congregate setting (e.g., corrections, long term care facility, homeless/shelters)
  • Patients working in critical infrastructure occupations (e.g., grocery stores, pharmacist, restaurants, gas stations, public utilities, etc.)
  • Patients with close household contacts who work in healthcare (including long term care and other congregate care settings) and public safety occupations.
  • Patients older than 60 years
  • Patients with underlying medical conditions
  • Pregnant women

The following individuals experiencing symptoms of COVID-19 (e.g. fever or cough or shortness of breath) can be tested at the WA DOH Public Health Lab:

  • Patients who work in any setting where healthcare services are delivered (including: hospital, department of corrections, juvenile detention centers, mental/behavioral health clinics, longterm care facilities, and similar)
  • Patients working in other public safety occupations (e.g., law enforcement, fire fighter, EMS)
  • Patients who live or work in an institutional or congregate setting (e.g., corrections, long term care facility, homeless/shelters)
  • Patients hospitalized with severe lower respiratory illness
  • Patients with close household contacts who work in healthcare (including long term care and other congregate care settings) and public safety occupations.

Testing is not recommended in members of the general public who are asymptomatic. A negative test result does not rule out an infection.

HOW TO TEST

https://www.cdc.gov/coronavirus/2019-ncov/lab/guidelines-clinical-specimens.html

The FDA and CDC have listed alternative testing sites (e.g. nasal, NP, OP, sputum), swabs, and transport media to address current shortages. Below are some current of the current recommendations, but NP swab submitted in viral transport medium is still considered to be the gold standard for diagnosing COVID-19 infection.

If a nasopharyngeal specimen is not available, then any of the following are acceptable:

  • oropharyngeal specimen collected by a healthcare professional (HCP);
  • mid-turbinate specimen by onsite self-collection or HCP (using a flocked tapered swab); or
  • anterior nares specimen by onsite self-collection or HCP (using a round foam swab)
  • multiple specimens may be taken with a single swab. Discontinue outpatient influenza testing unless you wish to perform both tests and your lab can run both from the same swab.

Refer to FDA and CDC guidelines for specific products recommended for COVID-19 testing, but examples of permissible swab types include several dacron, polyester and foam swabs from the following manufacturers: Puritan, Copan, BD, Fisher, DHI/Quidel. Be sure to observe recommended swab type for location being swabbed.

Other solutions may also be used for viral transport when universal (viral) transport media is not available. The FDA recommends use of phosphate buffered saline (PBS), including molecular grade PBS when available, and other similar formulations including Delbecco’s PBS, to collect and transport samples for molecular RT-PCR SARS-CoV-2 assays. If PBS is not available, normal saline may be used. FDA believes that a sterile glass or plastic vial containing between 1mL and 3mL of PBS or normal saline is appropriate. Specimens can be stored up to 72 hours at 4℃.

7. Recommendations for Airborne Contaminant Removal for Room Turnover

  1. Two hours is a necessary, and conservative estimate when a facility does not know what the air exchange rate is for a facility.
  2. If a facility can guarantee 6 or more exchanges per hour, that facility can move to a onehour turnover.
    Guidance document for testing:

https://www.doh.wa.gov/Portals/1/Documents/1600/coronavirus/Interim2019NovelCoronavirusQuicksheetProviders.pdf

8. Patient Education

Providers should review documents below with patients and provide a copy to take home at the time of evaluation. Providers should immediately notify patients of positive results and direct them to the patient education below. Positive cases should also be advised to notify close contacts and provide them with education below for “exposed to a confirmed”.

  • For symptoms—What to do if you have symptoms of COVID-19 and have not been around a person diagnosed with COVID-19.

  • For exposed—What to do if you may have been exposed to a person with COVID-19.
  • For confirmed or suspected—What to do if you have confirmed or suspected COVID-19.

Other patient resources available on WA DOH Coronavirus website

9. Resources: