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Posted on: March 10, 2020

March 9 COVID-19 Updated Guidance for Clinicians

COVID-19 Updated Guidance for Clinicians March 9, 2020 

SUMMARY: Please review this health alert for: 

  • Situation update 
  • Laboratory testing guidance 
  • Infection Prevention for Outpatient Settings 
  • Directions for Patients 
  • Health care worker exposure classification-and-management  
  • Telephone triage and tele-health 
  • Viability of SARS-CoV-2 on fomites  
  • Certification of COVID-19 deaths 

SITUATION UPDATE 
(as of 11 a.m. March 9) 
Total confirmed, presumptive positive, or probable cases: 41
Deaths: 1
Hospitalized: 12 

Presumed sources 

  • Travel-associated: 1 
  • Community-acquired: 19 
  • LTCF-associated: 13 
  • Under investigation: 8 

Cases have been diagnosed among residents from Bothell and Lynnwood in the south up through Everett and Marysville to the north and to Monroe and Sultan in the east. 

Modeling estimates of transmission in the Snohomish-King County region: 

  • Total infections March 10: 1,100 (90% CI 210-2800) 
  • Estimated doubling time:  5-7 days

LABORATORY TESTING 
COVID-19 Testing Information for Healthcare Providers (DOH): https://www.doh.wa.gov/Portals/1/Documents/1600/coronavirus/Interim-2019NovelCoronavirusQuicksheetProviders.pdf 

There are currently no restrictions on who can be tested for COVID-19 and commercial testing is becoming widely available. Healthcare providers may test any patient with symptoms consistent with COVID-19 (e.g., fever, cough, shortness of breath).  

The following patients with COVID-19 symptoms are considered at highest priority for testing:  

  • Healthcare workers  
  • Patients in other public safety occupations (e.g., law enforcement, fire fighter, EMS) 
  • Patients involved in an illness cluster in a facility or institution (e.g., healthcare, school, corrections, shelters)  
  • Patients with severe lower respiratory illness (hospitalized or fatal)  
  • Patients with worsening symptoms
  • Patients older than 60 years 
  • Patients with underlying medical conditions  
  • Pregnant women 

In general, healthcare providers should send specimens for COVID-19 testing to commercial laboratories. 

Note that we would like to be notified by the facility/provider regarding the following types of suspected cases upon collection of specimens, even if the testing is going through a private lab:  

  • Healthcare workers  
  • Patients in other public safety occupations (e.g., law enforcement, fire fighter, EMS)  
  • Patients involved in an illness cluster in a facility or group (e.g., healthcare, school, corrections, business)  

Testing for these and for uninsured patients is available through the Washington State Public Health Laboratories with prior approval from SHD, noting that turnaround time may be subject to specimen prioritization. 

INFECTION PREVENTION FOR OUTPATIENT SETTINGS 
Please refer to Washington State Department of Health guidance document: https://www.doh.wa.gov/Portals/1/Documents/1600/coronavirus/OutpatientGuidance-COVID19.pdf 

DIRECTIONS FOR PATIENTS 
Directions for test-positive COVID-19 cases. https://www.doh.wa.gov/Portals/1/Documents/1600/coronavirus/COVIDcasepositive.pdf 
SHD should be notified by the lab and be reaching out to these folks, too, but please give them this handout if in your presence.  

  • Directions for asymptomatic exposed individuals: https://www.doh.wa.gov/Portals/1/Documents/1600/coronavirus/COVIDexposed.pdf 
  • SHD should be reaching out to track these contacts (e.g., household, care providers, close friends). Close contacts include >10 minutes @ <6 feet distance since onset, but with our current and worsening future workload, timeliness may be an issue and more remote or lower risk contacts may not be prioritized for counseling.    
  • Directions for patients with mild illness and no risk factors for COVID-19 complications: https://www.doh.wa.gov/Portals/1/Documents/1600/coronavirus/COVIDconcerned.pdf 
  • Our key message is this: “If you do not have a high-risk condition and your symptoms are mild, you do not need to be evaluated in person and do not need to be tested for COVID-19.”  This message is an effort on our part to preserve health system capacity.  Do not let this guidance dissuade you from testing any patient for whom you feel it is clinically indicated.

HEALTH CARE WORKER EXPOSURE CLASSIFICATION-AND-MANAGEMENT 

  • Health care providers should refer to CDC guidance on risk assessment for management of potentially exposed health care workers: https://www.cdc.gov/coronavirus/2019-ncov/hcp/guidance-risk-assesment-hcp.html
  • Note that health care providers who were exposed without full personal protective equipment (PPE) to a COVID-19 case but who did wear a facemask-or-respirator AND eye protection (e.g., goggles or shield) do NOT need to be furloughed during the 14-day follow-up symptom monitoring period. See Table 1 in the linked guidelines for further details. This guidance is subject to the employer’s discretion but may be helpful in limiting unnecessary impacts on the healthcare workforce.   

TELEPHONE TRIAGE AND TELE-HEALTH 

VIABILITY OF SARS-CoV-2 ON FOMITES 

  • Though we don’t definitively know how long SARS-CoV-2 (the virus that causes COVID-19) can persist on surfaces, we do have information from the SARS virus. It appears that the SARS virus can persist on surfaces at least several hours and probably for several days. In cold and dry conditions, it may persist for weeks. The warmer and moister the air, the faster it becomes inactive. 
  • Until proven otherwise, it seem prudent to consider the virus a hearty one that can persist on surfaces up to several days, and possibly longer. This may explain its capacity to establish personto-person transmission in the absence of clear epidemiologic links between cases. 
  • SARS virus can be efficiently inactivated by surface disinfection procedures with 62-71% ethanol, 0.5% hydrogen peroxide or 0.1% sodium hypochlorite within 1 minute. Other biocidal agents such as 0.05-0.2% benzalkonium chloride or 0.02% chlorhexidine digluconate are less effective. 

Sources: https://www.hindawi.com/journals/av/2011/734690/ and https://www.journalofhospitalinfection.com/article/S0195-6701(20)30046-3/fulltext 

CERTIFICATION OF COVID-19 DEATHS 
In the interest of maintaining surveillance for COVID-19 deaths, please note that the CDC is developing guidance to certifiers on reporting deaths due to COVID-19. For the present, please follow the instructions below and, if you have questions, contact the Center for Health Statistics, Washington State Department of Health at 1-855-562-1928.  

  1. Coronavirus Disease 2019 or COVID-19 should be reporting on the death certificate for all decedents where the disease caused, or is assumed to have caused, or contributed to death. Other terminology (e.g., SARS-CoV-2) can be used as long as it is clear that it indicates the 2019 coronavirus strain. CDC would prefer the use of WHO’s standard terminology, i.e. COVID19. 
  2. Specification of the causal pathway leading to death is important. Please report all conditions contributing to death in the “Chain of Events – Etiology” section (Cause of Death tab) in EDRS. 

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