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Guidance for County Health Departments

Florida Health

Disease Control

 


Interim Enhanced Surveillance Guidance for County Health Departments (CHDs)

January 31, 2020

 

Summary

  • Surveillance: CHDs should apply the definition of person under investigation (PUI) for COVID-19 to determine if laboratory testing and public health investigation is needed.
  • Investigations: Investigations should occur for individuals meeting the definition of PUI for COVID-19 within the same day of CHD notification, including weekends and holidays.
    • County epidemiology staff should alert their regional epidemiologist and laboratory liaison, or BOE on-call epidemiologist if after-hours, of all PUIs for COVID-19.
  • Reporting PUIs and Cases: PUIs or persons meeting the confirmed or probable case definition for COVID-19 should be entered into Merlin within 24 hours (including weekends and holidays).
  • CHD Laboratory Results Notification Process for 2019-nCoV: Emailed from Bureau of Public Health Laboratories.
  • Documents on this topic dated after January 31, 2020, supersede this one. 

Background

On January 11, 2020, Chinese health authorities preliminarily identified more than 40 human infections with novel coronavirus in an outbreak of pneumonia under investigation in Wuhan City, Hubei Province, China. Chinese health authorities subsequently posted the full genome of the so-called COVID-19, in GenBank ®, the National Institutes of Health genetic sequence database.

The Centers for Disease Control and Prevention (CDC) continues to monitor this outbreak, which includes over 9,000 confirmed human cases in China and over 200 deaths. Exported cases from Wuhan have been identified in many countries. Sustained person-to-person spread is occurring in China.

Coronaviruses are a large family of viruses, some causing illness in people and others that circulate among animals, including camels, cats, and bats. Rarely, animal coronaviruses can evolve and infect people and then spread between people, as seen with Middle East Respiratory Syndrome and Severe Acute Respiratory Syndrome.

There is an ongoing investigation to determine more about this outbreak. This is a rapidly evolving situation. This document may become outdated as situations change.

For the latest situation updates, visit www.cdc.gov/coronavirus/novel-coronavirus-2019.html.

Investigations of PUI for COVID-19

Clinical FeaturesRisk Criteria
Fever1 or signs/symptoms of lower respiratory illness (e.g. cough or shortness of breath)ANDAny person, including health care workers, who has had close contact2 with a laboratory-confirmed3,4 COVID-19 patient within 14 days of symptom onset
Fever1 and signs/symptoms of a lower respiratory illness (e.g., cough or shortness of breath)ANDA history of travel from Hubei Province, China within 14 days of symptom onset
Fever1 and signs/symptoms of a lower respiratory illness (e.g., cough or shortness of breath) requiring hospitalization4ANDA history of travel from mainland China within 14 days of symptom onset


Patients with lower respiratory illness should also be evaluated for common causes of community-acquired pneumonia, guided by clinical presentation and epidemiologic and surveillance information. For these patients, testing for COVID-19 and other respiratory pathogens should be done simultaneously. Positive results for another respiratory pathogen (e.g., influenza) should not preclude testing for COVID-19 because co-infection may occur.

COVID-19 Case Definition:

Confirmed: A confirmed case is a person with laboratory confirmation of COVID-19 infection.
Probable: A probable case is a PUI with absent or inconclusive laboratory results for COVID-19 who is a close contact2 of a laboratory-confirmed COVID-19 case.
Suspect: A suspect case is a PUI with COVID-19 laboratory tests pending.

  1. Fever may be subjective or confirmed.
  2. Close contact is defined as—
    1. Being within approximately six feet (two meters), or within the room or care area, of a novel coronavirus for a prolonged period of time while not wearing recommended personal protective equipment (PPE [e.g., gowns, gloves, NIOSH-certified disposable N95 respiratory, eye protection]); close contact can include caring for, living with, visiting, or sharing a health care waiting area or room with a COVID-19 case, or
    2. Having direct contact with infectious secretions of a COVID-19 case (e.g., being coughed on) while not wearing recommended PPE.
    Data to inform the definition of close contact are limited. Considerations when assessing close contact include the duration of exposure (e.g., longer exposure time likely increases exposure risk) and the clinical symptoms of the person with COVID-19 (e.g., coughing likely increases exposure risk as does exposure to a severely ill patient). Special consideration should be given to those exposed in health care settings.
  3. Documentation of laboratory-confirmation of COVID-19 may not be possible for travelers or persons caring for patients in other countries.
  4. Category also includes any member of a cluster of patients with severe acute lower respiratory illness (e.g., pneumonia, ARDS) of unknown etiology in which COVID-19 is being considered that requires hospitalization. Such persons should be evaluated in consultation with state and local health departments regardless of travel history.

Investigations of PUI for COVID-19

  • County epidemiology staff should investigate each report of possible COVID-19 to determine if the PUI for COVID-19 criteria are met.
  • County epidemiology staff should contact their Regional Epidemiologist and Laboratory Liaison, or Bureau of Epidemiology (BOE) on-call epidemiologist (if after hours), if a county is investigating a potential PUI or if they have any questions.
  • Conduct patient/proxy or health care provider interviews and record reviews to obtain essential information, which includes history of present illness, medical history, travel dates, flight information, risk factors, differential diagnoses, and microbiology test results.
  • Enter the PUI into Merlin (see ‘Reporting COVID-19 PUI and Cases in Merlin’) and complete extended data within 24 hours of receipt of information.

Infection Control Considerations

  • PUIs should be asked to wear a surgical mask as soon as they are identified and be evaluated in a private room with the door closed, ideally an airborne infection isolation room, if available.
  • While a PUI for COVID-19 is receiving health care, it is important that standard, contact, and airborne precautions are used.

Management of Cases and PUIs

  • A PUI may be discharged before COVID-19 is ruled out. The decision to discharge a PUI for COVID-19 is up to the treating physician.
    • PUIs should be provided surgical masks and asked to isolate themselves at home until fever and symptom-free for 24 hours without antipyretic medication (acetaminophen, ibuprofen).
    • Close contacts of confirmed or probable cases who develop compatible symptoms should also be managed as COVID-19 PUIs. Specimens should be collected, and PUIS should be isolated at home or while seeking health care until COVID-19 testing at CDC is completed.
  • For confirmed COVID-19 cases, the decision to discharge is based on public health and medical assessment with the BOE, including presence of symptoms and multiple negative specimens.

Laboratory Testing and Specimen Collection

  • If PUI criteria are met, or if you have questions about a patient, contact your Regional Epidemiologist and Laboratory Liaison (FloridaHealth.gov/diseases-and-conditions/disease-reporting-and-management/disease-reporting-and-surveillance/_documents/investigation-unit-map.pdf) or the after-hours BOE on-call epidemiologist (850-245-4401) to arrange for specimens to be submitted to the Bureau of Public Health Laboratories (BPHL).
  • BPHL will ship specimens to CDC for testing until testing is made available at state public health laboratories.
  • Specimens should be collected as soon as possible once a PUI is identified regardless of symptom onset.
  • To increase the likelihood of detecting COVID-19, CDC recommends collecting three specimen types, lower respiratory, upper respiratory, and serum:
    • Upper respiratory: nasopharyngeal and oropharyngeal swabs in viral transport media, each in a separate container; nasopharyngeal wash/aspirate or nasal aspirate may be used as well.
    • Lower respiratory: sputum (induced if necessary), bronchial alveolar lavage/tracheal aspirate, in a sterile container
    • Serum (red top or tiger top tube)
  • If additional specimen types such as stool, urine, or whole blood are collected, they can be stored for potential future use.
  • Ship specimens overnight for arrival to BPHL in Jacksonville, Miami, or Tampa following notification to the appropriate BPHL location.
  • Shipments arriving on the weekend must be pre-authorized by BPHL and BOE.
  • Ship specimens using category B shipping containers.
  • Notification Process of Laboratory Results for Specimens Tested by CDC: Emailed from Bureau of Public Health Laboratories

Reporting COVID-19 PUIs and Cases in Merlin

  • Individuals meeting the confirmed, probable, or PUI (suspect) case definition for COVID-19 should be entered into Merlin.
    • Use the disease code COVID-19 – 00342” when entering PUIs in Merlin.
  • Enter PUIs within 24 hours of CHD notification.
  • PUI will be listed as suspect DX status until laboratory results have been returned.
  • Attach all available medical records, laboratory results, and paper PUI form (if available) to the Merlin case.
  • Attach CDC laboratory results to the case and submit.