News Flash

Update for Clinicians

December 2, 2020

SUMMARY 

See this update for:

• Correcting Misinformation about Isolation and Quarantine 
• Re-infection and Re-testing for COVID-19
• Washington [COVID-19] Exposure Notifications (WA Notify)

Correcting Misinformation about COVID-19 Isolation and Quarantine

Requested Actions

• Counsel patients according to standard guidance with respect to timelines for isolation and quarantine.
• Do not advise patients with negative test results to terminate their 14-day quarantine prematurely.
• Do not refer isolated or quarantined patients to the Health District for assistance with food, rent or personal protective equipment. Refer them instead to 211 for assistance with meeting socioeconomic needs.   

Background

Criteria for release of COVID-19 cases from isolation:

• Symptomatic cases
  1. ≥24 hours without fever and no use of fever reducing agents; and
  2. other symptoms improving; and
  3. ≥10 days since onset of symptoms (extend to ≥20 days if severe illness or if immunosuppressed)
• Asymptomatic cases
  1. ≥10 days since collection of the specimen yielding a positive result; and
  2. no intervening illness compatible with COVID-19

Criteria for release of COVID-19 contacts from quarantine¹:

• ≥14 days since last exposure^1,2; and
• remain asymptomatic with respect to COVID-19; and
• if tested, results are negative

¹Although the Centers for Disease Control & Prevention is signaling a forthcoming reduction in the duration of quarantine for COVID-19 contacts, this has not yet been put into effect nor has it been adopted and applied in Washington State.  We will notify you when that occurs, which may be soon. In the meantime, and despite what you may hear in the news, continue communicating existing quarantine guidelines to patients and families until the Health District advises otherwise. 

²Household contacts should remain in quarantine through 14 days after the closure of the last isolation period in the household case(s).  Such quarantines may last 24 or more days from the date of identification of the original case in the household.  

Through case and contact investigation work, the Health District is becoming aware of some recurring misinformation reaching patients in clinical settings that is at odds with public health tactics and disease control directives set forth above. Lack of harmony between clinician advice and public health direction can further undermine individuals’ cooperation with and the community’s support for COVID-19 control efforts.  Typical scenarios have included the following:

• A patient with COVID-compatible symptoms seeks testing on day 3 of the illness. On day 6 the results become available and are positive.  The patient reports to the clinician that he remains in isolation, he has been afebrile since day 4, and his other symptoms have resolved.  The clinician incorrectly advises the patient that he may terminate isolation and return to work.  The correct advice would be to tell the patient to remain in isolation until 10 full days have passed since onset, returning to normal activity on day 11.  
• Also, some clinicians are referring COVID-19 cases or contacts to the Health District for assistance with food, rent or access to personal protective equipment (PPE).  While the Health District does provide some very limited assistance with food when no alternative arrangement by the COVID-affected person is feasible, this intervention emanates from a case investigation rather from a health care provider referral.  The Health District does not provide any assistance with rent, bills, or other economic consequences of isolation-and-quarantine and we do not have a PPE supply chain supporting local residents.   Please refer patients with such needs to 211, which is better equipped to address them.  If such patients have no place to safely shelter, contact the Snohomish County Isolation & Quarantine Facility (425 238 3439) to explore eligibility for admission there.  

COVID-19 Re-infection & Re-testing

Requested Actions:

• Exercise restraint in ordering and caution when interpreting nucleic acid amplification testing (e.g., PCR) for SARS-CoV-2 among patients with a previous positive result in the past 90 days. 
• Rely upon the temporal criteria for release from isolation and avoid using test-based criteria. 

Background

The median time in follow-up to achieve negative PCR results among PCR-confirmed COVID-19 cases is approximately 21 days.  However, culturable virus is rarely if ever isolated beyond 8-10 days in experimental settings.  In many cases, this shedding of incompetent viral RNA may continue for weeks or months.  Detecting SARS-CoV-2 RNA >10 days beyond onset of illness does not mean that the patient is either still infectious or newly re-infected.  Re-infection, while documented in the medical literature, has thus far been exceedingly rare and not of significance with respect to the overall course of the pandemic.  

• For public health purposes, the Health District will consider a possible case of re-infection eligible for public health investigation and intervention as follows: detection of SARS-CoV-2 via molecular amplification or antigen test ≥90 days from the initial detection of SARS-CoV-2.  
• Other factors impacting clinical and epidemiologic decision making regarding possible re-infection include the following:
  1. interval resolution of the initial presenting clinical syndrome prior to the current illness
  2. interval negative results from SARS-CoV-2 testing
  3. availability of initial and follow-up specimens for whole genome sequencing
  4. specimen cycle threshold (Ct) <35 on new PCR result

In summary, virtually all repeat positive SARS-CoV-2 results obtained within 90 days of the initial positive result (and even some or many collected after 90 days) are deemed unlikely to represent new infection and are unlikely be counted or managed by the Health District as a new infection.  Such results also would not make an unsheltered individual eligible for admission to the Snohomish County Isolation & Quarantine Facility at the Evergreen Fairgrounds.

On a related note, recovered cases of COVID-19 who are re-exposed within 90 days of their initial diagnosis will generally not be directed to quarantine by the Health District.  Conversely, when re-exposed >90 days after a prior infection, individuals will be directed to quarantine.   

Washington [COVID-19] Exposure Notifications (WA Notify)

Requested Actions:

• Activate Exposure Notification on your iPhone or Android device.  
• Encourage colleagues and patients to do the same.

Background

• When you enable WA Notify, your phone exchanges random, anonymous codes with the phones of people you are near who have also enabled WA Notify. The app uses Bluetooth Low Energy (BLE) technology to exchange these random codes without revealing any information about you. If another WA Notify user you have been near in the last two weeks later tests positive for COVID-19 and adds their verification code to the app, you’ll get an anonymous notification that you have had a possible exposure. Studies have found that the more people who use exposure notification, the greater the benefit. Models based on three counties in Washington state show that even a small number of people there using WA Notify would reduce infections and deaths. Just like wearing masks, physical distancing and keeping gatherings small, WA Notify is another tool to help prevent the spread of COVID-19. 
• WA Notify is based on Google Apple Exposure Notification technology, which was designed to safeguard user privacy. The system never collects or shares any location data or personal information with Google, Apple, the Washington State Department of Health (DOH), or other users. Participation is entirely voluntary. Users can opt in or out at any time.
• Washington formed a state oversight group, including security and civil liberties experts and members of several communities, to review the Apple/Google solution. The group recommended adoption based on the platform’s proven reliability, robust data protection and use by other states.