Coronavirus Disease 2019 (COVID-19) Update

Infectious Disease Epidemiology and Outbreak Response Bureau

March 17, 2020

The information in this presentation is current as of March 17, 2020, unless otherwise noted, and subject to change.

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Interim Events

• Global pandemic declared

• U.S. ban on travel from Europe

• Community transmission in Maryland

• First confirmed case in nursing home resident in Maryland

• Statewide closure of schools, bars, and restaurants

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Epi Update

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Worldwide: Confirmed COVID-19 Cases

• 153,517 confirmed (10,982 in past 24 hrs)

• 5735 deaths (343 in past 24 hrs)

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Source: https://www.who.int/docs/default-source/coronaviruse/situation-reports/20200315-sitrep-55-covid-19.pdf?sfvrsn=33daa5cb_6, accessed March 17 2020

U.S.: Confirmed COVID-19 Cases

6 Source: CDC, https://www.cdc.gov/coronavirus/2019-ncov/cases-in-us.html , accessed March 16, 2020

• 4,226 cases, 75 deaths

Maryland: Confirmed COVID-19 Cases

• 57 confirmed cases

• Age• <18 years: 0

• 18-64 years: 37

• 65+ years: 20

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Testing

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UPDATE: Testing in outpatient settings MDH Clinician Letter 3/11/20

• Collection of NP specimens for COVID-19 testing using contact and droplet precautions with a surgical mask is appropriate. Eye protection should always be used.

• Specimen collection may be performed in an examination room with the door closed.

• Severely ill patients who will be transferred to a higher level of care should not be tested in an outpatient setting.

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UPDATE: COVID-19 testing guidanceMDH Clinician Letter 3/13/20

• Use commercial/hospital labs

• Health department approval not required for commercial/hospital lab testing

• Use clinical judgment for testing determination

• NP swab alone is ok for COVID-19 testing

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• MDH Lab testing the following groups: • Person who had close contact with a laboratory-confirmed COVID-

19 patient within 14 days of onset AND signs of infection including either fever or signs/symptoms of a lower respiratory illness

• Person who resides in a nursing home or long-term care facility AND who has either fever or signs/symptoms of a lower respiratory illness AND who tested negative for influenza on initial workup and no alternative diagnosis

• Hospitalized patients who have signs and symptoms compatible with COVID-19 and no alternate explanation in order to inform decisions related to infection control

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UPDATE: MDH Lab Testing MDH Clinician Letter 3/13/20

• LHD may approve COVID-19 testing at MDH lab if patient falls into one of these 3 groups

• Instruct submitter to enter your name and LHD name in the “Prior arrangements” box on the lower right area of lab slip

• Notify MDH of all test approvals (during business hours)

• New shipping guidance: triple packaging system

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UPDATE: MDH Lab Testing, cont. MDH Clinician Letter 3/13/20

Case InvestigationsKenny Feder, PhD

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Key Principles

• Always create an investigation in NEDSS ASAP• Identify all contacts during the period when the

patient was symptomatic• Offer guidance on isolation• Notify contacts – including health care settings – of

exposure and offer guidance

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Initiating an Investigation

• Three ways you may be notified:• Electronic Lab Report (ELR) – most cases• Report from a provider• Report from Maryland Department of Health

• Always create an investigation in NEDSS ASAP• Laboratory-confirmed cases: enter all data required for

QA + symptom onset, hospitalization, and living/deceased.

• ELR reporting negative test: create investigation and mark “Not a Case”

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Beginning of Investigation Interview

• Contact the patient• Verify they have been notified of test result• Verify contact information and address• Verify occupation• Verify date of symptom onset• Inquire about international or interstate travel in

two weeks prior to onset

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Contact Investigation

• Identify all household residents• Start at date of symptom onset• For each day until positive test:

• Did you have any visitors in the home?• Did you go anywhere outside the home?• Whom did you interact with there?• How did you get there?• Did you visit any healthcare settings?

• Record names, birthdates, contact info for all contacts and healthcare providers

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What is a contact?

• High Risk:• Share a household household• Intimate partners• Caretaker not taking proper precautions

• Medium Risk• Within 6 feet for extended period (e.g., >5 min)• Coughed or sneezed on• Sat within 6 feet on aircraft• Caretaker taking proper precautions

• Low Risk• Shared indoor environment

Detailed guidance: https://www.cdc.gov/coronavirus/2019-ncov/php/risk-assessment.html

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Home Isolation

• People diagnosed with COVID-19 must self-isolate• Must sign voluntary isolation agreement• Active monitoring: conduct if needed, but prioritize• Be sure to send letter releasing from isolation at

completion of isolation

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What to do with contacts?

• High Risk – Home isolation agreement, stay home 14 days

• Medium risk – stay home 14 days (no isolation agreement required)

• Low risk – self-monitor

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Discontinuation of home isolation

• People diagnosed 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 72 hours have passed since recovery, defined as resolution of fever without the use of fever-reducing medications and improvement in respiratory symptoms; and

• At least 7 days have passed since symptoms first appeared

21Source: https://www.cdc.gov/coronavirus/2019-ncov/hcp/disposition-in-home-patients.html

Discontinuation of home isolation

• People diagnosed with COVID-19 who have not had any symptoms and were directed to care for themselves at home may discontinue home isolation under the following conditions:

• At least 7 days have passed since the date of their first positive COVID-19 diagnostic test and have had no subsequent illness

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Source: https://www.cdc.gov/coronavirus/2019-ncov/hcp/disposition-in-home-patients.html

Healthcare Personnel Exposures Richard Brooks, MD, MPH

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Evaluation of HCP Exposures

• In general, follow CDC guidance: https://www.cdc.gov/coronavirus/2019-ncov/hcp/guidance-risk-assesment-hcp.html

• Requires knowledge of whether patient was masked and what PPE HCP was using at time of interaction

• High and Medium exposures exclude and actively monitor

• Low exposure do not exclude and self-monitor

• Low threshold to allow HCP to continue working IF asymptomatic and wears a facemask while working

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HCP w/ COVID-19 – Return to work

• Non-test-based strategy. Exclude from work until• At least 3 days (72 hrs) have passed since recovery

defined as resolution of fever w/o the use of fever-reducing meds AND improvement in respiratory symptoms; AND,

• At least 7 days have passed since symptoms first appeared

• If HCP were never tested for COVID-19 but have an alternate diagnosis, criteria for return to work should be based on the diagnosis

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Return to Work

• After returning to work, HCP should:• Wear facemask at all times in HC facility until sx fully

resolved or until 14d after sx onset, whichever longer• Be restricted from contact w/ immunocompromised pts.

until 14d after sx onset• Adhere to hand hygiene, resp hygiene, other aspects of

infection prevention and control• Self-monitor for sx and seek re-evaluation from occ

health if respiratory symptoms recur or worsen

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MDH Office of Preparedness and Response Sherry Adams, Director

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Higher Education, Business, and EnvironmentClifford Mitchell, MS, MD, MPH

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School Health Cheryl Duncan De Pinto, MD, MPH, FAAPDirector of Population Health Improvement

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Questions?

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