COVID-19: Interim Guidance for Health Care and Public Health Providers
Coronaviruses are a large family of viruses that are common in many different species of animals; some coronaviruses cause respiratory illness in humans. COVID-19 is caused by the novel (new) coronavirus SARS-CoV-2. It was first identified during the investigation of an outbreak in Wuhan, China, in December 2019. Early on, many ill persons with COVID-19 were linked to a live animal market indicating animal to person transmission. There is now evidence of person to person spread, as well as community spread (i.e., persons infected with no apparent high risk exposure contact). On March 11, 2020, the WHO recognized COVID-19 to be a pandemic.
All patients being released from the institutions, regardless of the patients’ COVID status, shall be offered COVID-19 testing one week before release with notification of the results sent to LHDs and DAPO and/or PRCS
All “Appendix 9” notification forms are required to be “cc’ed” to a newly established public health notification email box.
Diagnostic Testing includes updated lab test names, ordering instructions for Coronavirus Disease 2019 (COVID-19) and rapid influenza point of care testing, new stability data, Saturday pick-ups, and a new testing algorithm.
This document serves to provide INTERIM guidance for the clinical management of SARS-CoV-2 virus pandemic at CDCR facilities. Due to the quickly changing guidelines from the Centers for Disease Control (CDC), the World Health Organization (WHO), and other scientific bodies, information may change rapidly and will be updated in subsequent versions. Revision dates are located at the bottom left of the document. Substantive changes will be posted to the website if occurring before release of updated versions.
This guidance supersedes the COVID-19 Interim Guidance for Health Care and Public Health Providers, Document 1.0.
This guidance supersedes the 2019 Seasonal Influenza Guidance except where noted.
Agency for Healthcare Research and Quality
Acquired Immune Deficiency Syndrome
Administrative Officer of the Day
Airborne infection isolation room
Body Mass Index
California Correctional Health Care Services
Centers for Disease Control and Prevention
California Department of Corrections and Rehabilitation
California Department of Public Health
Clinical Laboratory Improvement Amendments
Chief Medical Executive
Chief Nurse Executive
Coronavirus Disease 2019
Director of Nurses
Electronic Health Record System
Environmental Protection Agency
Health Care Personnel
Health Care Worker
Human Immunodeficiency Virus
Higher Level of Care
Infection Control Nurse
Local Health Department
Nurse Consultant Program Review
National Institute for Occupational Safety and Health
Occupational Safety and Health Administration
Office of Employee Health and Wellness OEHW
Personal protective equipment
Powered air purifying respirator
Preliminary Report of Infectious Disease or Outbreak form
Public Health Branch
Public Health Nurse
Public Health Outbreak Response System
Rapid Influenza Diagnostic Test
Respiratory syncytial virus
Reverse Transcription Polymerase Chain Reaction
Return to Work Coordinator
Upper Respiratory Infection
Viral Culture Media
World Health Organization
PRIMARY PREVENTION AND ENVIRONMENTAL INFECTION CONTROL - Updated 5/06/2020
Primary prevention involves all people within the institution: staff, visitors, and inmates. The two prime goals are preventing the virus from getting into the institution in the first place, and preventing it from being transmitted between people.
COVID-19 can be spread by breathing in respiratory droplets from other people who are infected, especially when they cough or sneeze. It can be spread if something makes the virus move widely through the air in tiny particles or droplets, such as a nebulizer, continuous positive airway pressure (CPAP) machine, or various medical procedures. It can be spread by touching surfaces or other people who have the virus, and then touching your own face (eyes, nose, or mouth). Some people who have been infected with the virus do not have any symptoms and do not feel or look sick, so standard precautions must be used. (See Transmission section)
Since each institution has a unique physical lay-out and different missions, the actual application of the guidelines requires creative thinking about how to make things work best at that institution. It is recommended that a small working group of medical, nursing, and custody be formed to work through each guideline and situation, and determine exactly how it will be carried out at that institution. The members of this group should be high-ranking enough to make decisions and also knowledgeable about exactly how things are done practically throughout the institution.
Basic principles to prevent infection include:
Minimize movement of people (in and out of the institution and within the institution).
Practice social distancing – keeping at least 6 feet away from other people wherever possible. Usual social interactions such as handshaking, or the new idea of touching elbows, must stop. Bows or nods or waves from a distance of at least 6 feet away are okay.
Use good hygiene practices, including increased cleaning within the environment, especially of frequently touched surfaces; good hand hygiene; proper cough etiquette; wearing surgical/procedure masks or other cloth covering of the nose and mouth whenever you are around other people, particularly if you have to be within 6 feet of them; and use of personal protective equipment (PPE) according to guidelines (see Infection Control and Personal Protective Equipment section). Provide education regarding these for inmates, staff, visitors, and volunteers, using a variety of methods.
Pay extra attention to all these factors for people (staff and inmates) who are at high risk of severe disease if they become infected with COVID-19. Especially vulnerable populations including the elderly, those with underlying chronic diseases, and those who are immunosuppressed (see High Risk table in the Clinical Manifestations of COVID-19 section).
Special measures must be planned whenever there is high risk of the virus being spread through the air (aerosolized), which can happen with sneezing and coughing, with nebulizer use, with CPAP/bilevel positive airway pressure (BIPAP) use, and with a number of medical procedures and treatments. Even singing or forceful talking may spread the virus through the air beyond 6 feet (see Aerosol-Generating Procedures memo).
People who are known or suspected of being infected with COVID-19 must be in medical isolation. (If they have tested positive for COVID-19 and single room space is an issue, they may be housed with others who have tested positive – see Isolation subsection in Control Strategy for Suspected and Confirmed Cases of COVID-19 section). People who have been exposed to someone with COVID-19 must be quarantined for a minimum of 14 days to determine whether they have become infected (see Quarantine subsection in Control Strategies for Contacts to Cases of COVID-19 section).
There are three main ways the virus can enter the prison:
An inmate brings it in from the outside – coming from a different prison or a jail; coming back from an out-to-court legal appointment; coming back from a hospital, emergency room (ER), or medical specialty consultation; coming back from the outside community – work, a community program, or violating parole. To help prevent this:
Consider stopping all movement of inmates in and out of the prison except for essential legal and medical reasons.
Consider quarantining every inmate entering the prison for 14 days as recommended by the Center for Disease Control (CDC) for prisons and detention facilities.
Consider providing medical and legal visits through telemedicine and teleconferencing.
An employee or contractor brings it in from the outside – either asymptomatic, with mild symptoms, or ill.
Consider having employees telework whenever possible, minimizing the number of people coming from the community into the prison.
Consider screening the health of all employees entering the institution, checking each person’s temperature, and asking about symptoms of an acute respiratory illness. Anyone who is ill may not enter.
A visitor or volunteer brings it in from the outside.
Consider stopping all visiting and volunteer programs.
Consider screening the health of all visitors and volunteers entering the institution, checking for fever, and asking about symptoms of an acute respiratory illness. Anyone who is ill may not enter.
Consider having visits and programs by teleconferencing, using telephone or computer based methods such as Skype or Zoom, that allow people to interact without coming into contact with each other.
Consider beginning universal face barriers for staff and inmates when face coverings are in sufficient supply and there is National, State or Local Health Department advice for masking whenever outside or in public if it arises before CCHCS mandates and is acceptable to custody.
Face barriers can be cloth face coverings and include both California Prison Industry Authority (CalPIA) provided facial coverings as well as personally owned and provided surgical style masks.
As soon as an outbreak has occurred at your facility and face barriers are in sufficient supply, begin universal masking precautions.
Use caution to prevent stigma or harassment from differential facial-covering compliance. This is especially true for previously ill patients exiting isolation.
When universal face barrier use begins, inmates should use a cloth face covering within the institution during the following activities:
Any situation that requires movement outside of cell or while in a dorm setting
During interactions with other inmates (e.g., yard time, canteen, dayroom)
Movement to and from health care appointments
Movement to and from medication administration areas (except while actively eating or showering)
In situations when PPE is required (see PPE section), PPE respiratory recommendations supersede cloth facial coverings (this also includes PPE for inmate workers). Surgical masks are part of PPE, cloth face coverings are not PPE.
IDENTIFY OR CREATE SEPARATE SYMPTOMATIC SCREENING AND TESTING AREAS
Strongly consider providing a set-apart or dedicated clinic area or outside tent with canopy specifically for evaluation of patients with acute respiratory infection symptoms, to keep those individuals separate from patients needing other types of medical care. It is especially important to keep the evaluation and testing stations away from vulnerable populations, hospitalized patients, or patients sick with non-COVID ailments.
Screen all patients for fever and respiratory symptoms prior to bringing them into the dialysis unit, clinic, or waiting room.
Aerosol generating procedures are especially dangerous due to aerosolization of the viral droplets that persist in the air and can be inhaled.
AGP should be minimized to only the most medically necessary – refer to the Aerosol-Generating Procedures memo for detailed guidance.
Proactively find space for when these procedures will need to be performed. Negative pressure rooms or distant outside open air with canopy first, or single rooms with doors and preferably a unique ventilation system. PPE and strict cleaning protocols during and after these procedures must be adhered to.
EARLY IDENTIFICATION AND LOCATION FOR ISOLATION AND QUARANTINE ROOMS AND FUTURE COHORTS
It is crucial to be ready for your first cases and contacts of cases.
Analyze your ventilation systems and staff/inmate traffic patterns.
Consider what supplies you will need, inventory your current stock and order accordingly (e.g., testing kits and swabs, PPE, cleansers, trash receptacles, extra tissues, extra soap, portable wash stations, housing tents or canopies, portable showers, duct tape, oxygen, incentive spirometry, nasal cannulas, O2, surgical masks and tubing, etc.)
Mobilize your PPE: have it ready and available at the sites where it will be needed, including the the treatment and triage area (TTA), all medical and dental clinics, specialized medical housing, and for custody officers who may need to escort a symptomatic patient from the housing area to a site for medical evaluation.
Work with custody and supplies from the Office of Emergency Preparedness for physical space assistance. Ensure ability of patients to access showers, bathrooms, and path to exercise yards that will not expose other inmates to the virus.
ASSESSING AND OBTAINING RESOURCES FOR OUTBREAK PLANNING
For assessing needed supplies, the facility leadership, including the Chief Medical Executive (CME), Chief Nursing Executive (CNE), Warden, and Chief Executive Officer (CEO) should meet to discuss resources and allocation. After a leadership discussion at the institution, if there are needed items, lack of local resources, or concerns related to being able to provide needed precautionary or treatment measures, contact the Department Operations Center (DOC) (see below).
For requested items not available locally, a Form 213 Resource Request Message (CDCR networking is required for access) needs to be filled out and e-mailed to the DOC (e-mail address below). Form 213 can be sent by the Warden, CEO, or CME.
Note: A separate form should be submitted for each item (e.g., N95 respirators on one form, tents on another form). Needed items are obtained either from another institution that currently has extra, or from the state Office of Emergency Services (OES).
For questions, please contact the respective CDCR chain of command, or email the DOC at DOCCOVID19@cdcr.ca.gov.
The fewer people one comes into contact with, the less chance of becoming infected by COVID-19. The farther away people are, the less likely the virus will move between them. Six feet away is considered the minimum safe distance to avoid most respiratory droplet spread.
Decreasing the number of inmates in each prison, and the number of inmates in each cell or dormitory, would be helpful in giving enough room to allow proper distancing.
Consider stopping the entrance of new inmates to the prison.
Consider early parole, home detention programs, and expediting medical parole and compassionate release.
Early analysis and preparation for social distancing in buildings is essential. Wherever possible, rooms must be arranged to have as few inmates as possible and to allow as much social distancing as possible. A possible way to do this would be to set up tent housing, if available, for low security risk prisoners, leaving more room inside buildings. If cells have bars rather than walls, or are porous rather than solid closed doors, ideally one would leave an empty cell on each side of an occupied cell to maintain distancing.
If there are multiple inmates in a cell area, beds should be arranged to allow distancing. If there are bunks, inmates on the bottom bunks should have their heads facing one direction, and on the top in the other direction, so there is at least approximately six feet separation of their heads. Similarly if the beds or bunks are close together, the head of one inmate should be closest to the feet of the inmate in the adjacent bunk.
Consider temporary housing in buildings meant for other purposes, such as gymnasiums or classrooms.
Consider alternative portable housing such as tent accommodations, along with portable toilets, sinks, and showers.
Consider creative ways to decrease transmission in areas with many beds such as dorms. If space does not allow 6 feet between bunks, try making smaller cohorts, such as of 6-8 people, with 6 feet between each group. Try draping one side of the bunks with plastic sheeting to prevent movement of respiratory droplets.
If cells have bars rather than walls and solid closed doors, ideally one would leave an empty cell on each side of an occupied cell to maintain distancing.
Place plastic barriers along counters or other dividers of room spaces where appropriate to prevent respiratory droplet spread.
Consider moving smaller groups at a time into chow hall, according to housing divisions, and demarcate seating 6 feet apart.
Consider taping off sections with 6 foot distancing for cohorts if there is not sufficient space to distance the entire cafeteria.
Consider bringing hot and cold food carts into the housing day rooms.
Consider cell feeding if resources allow.
CLASSES AND GROUPS
Consider stopping all non-essential classes and groups.
Consider individualized rather than group work.
Consider classes via computer connection rather than in person.
Consider small groups that incorporate social distancing.
YARD AND DAY ROOM ACTIVITY
Consider moving smaller groups (cohorts) at a time to these areas, according to housing divisions or isolation/quarantine cohorts. Outside time, exercise, and activity is important to mental and physical health, so it should be encouraged with recommendation to maintain social distancing.
Consider moving smaller groups at a time to pill lines, according to housing divisions, and mark waiting spaces 6 feet apart in the line.
Consider a provider polypharmacy initiative of focused med. reduction/necessity to decrease the amount of wait time and possible exposure in all inmates waiting at pill line.
Change NA/DOT medication administration to KOP whenever possible, for the same reason.
MEDICAL, DENTAL, AND MENTAL HEALTH APPOINTMENTS
Consider postponing all non-essential, non-urgent appointments.
Consider using telemedicine for appointments.
Consider using letters to inform patients of medical results and plans when possible.
Consider spacing appointments farther apart, or calling patients when the provider is ready for them, to avoid need for patients to wait in the waiting room. Place waiting room seats 6 feet apart.
Consider adding waiting room space outside the clinic, such as with a canopy and portable chairs 6 feet apart.
Anyone with fever or cough should be given a surgical mask (by the correctional officer [C.O.] or other staff) and be sent for medical evaluation immediately. If escorting the patient, the C.O. or other staff member should don appropriate PPE (see Infection Control and Personal Protective Equipment section).
EDUCATION AND HYGIENE
Provide extra cleaning supplies for inmates to use in their cells and in common areas. Discuss liberalization of alcohol-based hand sanitizers with custody.
Provide extra hand-washing (and hand gel if allowed) stations for staff and inmates, especially in high use areas.
Provide all inmates with verbal instructions, written handouts for each inmate, audiovisual or TV programs where possible, and posted signs on hand hygiene, cough etiquette, and social distancing. Review the increased risk for elderly, those with underlying diseases especially of the lungs or heart, and those with immunosuppression.
For cells with automatic push buttons or handles regulating the flow of water, make sure the flow is set for 30 seconds to allow the full recommended 20 seconds of handwashing.
Provide plenty of soap, paper towels, tissues or toilet paper for coughs/sneezes (above the normal allotment for bathroom needs), and a no-touch lined trash receptacle. Provide alcohol-based hand sanitizer, if possible.
PROTECTING VULNERABLE POPULATIONS
Inmates at high risk of complications and death if infected with COVID-19 include the elderly, those with underlying disease(s) especially of the heart and lungs, and those with decreased immune function (see High Risk table in the Clinical Manifestations of COVID-19 section).
If at all possible, these individuals should be dispersed throughout the general population, not concentrated in one place. In CDCR, however, people with particular needs for help are often grouped together in an outpatient housing unit (OHU), central treatment center (CTC), or skilled nursing facility (SNF), or in American’s with Disabilities Act (ADA) housing. For this to be successful, careful thought needs to go into the movements and mixing of vulnerable and non-vulnerable populations.
In order to decrease exposure of these inmate/patients:
If there are special units, attempt to have dedicated personnel working in them, so there aren’t as many different staff members entering the unit. Screen inmate workers for these units prior to them leaving their yards with standard questions and temperature measurement (see the Screening of Critical Inmate Workers memo – CDCR networking access is required). Screen anyone entering a unit comprised of or containing vulnerable patients; or, if they are widely dispersed through the institution, consider universal screening at all housing units if feasible. Do not allow staff or inmate ‘visitors’ in those units, only essential workers. Signs regarding this should also be posted to encourage self-referral for care and voluntary social distancing from vulnerable wards.
Consider having vulnerable patients only leave their housing for urgent/emergent need, and for designated yard time with their housing cohort.
Consider providing cell feeding with disposable trays if possible.
Consider providing pill line at housing, ideally cell to cell, but at minimum at a separate time from other inmates, or within housing cohorts, in such a way that social distancing is possible and wait times are decreased. People in line should be spaced out 6 feet apart. Consider floor markings to delineate.
Consider having canteen items delivered to highly vulnerable inmate/patients – same with laundry, clothing, shoes, library resources, etc.
If “stay in place” for these individuals is enacted, educate the patient on what can be expected and on its challenges and temporary nature.
If physical therapy is needed, ideally provide it in the activity room of the housing unit if possible. If not possible, do not have the highly vulnerable patients mix with inmates from other housing areas.
Provide regular medical care within the unit if possible. If not possible, call the patient for medical evaluation when the provider is ready to see them so there is no wait time in a waiting area with other inmates.
STAFF AND VISITOR PRECAUTIONS AND RESTRICTIONS DURING THE PANDEMIC
Correctional facilities should have signage posted at entry points in English and Spanish alerting staff and visitors that if they have fever and respiratory symptoms, they should not enter the facility.
Visitor web sites and telephone services are updated to inform potential visitors of current restrictions and/or closures before they travel to the facility.
Instruct staff to report fever and/or respiratory symptoms at the first sign of illness.
Staff with respiratory symptoms should stay home (or be advised to go home if they develop symptoms while at work). Ill staff should remain at home until they are cleared by their provider to return to work.
Advise visitors who have fever and/or respiratory symptoms to delay their visit until they are well.
Consider temporarily suspending visitation or modifying visitation programs, when appropriate.
Visitor signage and screening tools are available from the CCHCS Public Health Branch (PHB) and can be distributed to visiting room staff.
Initiate other social distancing procedures, if necessary (e.g., halt volunteer and contractor entrance, discourage handshaking).
Post signage and consider population management initiatives throughout the facility encouraging vaccination for influenza.
RESPIRATORY HYGIENE AND COUGH ETIQUETTE
Post visual alerts in high traffic areas in both English and Spanish instructing patients to report symptoms of respiratory infection to staff.
Encourage coughing patients with respiratory symptoms to practice appropriate respiratory hygiene and cough etiquette (e.g., cover your cough, sneeze into your sleeve, use a tissue when available, dispose of tissue appropriately in designated receptacles, and hand hygiene).
Additionally, coughing patients should not remain in common or waiting areas for extended periods of time and should wear a surgical or procedure mask and remain 6 feet from others.
Ensure that hand hygiene and respiratory hygiene supplies are readily available.
Encourage frequent hand hygiene.
ENVIRONMENTAL INFECTION CONTROL
Routine cleaning and disinfection procedures should be used. Studies have confirmed the effectiveness of routine cleaning (extraordinary procedures not recommended at this time).
CellBlock 64 is effective in disinfecting for COVID-19 related virus.
After pre-cleaning surfaces to remove pathogens, rinse with water and follow with an Environmental Protection Agency (EPA) registered disinfectant to kill coronavirus. Follow the manufacturer’s labeled instructions which include, but are not limited to: the product’s dilution ratio and contact time. (For a list of EPA- registered disinfectant products that have qualified for use against SARS-CoV-2, the novel coronavirus that causes COVID-19, go to: https://www.epa.gov/pesticide-registration/list-n-disinfectants-use-against-sars-cov-2)
If an EPA-registered disinfectant is not available, use a fresh chlorine bleach solution by mixing 5 tablespoons (1/3 cup) bleach per gallon of water or 4 teaspoons bleach per quart of water.
Focus on cleaning and disinfection of frequently touched surfaces in common areas (e.g., faucet handles, phones, countertops, bathroom surfaces, door knobs, and light switches).
Staff should clean shared equipment (e.g., radios, service weapons, keys, and handcuffs) several times per day.
All non-dedicated, non-disposable medical equipment used for patient care should be cleaned and disinfected according to manufacturer’s instructions.
If bleach solutions are used, change solutions regularly and clean containers to prevent contamination. Prepare cleaning solutions daily or as needed.
Special handling and cleaning of soiled linens, eating utensils and dishes is not required, but should not be shared without thorough washing.
The contaminated (soiled) laundry is placed into the leak-resistant bags and are securely tied to prevent leakage. The contaminated laundry must be clearly labelled as “contaminated/soiled”.
Linens (e.g., bed sheets, towels, and cloth facial coverings) should be washed by using laundry soap and tumbled dry on a hot setting. Staff should not hold laundry close to their body before washing and should wash their hands with soap and water after handling dirty laundry. Laundry workers should wear appropriate PPE (e.g., gloves and protective garments) while handling the soiled linen.
Follow standard procedures for waste handling. Discard the used PPE in regular trash.
People with COVID-19 generally develop signs and symptoms (including respiratory symptoms and fever) an average of 5 days after exposure, with a range for symptom development being anywhere from 2-14 days after infection.
Given that some patients can be entirely asymptomatic, despite infection, the range of symptoms in outpatients is exceedingly broad but often falls along the spectrum between mild upper respiratory infections (URIs) and the more severe symptoms seen in hospitalized patients (see severe and critical disease below). Cases without cough or dyspnea, however, have been described, including presentations where gastrointestinal (GI) symptoms were the presenting complaint, fever was the only complaint, or a loss of the sense of smell (anosmia) or taste (dysgeusia) was the presenting feature. Fever is not always present.
Asymptomatic cases have been described and may be much more prevalent than initially thought. Studies have widely varying estimates, which have been called into question due to unreliable or unknown sensitivity and specificity of the Food and Drug Administration (FDA)-expedited serology tests. However, an Annals of Internal Medicine June 2020 review of the literature assessed a conservative asymptomatic rate of 30%, but stated it may be as high as 40-45%.
UNUSUAL PRESENTATIONS OF COVID-19
GI predominant presentation: nausea, vomiting, diarrhea
Loss of the sense of smell (anosmia) or taste (dysgeusia)
URI presentation: rhinorrhea, sore throat, headache
In the aged and immunocompromised: reduced alertness, reduced mobility, delirium, and absence of fever in addition to the atypical symptoms above
COVID-19 should mainly be distinguished from other known viral causes of pneumonia, depending on regional prevalence, such as influenza viruses and respiratory syncytial virus (also: parainfluenza virus, adenovirus, rhinovirus, human metapneumovirus, etc.); and also from coccidioidomycosis, mycoplasma pneumonia, chlamydia pneumonia, legionellosis, and bacterial pneumonia. In addition, non-infectious diseases such as vasculitis, dermatomyositis, and cryptogenic organizing pneumonia (formerly bronchiolitis obliterans with organizing pneumonia) should be considered.
The possibility of co-infection should also be kept in mind and has been studied to occur in 8% of cases.
Respiratory syncytial virus (RSV) season coincides with the influenza season, and coccidioidomycosis is always a concern in endemic areas or transfers from endemic areas.
The disease tends to start indolently, with varying symptoms as above. Patients’ respiratory status may start to worsen, along with fevers, followed by marked improvement, only to then have a steep decline. For this reason, patients with COVID-19 need to be monitored closely for clinical status. Patients who are older or have comorbid conditions need especially heightened vigilance. Dyspnea has a median of 7 days after onset, sepsis – 9 days, acute respiratory distress syndrome (ARDS) and intensive care unit (ICU) admission, and for mechanical ventilation – 15 days.
SPECTRUM OF DISEASE
Mild to Moderate Disease
Approximately 80% of laboratory-confirmed patients have had mild to moderate disease, which includes non-pneumonia and mild pneumonia cases. Most people infected with COVID-19 related virus have mild disease and recover.
Approximately 14% of laboratory-confirmed patients have severe disease (dyspnea, respiratory rate ≥30/minute, blood oxygen saturation: 93%, and/or lung infiltrates >50% of the lung field within 24-48 hours).
Approximately 6% of laboratory-confirmed patients are critical (respiratory failure, septic shock, thromboembolic disease, and/or multiple organ dysfunction/failure). Older patients and patients with co-morbid conditions (see table 5.2 below) are at higher risk of mortality and morbidity with COVID-19.
TYPICAL DIAGNOSTICS IN COVID-19 (HOSPITALIZED PATIENTS)
Typical laboratory findings in COVID-19 (many findings are non-specific):
CBC with lymphopenia (33-85%) and leukopenia (17-45%)
High CRP (81-86%)
Low procalcitonin (90-95%, unless severe disease develops)
High D-dimer, fibrinogen (and C-reactive protein [CRP]) in those found with deep venous thrombosis (DVT) on admission
Typical chest X-ray findings in COVID-19:
Patchy ground-glass opacities, which tend to be predominantly peripheral and basal.
The number of involved lung segments increases with more severe disease.
Over time, patchy ground glass opacities may coalesce into more dense consolidation.
Infiltrates may be subtle.
Chest X-ray findings which aren’t commonly seen, and might argue for an alternative or superimposed diagnosis:
Pleural effusion is uncommon (seen in only ~5%).
COVID-19 doesn’t appear to cause nodules, masses, cavitation, or lymphadenopathy.
CLINICAL FACTORS ASSOCIATED WITH PROGRESSION TO SEVERE DISEASE AND RESPIRATORY FAILURE
Amongst hospitalized patients, the following clinical parameters have been shown to be statistically associated with respiratory demise:
Chronic medical conditions as described in Table 5.2 below
Maximum body temperature at admission
Presence of secondary bacterial infection
Higher Sequential Organ Failure Assessment (SOFA) score (indicates sepsis)
Elevated inflammatory indicators in the blood as described in Table 5.3 below
Studies have shown long viral shedding periods, up to months after recovery. However, no viable virus has been able to be cultured beyond 9 days post-infection. Please refer to the discussion on viral shedding studies in the Release from Isolation section under “Maximum Time in Isolation: 21 days”.
Much remains to be known regarding immunity after resolved infections. A positive test after recovery does not indicate whether a person is shedding virus that is infectious. The consensus of the literature is that, between neutralizing antibodies and likely a strong role for cellular immunity, SARS-CoV-2 immunity is preserved after infection for at least 3 months. Information on the CDPH criteria for re-testing after recovery is in the Release from Isolation section.
TESTING FOR COVID-19 AND OTHER RESPIRATORY PATHOGENS - Updated 8/03/2020
This section contains information on diagnostic tests available for COVID-19, influenza, and other respiratory pathogens. COVID-19 viral testing (RT-PCR or antigen) is useful for a variety of purposes, including clinical testing of symptomatic patients, testing in response to an outbreak, public health surveillance testing, routine testing of asymptomatic patients at risk of acquiring or spreading infection, and testing as part of inter-facility and healthcare-related transfers. Direct viral tests include the RT-PCR and antigen test.
SEROLOGY (ANTIBODY) TESTING
At this time, serology testing for COVID-19 is not recommended for determining COVID-19 immunity. Antibodies become detectable about 2 weeks after the start of the infection. In addition to concerns with possible cross-reactivity with other coronaviruses, which and what levels of antibodies might confer immunity is unknown. According to the CDC, antibody test results should not be used to group people in actionable cohorts in correctional facilities.
Quest labs should be considered the first-line COVID-19 testing laboratory. Quest provides a high-quality RT-PCR with a turn-around time of 2-3 days and should be used as much as is practical before using a third party, non-electronic health records system (EHRS) interfaced laboratory.
In the event of a shortage of testing supplies or prolonged turn-around times with Quest, testing may be available through the local health department (LHD). Each institution should have a local operating procedure (LOP) for accessing COVID-19 testing through the county. (See the sample LOP [Appendix 12] for institutions from the Headquarters [HQ] Public Health Branch [PHB] to adapt to your facility). When testing outside of Quest is necessary, the LHD will serve as the liaison to access other laboratories, such as the University of California, San Francisco (UCSF) Biohub.
Additionally, requests for a large number (>300) of Quest test kits need to be vetted by the HQ PHB before distribution. Please email the HQ PHB concurrently with large-number kit requests: CDCRCCHCSPublicHealthBranch@cdcr.ca.gov. HQ PHB vetting is not needed for ongoing surveillance testing, testing to accommodate patient movements, or to maintain regular supply levels of kits.
COVID-19 RAPID ANTIGEN TESTING
The Quidel Sofia-2 Clinical Laboratory Improvement Amendments (CLIA)-waived rapid antigen test uses an immunofluorescent assay for a SARS-CoV antigen. This point-of-care (POC) test accurately detects viral proteins in about 15 minutes. Refer to the SARS Antigen Test Information below and APPENDIX 17 for more details.
The test is highly specific, and positive tests can confidently confirm a COVID-19 case. However, consider a follow-up RT-PCR for negatives in patients with high-risk exposures, transmission capability, and comorbidities. Also, any clinical suspicion for infection should be tested with RT-PCR to minimize potential false negatives.
In general, testing should be prioritized for symptomatic patients who are at the highest risk of progression (i.e., over age 65 or with medical comorbidities), at risk of being exposed, or at high risk of transmitting to others (e.g., an inmate worker with multiple contacts or resides in dorm housing). Please see Table 6.2 for testing priorities among symptomatic patients.
Testing is also recommended for selected asymptomatic patients, particularly in an outbreak.
Part of testing is education; patients need information regarding why testing is important, symptoms of COVID-19, availability of testing, risks of getting infected, and prevention of transmission.
Patients are allowed to refuse to test. Patients who have been exposed in the last 14 days need to be quarantined in the event of a refusal, or a negative or indeterminate test result. Because test sensitivity is imperfect, clinical judgment is essential in interpreting negative test results and discerning if additional testing is indicated.
DIAGNOSTIC COVID-19 TESTING FOR SYMPTOMATIC PATIENTS
Either RT-PCR or antigen testing can be used to diagnose patients with symptoms of COVID-19. If the antigen POC test is negative and suspicion for COVID-19 remains, RT-PCR should be performed.
Patients presenting with symptoms of COVID-19 pneumonia (subjective fever or temperature >100° F, cough, or shortness of breath [SOB]) should be prioritized for testing even if test supplies are limited. Patients with these symptoms who are over age 65 or with medical comorbidities that put them at risk for complications are the highest priority for testing.
Patients with any new/unexplained viral symptoms listed below should be tested. Patients with a relatively low suspicion for COVID-19 (no recent or high-risk exposures, a facility with no outbreak, and mild non-specific symptoms) generally do not need to be isolated pending the test results and may return to their assigned housing. Co-test for other respiratory pathogens if clinically indicated. (See Other Respiratory Virus Testing Considerations below).
Repeat testing is recommended for patients in which there is a high clinical suspicion of COVID-19, but an initial negative test.
Testing is not recommended for explained symptoms such as typical allergic symptoms in a patient with a known history or other chronic conditions.
A plan for giving test results and education on isolation and COVID-19 should be in place.
When an outbreak is detected (see COVID-19 Related Public Health Definitions), institutions should immediately notify and engage the local public health department to support integrated staff-inmate contact investigations and consult on testing strategies.
Symptom screening alone is inadequate to promptly identify and isolate infected persons in congregate settings such as correctional and detention facilities. Persons with COVID-19 can be asymptomatic, or symptoms can be subtle and non-specific. In addition, incarcerated persons may be reluctant to report symptoms, even with active screening. Recent data from
COVID-19 outbreaks indicate that symptom-based testing can fail to identify more than 80% of COVID-19 cases in these settings and that asymptomatic or pre-symptomatic staff or residents may contribute to transmission.
As soon as possible, after one or more COVID-19 positive individuals (patients or staff) are identified, outbreak response testing should be directed to those at the highest risk:
Staff or other inmates identified as close contacts to a confirmed case
Patients in the housing area who are at the highest risk of complications and death
Patients in the housing area who are at risk of transmitting the virus (e.g., essential workers)
Patients who require transfer or release
Where sufficient testing resources are available, broad testing strategies, including testing of asymptomatic patients, can be used in correctional facilities to determine the scale of the needed outbreak response based on an assessment of the extent of COVID-19 spread within the facility (see Table 6.3).
Testing strategies should consider:
The stage of the ongoing outbreak (i.e., more frequent testing in the context of escalating outbreaks, less frequent testing when the transmission has slowed).
The availability of testing supplies and the capacity of staff to perform repeat testing without negatively impacting other essential health care services.
Financial resources to fund repeat testing, including procurement of testing supplies, laboratory testing services, and personal protective equipment (PPE).
The capacity of on-site or public health laboratories that will be performing the tests.
The expected wait time for test results (and resulting capacity for timely action based on the results).
RT-PCR is generally used for outbreak response testing. Antigen POC testing can be used if the number of tests needed is manageable and turn-around times for RT-PCR are too long for the situation and/or to target test those with the highest risk to get a quick estimate of the extent of an outbreak.
Testing does not replace or preclude other infection prevention and control interventions including case investigation, isolation of infected individuals, quarantine of exposed individuals, monitoring of quarantined individuals, screening of employees at the start of a shift for signs and symptoms of COVID-19, universal use of cloth face coverings by staff and inmates for source control, use of recommended PPE by staff working with the suspect and confirmed cases, and environmental cleaning and disinfection.
When testing is performed, a negative test only indicates that an individual did not have a detectable infection at the time of testing; individuals might have a SARS-CoV-2 infection that is still in the incubation period or could have ongoing or future exposures that lead to infection.
Testing must be accompanied by plans for use and follow-up of test results, including:
How patients will be educated about why testing is being done
How patients who choose not to be tested will be managed
How individual results will be explained
How results will be used to guide the implementation of infection control measures: isolation, quarantine, and cohorting
How results will be communicated to ensure appropriate management when inmates are released or transferred
During ongoing outbreaks, plans for repeat testing of patients who test negative and are still within 14 days of their last potential exposure, is recommended every 3-7 days, depending on risk
As soon as possible, after one or more COVID-19 positive patients are identified in a facility or housing unit, a testing strategy should be created. Epidemiologists in the PHB are available for consultation: CDCRCCHCSPublicHealthBranch@cdcr.ca.gov. Table 6.3 provides a summary of the asymptomatic testing strategies.
Where testing resources (supplies or staffing) are limited, testing can be prioritized as follows, in descending order. If sufficient resources are available, all groups listed should be tested.
Close contacts of the case:
Named close contacts (<6 feet for at least 10 minutes), regardless of whether the case and/or contact were masked
Close exposures to the case:
Inmates in the adjacent beds in a dorm housing setting
Inmates in the adjacent three cells in a celled housing setting
Inmate coworkers, including those residing in other housing units
Inmates in an inmate-case’s housing unit, or in the housing unit or other location where an infected employee worked or spent time indoors while infectious (e.g., classes, recovery groups, or worship activities)
Testing can be done by housing tier, beginning with the highest risk on the case’s tier and then the remainder of the case’s tier, in order by risk
Testing can progress to other tiers, as appropriate, based on the identification of additional cases
If multiple cases are noted in a single housing unit, the entire housing unit should be tested. The more promptly this testing is done, the more likely that the outbreak can be controlled.
Serial retesting of housing unit inmates and others who are at potential exposure risk, who are quarantined, and initially test negative should be performed every 3-7 days until no new cases are identified. Retesting can be prioritized according to the likelihood of contact with previous cases (e.g., inmates on a housing tier where cases were previously identified). Once a patient tests positive, no additional testing is needed for that patient.
If an institution has a longstanding outbreak that involves cases in various housing units throughout the institution, and mass testing has not been previously conducted, several testing strategies can be considered. Because of the high number of previously undetected cases that are likely to be identified and may or may not be currently infectious, it is imperative that the institution plan ahead for separation of inmates into the cohorts listed below.
If resources allow, testing can be done on all inmates in the institution.
If it is not feasible to test all inmates, specific housing units can be selected.
Mass testing of more recently affected housing units at the “leading edge” of the outbreak allows for outbreak control in those housing units.
Mass testing of housing units that have had cases for weeks allows for positives to be identified, cohorted and/or isolated, and then released from isolation and quarantine once they meet criteria. This may cut down on the number of inmates under quarantine restriction, but may not be an effective outbreak control strategy.
Housing units that are housing a disproportionately high quantity of high-risk inmates or inmates unable to follow physical distancing requirements (e.g., developmentally disabled inmates).
If mass testing is not possible, consideration can be given to testing individual inmates who are at the highest risk of complications of COVID-19 based on underlying conditions and/or age. Inmates who test negative can be separated from the general inmate population to prevent their becoming infected, and those who test positive should be isolated and closely monitored for progression of the illness.
RT-PCR is generally used for mass testing. The rapid POC tests may be useful when immediate targeted testing of the highest-risk persons or housing units is needed and RT-PCR turn-around times are too long.
COHORTS: COVID-19 MASS TESTING
Inmates should be placed into separate cohorts based on exposure and test results:
Negative, with known exposure within the last 14 days
Refused or indeterminate, with known exposure within the last 14 days
Negative or refused, without known exposure within the last 14 days
Inmates are allowed to refuse to test. Inmates who have been exposed in the previous 14 days need to be quarantined in the event of a refusal, negative, or indeterminate test result.
ADDITIONAL CONSIDERATIONS FOR MASS TESTING
Given the potential for high numbers of asymptomatic infections, ensure that plans include isolation options to house large numbers of infected individuals and quarantine options to house large numbers of close contacts, ideally separating exposure cohorts.
Consider how the facility’s housing operations could be modified for multiple test result scenarios (e.g., if testing reveals that 10%, 30%, 50%, or more of incarcerated or detained persons test positive for COVID-19).
Will specific housing units/pods be designated for people who test positive?
If testing reveals that more people are positive than negative, will those who test negative be reassigned to different housing (rather than reassigning those who test positive)?
How will housing areas be systematically and thoroughly cleaned and disinfected if large numbers of positive individuals are identified, and housing units are rearranged?
How will the facility manage the logistics of moving large numbers of people into different housing arrangements (e.g., where will incarcerated or detained individuals go while the housing units are being cleaned and disinfected, and how will positive and negative individuals be separated during this time)?
COVID-19 EMPLOYEE TESTING DURING OUTBREAKS
In response to initial cases, outbreaks, or clusters in a facility or a specific housing unit, the California Department of Public Health (CDPH) recommends testing for all employee contacts of inmate and employee cases. CDCR Office of Employee Health can provide information on testing resources. Employee testing should occur at the same time as inmate testing and in coordination with inmate testing. Delaying employee testing will impair control of transmission within the facility.
If resources allow, testing can be done on all employees in the institution.
Employees should be tested in this priority:
Named close contacts to inmate and employee cases
Staff present in the same work location or break room as an employee case during their infectious period
Staff present in the same location (housing unit or other location such as an office or kitchen) as an inmate case during their infectious period.
Expanded testing may be indicated in the setting of a large outbreak. Local and state public health officials should be engaged in developing testing and cohorting strategies and return to work policies.
COVID-19 TESTING OF QUARANTINED PATIENTS AND PRIOR TO RELEASE FROM QUARANTINE
Patients who develop symptoms while in quarantine should be isolated immediately while awaiting test results. Asymptomatic patients who have been exposed to COVID-19 should be offered viral testing at the start of quarantine (see Table 6.3), within 24 hours. If they test positive, they need to be removed from quarantine and isolated. The CDC recommends that patients who initially test negative should be retested every 3-7 days. The interval can be chosen with the outbreak status, with more frequency in the context of escalating outbreaks. POC antigen tests may be useful in some situations if immediate results are necessary and RT-PCR turn-around times are too long.
In asymptomatic patients, follow up of negative tests with RT-PCR is not necessary to rule out false negatives because the quarantine time will cover any infectious period. However, if there is high clinical suspicion, high-risk exposures, or concern, using RT-PCR to confirm a negative is indicated. Additionally, for high-risk exposures, patients at high risk for severe COVID-19, or if coming in from a facility or county with a known outbreak, consider testing at day 7 of quarantine.
Those that test negative or refuse to test, need to remain in quarantine for 14 days. At the end of a 14-day quarantine, they may be potentially infectious even without having developed symptoms. Testing is the only means of identifying asymptomatic infections. Thus, patients should be offered viral testing prior to release from quarantine. If they test negative, they can be considered safe to release after the 14-day quarantine. Testing can be performed up to 2 days prior to the scheduled release date. If they test positive, they need to be isolated. If they refuse to test, the quarantine should be extended another seven days. Testing should be re-offered, allowing inmates to be released if they test negative. At the end of the extended (21-day) quarantine, if there are no new exposures and no new symptoms, inmates can be released.
PUBLIC HEALTH COVID-19 SURVEILLANCE TESTING
Surveillance testing is used to determine the extent of active infection in a population. Active infection is diagnosed by testing upper respiratory tract specimens using RT-PCR. Surveillance testing is used to detect outbreaks in an early phase, even before the development of symptoms. Early detection and rapid outbreak response can limit the spread of infection and prevent morbidity and mortality. Additionally, with sufficient numbers of appropriately selected patients testing negative, an institution can demonstrate with some confidence the absence of an outbreak.
For institutions without any new cases in the past 14 days, a bimonthly institution-wide symptom screen and temperature check should be used to identify patients appropriate for clinically based testing. Critical inmate workers should be screened before work as detailed in the Screening of Critical Inmate Workers memo (CDCR networking access is required). Institutions with active outbreaks should conduct symptom and temperature screening in areas of the prison that appear not to be affected by the outbreak.
RT-PCR is generally used for surveillance testing.
HOW MANY TO TEST FOR COVID-19 SURVEILLANCE
Public health surveillance testing using RT-PCR should be conducted for at least 15 patients per housing facility every month using the following principles (see Table 6.3):
A sufficient number of patients in each yard or housing facility need to be tested. For 80% confidence in detecting a prevalence of 10%, a minimum of 15 patients is required. On average, per month, each institution should test 60-100 inmates as part of surveillance testing.
If there are multiple housing units (buildings) within a facility or sharing a yard, patients from each of the units should be tested.
Sampling for each yard should be weighted to include testing of vulnerable patients. Vulnerability is defined by a COVID-19 registry risk score of 4 or higher. For institutions with 60 or fewer higher-risk patients, test ALL higher-risk patients.
Test at least 15 higher risk patients per housing facility; if there are <15 higher-risk patients in a housing facility, test enough lower-risk patients to total at least 15 patients per facility.
If a housing facility is a mixed dorm and celled housing, test at least ten patients from dorms.
Patients who come forward with any symptoms consistent with COVID-19 should be isolated and tested.
ROUTINE COVID-19 TESTING OF HIGHER-RISK ASYMPTOMATIC PATIENTS
Patient care for COVID-19 includes routine viral testing of asymptomatic patients who are at high risk of exposures and/or transmissions (see Table 6.3).
In general, RT-PCR can be used for routine testing of high-risk patients. The rapid antigen test may be useful when a result is needed urgently and RT-PCR turn-around times are too long.
Selective testing among asymptomatic patients is recommended for those using aerosol-generating procedures (AGPs) such as nebulizers or continuous positive airway pressure (CPAP) as well as those at risk of severe complications. Routine testing is recommended, and repeat or serial testing may be valuable for patients with ongoing risk. This is particularly important if the areas in which these devices are used cannot be adequately ventilated or cleaned. In addition to routine serial testing, antigen POC testing may be used immediately before procedures.
Patients being released from quarantine should be offered testing with an extension of quarantine for those who refuse, as discussed above (see Testing Quarantined Patients and Prior to Release from Quarantine).
Testing can be used for the release of asymptomatic patients with confirmed COVID-19 from isolation and transmission-based precautions into a congregate setting. See Control Strategies for Suspected and Confirmed Cases for the testing strategy for releasing from isolation.
Consider monthly testing for patients aged 65 or older or with medical comorbidities that put them at risk for complications of COVID-19.
Routine testing should be considered for essential inmate workers who have a high level of contact with staff or other inmates as part of their work (e.g., kitchen staff). Refer to the Screening of Critical Inmate Workers memo (CDCR networking access is required).
Similar to the community, patients should be able to request COVID-19 testing regardless of symptom status.
COVID-19 TESTING OF TRANSFERS
Transfers to and from the institution may increase the risk of introduction and spread of COVID-19 between facilities. The COVID Screening and Testing Matrix for Patient Movement provides additional specifications on the testing strategy, housing, and what to do if the patient refuses to test.
Inmates arriving from county jails should be tested on arrival. If they are negative, they should still complete the 14-day quarantine and receive testing before release into the general population. See Quarantine Testing above and Table 6.3.
The POC antigen test may be used for incoming and exiting transfers to/from jails, between institutions, before transfer to a higher level of care (HLOC), and before travel for court or medical appointments. If there are high-risk exposures or any clinical suspicion of a false negative, a nasal specimen for RT-PCR should also be collected. Also, in addition to an RT-PCR that is 4-7 days old, POC testing immediately before movement may also be considered.
Transfers between institutions, including those for mental health, medical, or dental services, may be tested within a week prior to transfer or upon arrival. Testing allows for more rapid identification of individuals who may be infectious so that they can be isolated.
Patients who transfer to or from a community hospital, emergency department, or Department of State Hospitals (DSH) facility should be tested within a week prior to transfer or upon arrival if no test was performed within the past seven days. A POC antigen test can be immediately run before departure.
Additional testing considerations may include periodic testing of patients who frequently leave the facility for hemodialysis, chemotherapy, or other services. The POC antigen test can be used in addition to routine serial RT-PCR for this purpose, immediately before movement.
Retesting an individual is not necessary if they have tested negative in the previous seven days provided that they (1) have not developed symptoms, (2) remain afebrile, and (3) are not a contact to a COVID-19 case.
COVID-19 TESTING OF EXPEDITED RELEASES/PAROLEES
Offer testing to all exiting persons who are neither resolved nor currently infected (see Re-Testing Previously Positive Patients and Employees after Recovery from COVID-19). This includes:
All patients whether in quarantine or not, including those who resolved from a prior COVID illness (see criteria below) and are cleared for release
Everyone else who tests negative and is cleared for release
Everyone who refuses to test:
Will be quarantined for two weeks and then they will be allowed to be released
If in quarantine, will remain in quarantine for 21 days and then they will be allowed to be released
Positives (current active infection) will be held until they are resolved, then they will be allowed to be released
RE-TESTING PREVIOUSLY POSITIVE PATIENTS AND EMPLOYEES AFTER RECOVERY FROM COVID-19
SUMMARY OF LITERATURE ON VIRAL SHEDDING AND REINFECTIONS
Although there are scattered events reported, there are no confirmed cases of SARS-CoV-2 reinfection. Below details a summary of the CDC analysis and review of literature on this topic.
Many studies show viral shedding to be prolonged after the resolution of symptoms of COVID-19, in some cases, as long as 60 days from symptom onset (median 31 days). Recovered patients can have SARS-CoV-2 RNA detected in their respiratory secretions for up to 12 weeks.
However, detecting viral RNA via PCR does not necessarily mean that an infectious virus is present. Viral shedding studies show that prolonged shedding is not likely to be infectious.
CDC analysis and review of literature shows that viral shedding beyond 9 days from the onset of symptoms has not been able to be grown in viral culture, with the exception of immunocompromised patients with severe COVID-19. But even in these patients, 88-95% of specimens were no longer replication-competent after 10 and 15 days respectfully.
The viral load found after 2 weeks of symptoms is orders of magnitude less than that in the first 5 days.
The statistically estimated likelihood of recovering replication-competent virus approaches zero by 10 days from the onset of symptoms, if immunocompetent.
Also, as the likelihood of isolating replication-competent virus decreases, anti-SARS-CoV-2 IgM and IgG can be detected in an increasing number of persons recovering from the infection.
Concentrations of SARS-CoV-2 RNA in respiratory secretions decline after the onset of symptoms. Among those who continue to have detectable RNA, concentrations of detectable RNA 3 days following recovery are generally in the range at which replication-competent virus has not been reliably isolated by CDC in unpublished data.
Infectious virus has not been cultured from urine or reliably cultured from feces in multiple studies; these potential sources pose minimal, if any, risk of transmitting infection, and any risk can be sufficiently mitigated by good hand hygiene.
A large contact study demonstrated that high-risk household and hospital contacts did not develop the infection if their exposure was 6 days or more after the case-patient’s symptom onset.
A Korean investigation reported by the Korean CDC of 285 “persistently positive” persons, which included 126 persons who had developed recurrent symptoms, found no secondary infections among 790 contacts attributable to contact with these case-patients. Efforts to isolate replication-competent virus from 108 of these case-patients were unsuccessful.
Despite some studies showing antibodies quickly declining, the scientific consensus is that immunity lasts at least 3 months. Cellular immunity is shown to be involved. An unpublished report of 20,000 people finds that 90% of antibody responses lasted at least 3 months.
Hence, after a review of the available literature, CDPH has responded with the following policy:
Previously positive SARS-CoV-2 COVID-19 patients (inmates and employees) who have recovered, require re-testing (all prior-to-infection testing including: pre/post movement or transfers and quarantine/targeted housing/serial/mass/and surveillance testing) when:
Time elapsed since release from isolation is >3 months.
Time since release from isolation is <3 months and develops new symptoms consistent with COVID-19.
July CDC updates state that for persons who develop new symptoms consistent with COVID-19 during the 3 months after the date of initial symptom onset, if a provider cannot identify an alternative etiology, then the person may warrant re-testing; consultation with infectious disease or infection control experts is recommended. Isolation may be considered during this evaluation based on consultation with an infection control expert, especially in the event symptoms develop within 14 days after close contact with an infected person.
Time since release from isolation is <3 months, and the individual is severely immunocompromised (i.e., ongoing chemotherapy, hematologic malignancy, bone marrow transplant recipient, or on immunosuppressive therapy).
Time since release from isolation is <6-8 weeks, and the individual is a resident in a skilled nursing facility level of care. Re-testing after 6-8 weeks may be appropriate per CDC guidance.
Per CDPH guidelines, patients who do not meet the criteria above do not need to be re-tested for SARS-CoV-2 if they are <3 months since their release from isolation. If asymptomatic, they are not considered infectious during this timeframe, do not need to be quarantined, can be released to any type of housing, do not need testing for transfers or surveillance, and any tests conducted in the 3 months after release from isolation can be considered false positives. Always use clinical judgment. See the Release from Isolation section for more information.
CONCERN FOR COVID-19 FALSE POSITIVES
Being in a congregate setting, we must be conservative in our policy toward potential false positives.
The CDPH (July 2020) supports the policy that at CDCR, every positive viral test should be treated as a true positive, unless proven otherwise. Our setting and its extremely high risk of widespread transmission requires us to be more conservative regarding false positives. Hence, all positive tests, even if suspected a false positive, must be isolated and a contact investigation conducted immediately.
A false-positive result can be considered if all of the following specific scenarios are met:
The patient is completely asymptomatic
The patient is low risk for having been exposed
The patient was tested as part of surveillance/transfer/release (i.e., low suspicion)
The institution is not experiencing an outbreak
Surveillance rounds are completed on housing contacts, and all contacts are asymptomatic
Following a contact investigation and further testing, no other inmates/staff who were contacts tested positive
If an asymptomatic individual meets the criteria above, it may indicate the first test is a false positive. The patient must remain in isolation and the contacts in quarantine while the following steps are taken to investigate:
COLLECT A NEW SPECIMEN FROM THE INDEX PATIENT FOR REPEAT TESTING AT QUEST as soon as possible.
If this test is positive, stop, and treat the patient as a true positive
If this test is negative, send one more specimen for NAAT testing
If the patient has remained asymptomatic, has low exposure risk, no other cases were identified from the contact investigation, AND all the repeat tests are negative, the patient may be considered a false positive and transmission interventions may be lifted if approved by the Chief Medical Executive (CME) and LHD. Please send an informative email to the public health branch at CDCRCCHCSPublicHealthBranch@cdcr.ca.gov.
COVID-19 TEST ORDERING INFORMATION
COVID-19 QUEST RT-PCR TEST
Order SARS-CoV-2 RNA (COVID-19), Qualitative Real-Time RT-PCR testing (Enter “COVID” into the order search menu, and choose “CoV-2 RNA QUAL NAAT” in EHRS; Quest Test Code: 39448).
IMPORTANT: COVID-19 NAAT testing should be ordered as “ASAP.” Please do not order as “routine” (delays one week) or “STAT” (will not process).
NOTE: Full PPE required when obtaining specimens include an N95 mask, eye protection, gown, and gloves.
RT-PCR specificity is >99%, and sensitivity is >90% if done within the first five days of symptoms and with proper collection technique (see below).
Past literature and consensus have suggested that test performance for PCR is best with an NP sample, then mid-turbinate, then nasal. However, the CDC has removed the preference for NP specimens for SARS-CoV-2 testing.
COVID-19 POC RAPID ANTIGEN TEST ORDERING
COVID-19 POC CLIA-waived rapid antigen test can be run on the Sofia-2 device that was provided for rapid influenza detection (RIDT) during the influenza season. Ordering and charting results will be very similar to that for RIDT. Instructions and training will be provided in separate communications.
The POC test may be ordered in the EHRS as follows:
Find the COVID-19 order options and choose the, “COVID-19 Rapid Test POC”.
Then under “Type of Test,” choose “Antigen FIA Test.”
CHARTING COVID-19 POC TEST RESULTS IN EHRS
Chart POC COVID-19 results using: the Task List tab > Schedule Patient Care tab > double click on the Influenza-Like Illness POC Results task > the PowerForm will pop up > document and sign the PowerForm > task and the order will complete.
There are also Webinar videos on Lifeline ECHOS/EHRS Project > ECHOS Learning Team > Nurse Webinars tab for instructions.
NON-QUEST COVID-19 TEST ORDERING
All non-Quest testing must be entered as an order in EHRS as “Misc Test Other-COVID19” to allow tracking of the pending test and for the results to later be stored as discrete reachable data. See image below:
The results come to CDCR through the county. CDCR staff must manually enter the results into these areas:
Manual entry into the EHRS results section, which is critical for testing statistics to be captured by internal and external monitoring databases and dashboards.
The PHB SharePoint website, entered by the public health nurse (PHN) or infection control nurse (ICN).
Note: Orders for isolation or quarantine, if indicated, should be placed and will prompt the surveillance requirements and allow tasking and tracking by nursing and the PHB.
STRATEGIES TO MAXIMIZE SENSITIVITY OF COVID-19 TESTING
Test early: CDC recommends that specimens should be collected as soon as possible once a suspect case is identified, regardless of the time of symptom onset. Viral load is highest in respiratory specimens early on in the course of the disease when symptoms tend to be mild (first five days). The median time to a negative PCR is 9 days. Studies show a patient with COVID-19 may have a negative upper respiratory PCR sample, while the virus can still be found in the lower respiratory tract in a patient with pneumonia.
Use NP and OP collection together if possible: For initial diagnostic testing for COVID-19, only one NP swab is needed, and the NP specimen has the best sensitivity studied; however, it is prone to a variable collection technique, and a poor specimen collection can dramatically affect the sensitivity. Testing both NP and OP further increases sensitivity. If collecting both an NP and OP swab, they can be put in the same media tube, as long as both tips are in the liquid. When testing supplies/swabs are in short supply, OP and NP collection can be performed using the same swab.
NOTE: Use a separate order and collect a separate specimen for each viral test being conducted (e.g., one or two swabs for influenza, and one or two swabs for SARS-CoV-2 RT-PCR).
Use the appropriate collection technique: NP Swab Technique: Insert the swab into one nostril parallel to the palate, gently rotating the swab inward until resistance is met at the level of the turbinates; rotate against the nasopharyngeal wall (approximately 10 seconds) to absorb secretions. See mid-turbinate and nasal techniques below.
NOTE: Sputum inductions are not recommended as a means for sample collection.
For the antigen POC test only, use a DRY SWAB. If the patient collection area is far from the device, put the swab in a sterile tube for transport over to the device location.
PATIENT SELF-COLLECTED COVID-19 SPECIMENS
MID-TURBINATE (MT) SELF-COLLECTION
ONLY FLOCKED SWABS can be used for MT collection, for example, Copan® FLOQSwab or MDL® NasoSwab™.
MT Collection instructions: Use a single flocked swab for collecting specimens from both mid-turbinates of a symptomatic patient. Instruct the patient to tilt their head back and look at the ceiling. Gently insert the soft tip of the swab into one nostril until the safety stopper touches the edge of the nostril. Gently twist the handle for 15 seconds. Remove the flocked swab and insert the same swab into the other nostril and repeat the same 15-second procedure. If the health care worker (HCW) remains 6 feet from the patient, self-collection with MT sampling does not require an N95 respirator; a surgical mask is sufficient (provided it is not in an area where global N95 use is recommended, such as quarantine and isolation).
COVID-19 ANTERIOR NARES (AN) SELF COLLECTION
ONLY FOAM SWABS can be used for NARES collection, for example, Puritan 6’ Sterile Standard Foam Swab w/ Polystyrene Handle.
AN collection instructions: Use a single foam swab for collecting specimens from both nares of a symptomatic patient. Insert foam swab into one nostril straight back (not upwards). Once the swab is in place, rotate it in a circular motion two times and keep it in place for 15 seconds. Repeat this step for the second nostril using the same swab. Remove foam swab and insert the swab into an acceptable viral transport medium (or dry swab for the POC antigen test) listed in this guide. If the HCW remains 6 feet from the patient, self-collection with AN sampling does not require an N95 respirator; a surgical mask is sufficient (provided it is not in an area where global N95 use is recommended, such as quarantine and isolation).
NOTE: AN specimens can also be collected with OP to increase sensitivity. If collecting both an AN and OP swab, they can be put in the same media tube, as long as both tips are in the liquid. When testing supplies/swabs are in short supply, OP and AN collection can be performed using the same swab.
COVID-19 SAMPLE SPECIFICATIONS FROM QUEST
Dry swab submissions are unacceptable and will be rejected. (Use dry swabs for Sophia-2 rapid POC testing only).
Accepted specimen: NP (and NP with OP), MT, AN (and AN with OP) swab collected in a sterile collection tube containing 3 ml of viral transport medium. Sterile saline (2-3 ml) can also be used as a transport media. Acceptable tubes include, but are not limited to, phosphate-buffered saline (PBS) red top tube, diagnostic hybrid tubes (VCM) medium green-cap tube, universal transport medium (UTM), BD universal viral transport (UVT), M4, M4RT, M5, M6 or Copan ESwabs™ or BD ESwabs™ transport media.
Sputum (not induced) may also be collected and sent to Quest in a plastic, sterile, leak-proof container, such as a urine cup.
Important: Leakage can be a concern. Take caution to tighten the cap properly to avoid leakage. If possible, freeze samples upright at -20° C (-68° F) before pick up. This can minimize the leakage risk.
Storage and Transport: COVID-19 specimens are best refrigerated and transported with cold packs. Follow standard procedure for storage and transport of refrigerated samples.
Cold packs/pouches must be utilized if samples are placed in a lockbox.
All media: Frozen -68° F (-20° C or -4° F) specimens are stable for 7 days (freezing will mitigate potential leakage).
All media are stable at room temperature (2-25° C or 35.6-77° F) or refrigerated (2–8° C or 35.6-46.4° F) for 5 days.
COVID-19 is not a STAT test, and a STAT pick-up cannot be ordered.
Turn-around time (TAT), published as 3-4 days, may be delayed in times of high demand
Calcium alginate swabs, wooden shafted swabs, charcoal medium, anaerobic swabs, or transport medium are NOT acceptable.
Any swab submitted in media containing guanidinium or guanidine isothiocyanate, guanidine or guanidinium thiocyanate, or like component is NOT acceptable and will be rejected.
Examples of unacceptable swabs/transport: Ruhof kits, Abbot Multi-collect, Babio VTM, and MANTACC UTM.
PRECAUTIONS FOR COVID-19 QUEST SPECIMEN COLLECTION
The collection of upper respiratory specimens is considered an AGP. In choosing the location for specimen collection, consideration should be given for minimizing any unnecessary exposure. The preferred location for specimen collection is in a room with only the individual being sampled, the door closed, and no other individuals present.
When collecting diagnostic respiratory specimens (e.g., NP swab or HCW collected MT and AN) from a possible COVID-19 patient, all Health Care Personnel (HCP) in the room should wear an N95 respirator, eye protection, gloves, and a gown during collection. HCP present during the procedure should be limited to only those essential for that patient’s care and procedure support. Specimen collection should be performed in a location and circumstance that minimizes exposure. (See the Aerosol-Generating Procedures memo).
If individual rooms are not available, other options include:
Large spaces (e.g., gymnasiums) where sufficient space can be maintained between swabbing stations (i.e., greater than 6 feet apart).
An outdoor location, weather permitting, where other individuals will not come near the specimen collection activity.
Considerations for multiple persons being swabbed in succession in a single room:
Consider the use of portable high-efficiency particulate air (HEPA) filters to increase air exchanges and to expedite removing infectious particles.
Minimize the amount of time each person will spend in the room.
People awaiting swabbing should not wait in the room where swabbing is being done.
Those swabbed should have a face mask or cloth cover in place for source control throughout the process and should only be removed during swabbing.
Those awaiting collection should physically distance as much as possible.
Minimize the equipment kept in the specimen collection area.
OTHER RESPIRATORY VIRUS TESTING CONSIDERATIONS
For patients presenting with symptoms of pneumonia, test for influenza and COVID-19 concurrently. Use RT-PCR for influenza testing until the beginning of the 2020-2021 influenza season in the fall. RIDT can be used for rapid flu testing during flu season.
Clinicians should use their judgment in testing for other respiratory pathogens, including respiratory syncytial virus (RSV) and coccidioidomycosis (Valley Fever).
Repeat testing for SARS-CoV-2 (and other respiratory pathogens if indicated) with NP and oropharyngeal (OP) specimen(s) by PCR is recommended when clinical suspicion is high, but initial PCR testing is negative.
INFLUENZA PCR TEST ORDERING
Influenza A/B RNA, Qual, PCR; Test Code 16086; the preferred specimen is NP swab.
Influenza A and B and RSV RNA Qual Real-Time PCR; Test Code 91989; preferred specimen nasal or NP swab.
NOTE: Influenza specimen collectors usually use droplet precautions, but because all with an ILI must also be considered for COVID-19, PPE for COVID-19 should be used as above.
RAPID INFLUENZA CLIA WAIVED DIAGNOSTIC TEST (RIDT)
IMPORTANT: Influenza activity is “sporadic” throughout California, so RIDT should not be used for the rest of the spring and summer 2019-2020 season. Use the RT-PCR for influenza testing.
When influenza is prevalent (transmission designated “Regional” or “Widespread” in your region by CDPH Weekly Influenza Report or CDC Weekly Flu View), rapid test kits for point of care influenza testing may be used to identify influenza infections quickly.
Due to unreliable sensitivity (regardless of season), if the RIDT result is negative, further testing is always indicated. Order the influenza A/B RNA Qualitative PCR (test code 16086) and COVID-19 RNA Qualitative NAAT (test code 39448). See the details below.
RIDT is only useful for ruling in influenza when prevalence is high. When the CDPH specifies that influenza transmission has downgraded to “sporadic” for your institution’s geographic area, DO NOT USE the RIDT tests any longer.
Headquarters PHB will send notification of when RIDT is no longer useful due to decreased prevalence in your geographic area and when to restart use in new fall seasons.
In the future, combination test cassettes with COVID-19 and influenza may become available.
Chest X-rays, CT scans, and lab testing (e.g., LDH, ALT/AST, CBC, D-Dimer, CRP, and Procalcitonin) are generally used in the inpatient setting but may assist in diagnosis when there is a respiratory decline of uncertain etiology or in predicting progression to respiratory failure (see Clinical Manifestations section).
TRANSMISSION - Updated 4/21/2020
The virus is spread person-to-person through respiratory droplets that are dispersed when an infected person speaks, sneezes or coughs and then lands in the mouth, nose or eyes of an uninfected person.
This direct transmission occurs between people who are in close proximity with one another (within 3.6 feet). The policy for 6-foot-distancing has been adopted to be conservative.
Transmission also occurs from contact when a person touches a contaminated surface, then touches their mouth, nose or eyes. Studies have shown that the virus can survive on plastic and stainless steel for 72 hours, on cardboard for 24 hours, and copper for 4 hours. SARS-CoV-2 has been shown in hospitals and intensive care units to have a high rate of positivity throughout the hospital; on floors, computer mice, trash cans, sickbed handrails and patient masks. Thus, there is clear viable virus particles on fomites, but infectiousness and amount of virus necessary to cause disease by this modality is unclear at this time.
SARS-CoV-2 RNA has been isolated from upper and lower respiratory tract specimens and stool samples. While respiratory samples are clearly contagious, the infectiousness of fecal specimens are not clear. It is not yet known if other bodily fluids such as blood, urine, breast milk or vomit contain viable transmissible SARS-CoV-2.
The virus is highly transmissible, even when only having mild symptoms. Viral shedding is highest around the time of symptom onset and lessens after the first 5 days of symptoms.
More evidence is emerging regarding asymptomatic transmission. Studies have demonstrated viral shedding 1 to 3 days prior to symptom onset. Among patients infected with COVID-19 who were asymptomatic at the time of testing, the mean time to symptom development was 3 days. Further, among patients whose infection has resolved, viral shedding may continue for two or more weeks after recovery from the time of symptom onset. The infectiousness of this post-recovery shedding is unclear, but it has been shown to have 1,000 times less viral particles than at the beginning of symptoms. Transmission from asymptomatic individuals has been demonstrated and may be responsible for 6-13% of COVID-19 cases. The infectious period for this virus is now considered to be 48 hours prior to symptom onset.
Airborne transmission (virus suspended in air or carried by dust that may be transported further than 6 feet from the infectious individual) is a possible mode of transmission, but not currently thought to be a major driver of the pandemic. However, aerosol generating procedures will cause significant airborne transmission and SARS-CoV-2 has been shown to remain viable in aerosols for sustained periods of time.
Aerosol generating procedures require increased vigilance for infection control because they cause a very high risk of transmission as the viral particles suspend in the air for hours and can be inhaled. Non-dental Aerosol Generating Procedures (AGP) typically utilized in CDCR include:
This section will cover the treatment of COVID-19 and influenza. For diagnosis and treatment of other respiratory pathogens such as respiratory syncytial virus, coccidioidomycosis, tuberculosis (TB), and bacterial pneumonia, see relevant CCHCS care guides and/or Up to Date and national guidelines.
TREATMENT OF COVID-19 AT THE INSTITUTION
Studies continue to seek effective treatments for COVID-19 infection. At present, the treatment of COVID-19 in the outpatient setting is largely supportive. Key treatment considerations are listed in Table 8.1.
The National Institute of Health (NIH), Infectious Disease Society of America (ISDA), the Center for Disease Control (CDC), and the World Health Organization (WHO) currently DO NOT recommend antiviral medication for the treatment of mild or moderate COVID-19 outside of a clinical trial setting.
Patients with diabetes: Because patients with diabetes are at increased risk for severe illness, the American Diabetes Association recommends to consider stopping sulfonylureas, metformin, and SGLT-2 inhibitors, as with all seriously ill patients with diabetes. Also, GLP-1 medications can cause nausea, vomiting, diarrhea, and anorexia; assessment of its continued use during COVID-19 illness is advised.
Patients on steroids: Patients prescribed oral or inhaled corticosteroid therapy prior to COVID-19 for another underlying condition should not discontinue it. If on oral therapy, supplemental or stress-dose steroids may be considered on a case-by-case basis if the patient becomes moderately or severely ill.
PATIENTS NEEDING HOSPITALIZATION
The NIH defines patients with COVID-19 illness into the following categories:
Asymptomatic or Presymptomatic Infection: Individuals who test positive for SARS-CoV-2 but have no symptoms.
Mild Illness: Individuals who have various signs and symptoms (e.g., fever, cough, sore throat, malaise, headache, diarrhea, muscle pain) without shortness of breath, dyspnea, or abnormal imaging.
Moderate Illness: Individuals who have evidence of lower respiratory disease, by clinical assessment or imaging, and saturation of oxygen (SpO2) ≥94% on room air at sea level.
Severe Illness: Individuals who have respiratory frequency >30 breaths per minute, SpO2 <94% on room air at sea level, a ratio of arterial partial pressure of oxygen to fraction of inspired oxygen (PaO2/FiO2) <300, or lung infiltrates >50%.
Critical Illness: Individuals who have respiratory failure, septic shock, and/or multiple organ dysfunction.
In general, patients who are healthy at baseline and asymptomatic, mild or moderate illness can be managed in the institutions. Older patients and those patients of any age with significant chronic medical conditions who are at higher risk for complications with COVID-19 should be watched more closely, and the provider should have a lower threshold to consider transfer to HLOC.
Moderate COVID-19 illness is defined as evidence of lower respiratory disease by clinical assessment or imaging with SpO2 ≥94% on room air. Rapid progression of pulmonary disease is possible, so close monitoring of patients with moderate disease is recommended.
Providers rounding on symptomatic patients (in isolation) may order additional tests such as a chest X-ray and labs, especially if the patient has signs and symptoms suggestive of lower respiratory tract disease or worsening respiratory status (see Monitoring Patients with Suspected or Confirmed COVID-19 section).
Based on the NIH COVID-19 Treatment Guidelines, any of the following suggest severe COVID-19 disease and transfer to an HLOC is strongly recommended:
Patient with a saturation of oxygen (SaO2) <94% on room air (or significant drop from baseline if prior chronic hypoxia)
Patient with a respiratory rate >30 breaths per minute
Patients with lung infiltrates >50% of lung volume
Patients with evidence of lower respiratory disease by lung auscultation or chest X-ray, but saturation of oxygen (SaO2) >94% on room air
USING SEPSIS SCORES TO MONITOR FOR POSSIBLE NEED FOR HLOC
Using the Quick Sepsis-Related Organ Failure Assessment (qSOFA) score has been shown to correlate with the odds of in-hospital death with COVID-19. It is recommended by the International Consensus Sepsis-3 for outpatients to predict mortality (not sepsis itself).
It uses findings of an altered mental status (Glasgow Coma Score <15), a respiratory rate ≥22, and systolic blood pressure ≤100. The score calculator can be found at the MDCalc website on qSOFA. A score of 2 or higher suggests a high risk of poor outcome; these patients should be sent to an HLOC.
The literature is mixed regarding the use of the Systemic Inflammatory Response Syndrome Score (SIRS). A SIRS score is more sensitive, has more false-positive results, and can detect conditions other than sepsis. Reviewing the SIRS criteria may be useful in assessing patients who might be demonstrating very early sign of sepsis and may need heightened surveillance beyond twice a day.
SIRS Score: (1 point each indicator)
Temperate >38 °C (100.4 °F)
Heart rate >90
Respiratory rate >20
WBC >12,000/mm3, <4000/mm3, or >10% bands, suspected or present source of infection, lactic acidosis
A score of 2 or higher meets the SIRS definition. The SIRS Score calculator can be found at the MDCalc website on SIRS.
OTHER PRE-HOSPITAL CONSIDERATIONS
Thrombotic related complications: Other complications that have been described in COVID-19 patients include acute, life-threatening conditions such as acute pulmonary embolism, acute coronary syndrome, and acute stroke. Clinical suspicion for these complications should be heightened when caring for COVID-19 patients, and patients should be transferred to HLOC immediately. To date, there is NO recommendation for outpatient anticoagulation or thrombotic prophylaxis in these patients.
Advance Care Planning: Strongly consider discussing advance care plans, such as desires for intensive care support and desire for palliative care with patients who are frail or otherwise at high risk for complications and mortality due to COVID-19. Please refer to the CCHCS Palliative Care Guide and the many resources available in the Provider Resource Library (PRL) (CDCR networking is required for access) for End of Life Planning and Treatment, including COVID-19 Advanced Care Communication Tips for discussions with patients. It is extremely important to clarify who the patient would like to be their surrogate decision-maker and ensure this is documented, ideally in an Advance Directive for Health Care, but at very least on the Next of Kin form and in your progress note.
Note: Up to Date June 2020 states that if a death should occur in one of our patients due to COVID-19, the cause of death should be listed as the new ICD-10 category “COVID-19”. Do not list the non-specific term “coronavirus.” (Currently, COVID-19 is NOT an available code within the EHRS ICD10 code set, so for a Problem List, you will need to use a “coronavirus infection: code.)
TREATMENT OF COVID-19 PATIENTS ADMITTED TO THE HOSPITAL
Patients with COVID-19 who are admitted to the hospital may be treated with a variety of agents.
Recent randomized controlled studies for hospitalized patients with COVID-19 have shown encouraging results with Remdesivir and potential for treatment with a regimen of interferon beta-1b, lopinavir/ritonavir, and ribavirin. However, so far, a mortality benefit was not shown in either study. Whether giving the antiviral medications earlier could lower mortality or disease progression to severe, is yet to be determined. Recent studies on dexamethasone have changed the current recommendations on steroids. The NIH recommends the following regarding use of medications for COVID-19:
Post-hospital isolation, housing, and mask requirement: Patients may return from the hospital on oxygen and will need close medical attention. They should continue in isolation until release criteria have been met (see Release from Isolation). Patients may require more frequent surveillance than the scheduled twice-a-day monitoring depending on the patient’s clinical course and risk factors. If so, medical housing would be appropriate. Wearing a surgical mask by the patient should be continued for at least two weeks and until there is complete resolution of cough. Thereafter, a cloth mask will be required as it is for all staff and patients.
Clinical Trials: Hospitals have been contacting CDCR/CCHCS providers to ask permission for CDCR patients with moderate-severe COVID-19 disease to enter clinical trials. Note, this is NOT the decision of the CDCR/CCHCS provider. Although there is a general prohibition regarding “experimenting” on incarcerated patients, Penal Code 3502.5 states a prisoner may participate in a clinical trial of a drug if it has potential benefit. The decision would be up to the patient (or their surrogate decision-maker if the patient too ill to consent) and his or her attending physician. Any medications used in the setting of a clinical trial would likely be completed prior to discharge. In rare cases, if the discharging physician indicates that the clinical trial medication is required to be continued upon discharge, CCHCS should be sure to include institution leadership and legal in the decision on whether this clinical trial medication can be continued in our setting. Information on registered clinical trials for COVID-19 in the United States is available atClinicalTrials.gov.
Off-label medication use: Patients may be started on an off-label medication regimen (NOT in the context of a clinical trial) while hospitalized. Once the patient is returned to a CDCR facility, we are the medical decision-makers for our patients. In this capacity, we have no obligation to continue with the hospital’s treatment (experimental, trial, or otherwise); instead, we must make decisions based upon what we determine is medically indicated for each patient. This determination would likely involve our providers having discussions with the discharging physician and with the patient about continued care to determine the best course of action. If continuing a medication, be aware of significant drug-drug interactions (DDIs) that have been described, especially with cardiac, central nervous system medications, and antibiotics. Be sure to use a DDI checker for experimental COVID-19 drugs.
Rehabilitation: Patients may require attention to physical deconditioning, respiratory, swallow, cognitive, and mental health impairments after serious and especially post-intensive care for COVID-19. Referral to rehabilitation specialists may be needed, such as physical therapy, occupational therapy, mental health, cardiac and pulmonary rehabilitation, etc.
Vaccines for COVID-19 are not yet available and are anticipated to take a minimum of 9-18 months until they are available to the public. Clinical trials are currently ongoing by Kaiser Permanente, Oxford’s Jenner Institute, Moderna, and others.
TREATMENT OF INFLUENZA
During “flu season,” typically fall and winter, we may see patients presenting with influenza-like illness (ILI) who actually have influenza and not COVID-19. The following is a review of the antiviral treatment, chemoprophylaxis, and vaccination available for influenza.
ANTIVIRAL TREATMENT OF INFLUENZA
Whom to Treat: Antiviral medication is generally indicated for those patients at higher risk for influenza complications based on their age or underlying medical conditions, as well as hospitalized or severe cases. Those patients at higher risk for complications from influenza are the same as for COVID-19 with the addition of patients with Native American or Alaska Native background and patients 18 to 19-years-old on chronic salicylate medications.
Antiviral medication is generally not indicated for healthy individuals. Still, it can be considered for any previously healthy symptomatic outpatient with confirmed or suspected influenza, based on clinical judgment, if treatment can be initiated within 48 hours of illness onset.
Timing of Antiviral therapy for influenza: While the maximum benefit likely occurs when antiviral treatment is started within 48 hours of symptom onset, there is some evidence to suggest that starting treatment later may provide benefit, especially in patients with worsening symptoms and hospitalized or critically ill patients. During the influenza season, do not wait for laboratory confirmation of influenza; the rapid influenza diagnostic point-of-care tests can be of use in this regard.
Available Medications: The summary of the treatment for influenza is described in Table 8.3 below. NOTE: CDC is currently NOT recommending adamantanes in the US due to marked resistance emergence unless local resistance is low.
Oseltamivir may also be used for prophylaxis if less than 48 hours has elapsed since first exposure. The CDC states that antiviral medications can be considered for chemoprophylaxis to prevent influenza in certain situations, such as the following examples:
It is imperative to have all patients vaccinated against influenza annually if not contraindicated**. Consider a patient education session with healthcare staff for patients who refuse vaccination. All employees should be strongly encouraged to get a seasonal influenza vaccine as well. Vaccination begins every fall and extends as long as influenza is circulating.
History of a severe allergic reaction to the vaccine or any of its components. Information about vaccine components is located in package inserts from each manufacturer.
Egg allergy is not a contraindication for receiving influenza vaccine; however, patients who have a history of a severe allergic reaction to egg (i.e., any symptoms other than hives) should be vaccinated in a medical setting under the supervision of a healthcare provider or with a vaccine formulation that does not contain egg protein.
Moderate or severe acute illness with or without fever.
Guillain-Barré syndrome within 6 weeks following a previous dose of influenza vaccine.
Note: Deaths in laboratory-confirmed cases under the age of 65 should be reported to the local health department within 7 days.
Treatment of RSV is supportive: oxygen and IVFs. Most medical treatment has been studied in children, including bronchodilators and corticosteroids. However, their use in adults with asthma and chronic obstructive pulmonary disease (COPD), or elderly adults with wheezing is deemed reasonable. Many different entities are researching RSV vaccines.
Antifungal therapy is NOT needed for healthy patients. Treatment should be administered to those with severe disease and those at high risk for developing more serious/complicated/disseminated disease. Please refer to the Cocci Risk Registry (CDCR networking is required for access).
A positive laboratory test for the virus that causes COVID-19 in at least one respiratory specimen.
HIGH SUSPECT COVID-19 CASE
Any fever, respiratory symptoms, or evidence of a viral syndrome in a patient who had:
Close (within 6 feet and prolonged [generally ≥10 minutes]) contact with a confirmed case of COVID-19 within 14 days of onset
Linkage to a high risk group defined by public health during an outbreak (for example: an affected dorm, housing unit, or yard) but without a test result for COVID-19
LOW SUSPECT COVID-19 CASE
Fever OR new or worsening cough OR shortness of breath (dyspnea) with evidence of a viral syndrome (ILI) of unknown etiology in a person without test results for COVID-19 and without high-risk exposure
ASYMPTOMATIC CONTACT OF COVID-19
A person without symptoms of COVID-19 who has had close (within 6 feet and prolonged [generally ≥10 minutes]) contact with a confirmed case of COVID-19 OR direct contact with secretions of a confirmed case of COVID-19 within the past 14 days
Who has had no positive tests for COVID-19
CONTACT OF A CONTACT
The contact of an asymptomatic contact is NOT to be included in the exposure cohort. The patient does not need to wear a mask. Health care workers do not need PPE
OUTBREAK OF COVID-19
Two or more confirmed cases of COVID-19 in patients with symptom onset dates within 14 days of each other in the same housing unit OR at least one confirmed case of COVID-19 in a patient with epidemiological linkage (e.g., close contact during the infectious period) to another confirmed COVID-19 case in a patient or a staff member at the same institution.
Separation of ill persons who have a communicable disease (confirmed or suspected) from those who are healthy. People who have different communicable diseases (e.g., one patient with COVID-19 and one with influenza), or who may have different diseases should not be isolated together. Isolation setting depends on the type of transmission-based precautions that are in effect. For airborne precautions, an airborne infection isolation room (AIIR) is the ideal setting; a private room with a solid, closed door is an alternative. Precautionary signs and PPE appropriate to the level of precautions should be placed outside the door to the isolation room.
The separation and restriction of movement of well persons who are contacts of a confirmed communicable disease. Quarantine facilitates the prompt identification of new cases and helps limit the spread of disease by preventing new people from becoming exposed. In CDCR, patients who are quarantined are not confined to quarters, but they do not go to work or other programs. They may go to the dining hall as a group and go to the yard as a group, but not mix with others who are not quarantined. Social distancing between quarantined individuals should be implemented when at all possible.
Cohorting is the practice of grouping together patients who are infected with the same organism to confine their care to one area and prevent contact with other patients. It also can conserve respirator use in times of shortage. Cohorts are created based on clinical diagnosis, microbiologic confirmation when available, epidemiology, and mode of transmission of the infectious agent. When single patient rooms are not available, patients with the same confirmed viral respiratory pathogen may be placed in the same room.
PROTECTIVE SHELTER IN PLACE
During the COVID-19 pandemic, CCHCS institutions may implement additional measures to protect vulnerable patients who are at increased risk for severe COVID-19 disease (e.g., single-cell or protected housing area, limited movement, separate dining and yard time, and telemedicine services). Patients in protective shelter in place should be educated regarding their risk and how to protect themselves, early symptom recognition and request for medical attention, and the availability of testing for COVID-19. These patients are not on quarantine and do not need daily symptom surveillance rounds.
Prohibition of the transfer of a patient to another facility except for legal or medical necessity. In CDCR, medical holds are employed for both isolation and quarantine.
END OF A COVID-19 OUTBREAK
A COVID-19 outbreak ends when there are no new cases in the housing unit for 14 days since the onset of symptoms in the last identified new case.
NOTIFICATIONS AND REPORTING
If health care or custody staff become aware of or observe symptoms consistent with COVID-19 (e.g., fever, cough, or shortness of breath) in a patient, staff person, or visitor to the institution, they should immediately notify the Public Health Nurse (PHN) or PHN alternate (often the Infection Control Nurse[ICN]).
For employee exposures, please refer to Health Care Department Operations Manual (HCDOM) section on Employee Exposure Control.
When a patient with fever or cough or shortness of breath is identified, institutional processes for notification to the PHN or PHN alternated must be established for ongoing surveillance and reporting.
Laboratory confirmed COVID-19 cases and suspect cases of COVID-19 shall immediately be reported to the PHN or PHN alternate by phone or Electronic Health Record System (EHRS) messaging.
A patient with symptoms consistent with COVID-19 should be immediately referred to a provider for evaluation.
If a patient has a confirmed case of COVID-19, the PHN, ICN, or designee should immediately notify institutional leadership, including the Chief Executive Officer (CEO), Chief Medical Executive (CME), Chief Nurse Executive (CNE), Warden, and Public Information Officer (PIO).
Institutional leadership is responsible for notifying the Office of Employee Health and Wellness (OEHW) and Return to Work Coordinator (RTWC) of the possibility of employees exposed to COVID-19 related virus.
The PHN or PHN alternate is responsible for reporting of respiratory illness and outbreaks to the PHB and the local health department (LHD).
Single or hospitalized cases of COVID-19, outbreaks of ILI, and influenza should be reported to the PHB via the Public Health Outbreak Response System (PhORS) http://pors/ (CDCR networking is required for access). Single cases of lab-confirmed influenza and single cases of ILI that result in hospitalization or death should be reported to PhORS.
Confirmed COVID-19 cases should be immediately reported by telephone to the LHD. Outbreaks of COVID-19 should also be immediately reported to the LHD. Follow usual guidelines for reporting influenza to the LHD. See Appendix 11 for the LHD contact list.
Notify CCHCS PHB immediately at CDCRCCHCSPublicHealthBranch@cdcr.ca.gov if there are significant developments at the institution (e.g., first time the institution is monitoring one or more contacts, first confirmed case at the institution, or first COVID-19 contact investigation at the institution.)
The following events require same-day reporting to the COVID-19 SharePoint: https://cdcr.sharepoint.com/sites/cchcs_ms_phos (CDCR networking is required for access). No report is needed if there are no new cases/contacts and no significant updates to existing cases/contacts.
All new suspected and confirmed COVID-19 cases.
All new COVID-19 contacts.
For previously reported cases: new lab results, new symptoms, new hospitalizations, transfers between institutions, discharges/paroles, releases from isolation, and deaths.
For previously reported contacts of cases: new exposures, transfers between institutions, discharges/paroles, and releases from quarantine.
TABLE 11.1: STANDARD, CONTACT, DROPLET, AIRBORNE PRECAUTIONS AND PPE USE
* Due to shortages, gowns will be reserved for specific procedures, e.g., aerosol-generating and transport of patients with respiratory symptoms.
** Due to shortages, N-95 respirators will be reserved for aerosol-generating procedures, procedures generating splashes and sprays, procedures that are very close and involve prolonged exposure to a COVID-19 case, and vehicular transport of patients with respiratory symptoms.
Donning PPE upon room entry and discarding before exiting the room
Shoe or boot covers are not required
PPE SCENARIOS FOR INFLUENZA-LIKE ILLNESSES (ILI), INFLUENZA, and COVID-19
This section describes the PPE recommended for several of the patient-care activities being conducted by staff. See Table 11.1, “Recommended PPE for Incarcerated/Detained Persons and Staff in a Correctional Facility during the COVID-19 Response.”
During this time of potential PPE shortages, consult Table 11.1 for suggested alternatives. The surgical/procedure mask is an acceptable alternative when the supply chain of the N95 respirator cannot meet the demand. The available N95 respirators should be prioritized for procedures that pose a high risk to staff. These procedures or activities include the following:
Procedures with splashes and sprays
Aerosol-generating procedures (anyone in the room)
Procedures where there is very close (less than 6 feet) or prolonged exposure (more than 10 minutes) to a COVID-19 case
CDCR staff engaged in vehicle transport of patients with respiratory symptoms
CDCR staff engaged in the escort of symptomatic patients
CDCR staff spending extended periods with quarantined cohorts
STAFF PPE FOR ILI / SYMPTOMATIC PATIENT
Patients presenting with ILI should be considered infectious for COVID-19 until proven otherwise. Standard, contact, droplet, and airborne precautions, plus eye protection are recommended for any patient with ILI symptoms. An N95 Respirator, gloves, gown, face shield or other eye protection are recommended. An N95 is preferred; however, based on potential supply shortages, surgical/procedure masks are an acceptable alternative when the supply chain cannot meet the demand. During this time, available N95 respirators and gowns should be prioritized for health care workers (HCWs) engaged in procedures that are likely to generate respiratory aerosols or HCWs and custody staff engaged in vehicle transport or escort of these individuals.
STAFF PPE FOR SUSPECTED AND CONFIRMED COVID-19 CASE
Standard, contact, droplet, and airborne precautions, plus eye protection are recommended for patients with suspected or confirmed COVID-19 infection. A N95 respirator, gloves, gown, face shield or other eye protection are the recommended PPE. A N95 respirator is preferred; however, based on potential supply shortages, surgical/procedure masks are an acceptable alternative when the supply chain cannot meet the demand. During this time, the available N95 respirators and gowns should be prioritized for HCWs engaged in procedures that are likely to generate respiratory aerosols or HCWs and custody staff engaged in vehicle transport or escort of these individuals.
STAFF PPE FOR CONFIRMED INFLUENZA CASE
Standard, contact, and droplet precautions are recommended for patients with confirmed influenza. A surgical/procedure mask, gloves, and gown are the recommended PPE. During this time, if there is a shortage of gowns, gowns should be prioritized for HCWs engaged in procedures that are likely to generate respiratory aerosols or HCWs and custody staff engaged in vehicle transport.
STAFF PPE FOR SURVEILLANCE OF ASYMPTOMATIC CONTACT OF A CASE
Standard, contact, and droplet precautions are recommended. A surgical/procedure mask, eye protection, and gloves are the recommended PPE. Custody or other personnel that are stationed with this quarantined cohort for extended periods or entire day shifts should wear an N95 respirator.
PPE FOR CONTACT OF A CONTACT
Standard precautions are sufficient for the patient who is a contact of a contact.
N95 and other disposable respirators should not be shared by multiple HCWs. Use a personal identification label to minimize potential cross-contamination if reusing.
N95 respirators or respirators that offer a higher level of protection should be used (instead of a facemask) when performing or present for an aerosol-generating procedure. Such procedures should be prioritized in times of N95 shortages, and extended wear not employed.
Contingency strategies for optimizing the supply of N95 respirators:
Temporarily suspend annual fit-testing of respirators per interim guidance from the Occupational Safety and Health Administration (OSHA).
Use respirators beyond the manufacturer-designated shelf life for training and fit-testing.
Implement extended use:
Extended use refers to the practice of wearing the same N95 respirator for repeated close contact encounters with several different patients, without removing the respirator between patient encounters. Extended use is well suited to situations wherein multiple patients with the same infectious disease diagnosis, whose care requires use of a respirator, are cohorted (e.g., housed on the same housing unit). HCWs use cleanable face shields to prevent droplet spray contamination to N95 respirators. HCWs remove only gloves and gowns (if used) and perform hand hygiene between patients with the same diagnosis (e.g., confirmed COVID-19) while continuing to wear the same eye protection and respirator. The maximum recommended extended use period is 8 – 12 hours. Respirators should not be worn for multiple work shifts and should not be reused after extended use. Respirators should be removed and discarded before activities such as meals and restroom breaks.
Crisis strategies for optimizing the supply of N95 respirators:
Use beyond the manufacturer-designated shelf life, provided that visual inspection before use does not reveal concerns that prompt discarding.
Use respirators approved under standards used in different countries that are similar to the Center for Disease Control’s (CDC’s) National Institute for Occupational Safety and Health (NIOSH)-approved respirators.
Limited reuse of respirators:
Re-use refers to the practice of using the same N95 respirator by one HCW for multiple encounters with different patients but removing it after each encounter. Restrict the number of reuses to the maximum recommended by the manufacturer or to the CDC recommended limit of no more than five uses per device.
To maintain the integrity of the respirator, it is important for HCWs to hang used respirators in a designated storage area or keep them in a clean, breathable container such as a paper bag between uses. It is not recommended to modify the N95 respirator by placing any material within the respirator or over the respirator. Modification may negatively affect the performance of the respirator and could void the NIOSH approval.
Prior to the reuse of the N95 respirator, the HCW should inspect the device for physical damage (i.e., Straps stretched out that they no longer provide enough tension for sealing to the face).
Proper hand hygiene before and after touching or adjusting the respirator (if necessary for comfort or to maintain fit).
Use non-sterile gloves when donning a used N95 respirator and performing a user seal check. Then hand hygiene after glove removal.
Use of additional respirators beyond the manufacturer-designated shelf life for healthcare delivery that have not been evaluated by NIOSH.
Examples of N95 alternatives:
A powered air-purifying respirator (PAPR) which is reusable, has a whole/partial head and face shield breathing tube, and battery-operated blower and particulate filters, can be used if available. Loose-fitting PAPRs do not require fit-testing and can be worn by people with facial hair. Do not use in surgical settings. All reusable respirators must be cleaned and disinfected according to the manufacturer’s reprocessing instructions prior to reuse.
A face mask
When the supply chain is restored, staff should adhere to the PPE recommendations for specific transmission-based precautions.
FACEMASKS, FACE SHIELDS, AND EYE PROTECTION GUIDANCE
Facemasks, face shields, and eye protection should be examined prior to use and discarded if visual inspection reveals concerns or damage.
All reusable respirators must be cleaned and disinfected according to the manufacturer’s reprocessing instructions prior to reuse.
Contingency strategies for optimizing the supply of facemasks, face shields, and eye protection:
Implement extended use
Crisis strategies for optimizing the supply of facemasks, face shields, and eye protection:
Use beyond the manufacturer-designated shelf life, provided that visual inspection prior to use does not reveal concerns that prompt discarding.
Implement limited reuse of facemasks: Folding the outer surface inward against itself and storing between uses in a clean, sealable paper bag or breathable container.
Contingency strategies for optimizing the supply of gowns:
Shift gown use towards cloth isolation gowns that can be safely laundered, and ensure routine inspection, maintenance, and replacement.
Use expired gowns beyond the manufacturer-designated shelf life for training.
This guidance is not a substitute for healthcare and custody staff following the current CDC or local health department recommendations in dealing with suspected, quarantine, or diagnosed patients.
Staff and inmates/patients are required to wear a face barrier (cloth mask) within the institutions. This reduces the release of infectious particles into the air when someone speaks, coughs, or sneezes, including someone who has COVID-19 but feels well.
A Cloth mask is not a substitute for physical distancing and washing hands.
Cloth masks should be routinely washed, at least daily: laundered with detergent and hot water and dried on a hot cycle.
INFLUENZA-LIKE ILLNESS (ILI) CASE AND OUTBREAK IDENTIFICATION
Patients should be triaged as soon as possible upon arrival to a facility (right after leaving the transportation bus) for symptom assessment and temperature check per current policy protocols prior to allowing patients to be within 6 feet of other persons. ILI screening in a separate clinic area with rooms and doors, or a physically removed area that is outdoor with canopy or indoor separated, is highly recommended. If a patient presents with ILI symptoms, place a surgical facemask on the patient and isolate them immediately until a health care provider can clinically assess and evaluate them. Non-symptomatic patients who are contacts of confirmed cases should be placed in quarantine according to CCHCS current policy, and tested within 24 hours.
All people who refuse testing should be given educational information in an accessible format and an opportunity to have their concerns expressed and questions answered. Patients should NOT face discipline or any punitive reprisals for refusal to test.
People who refuse testing after showing symptoms should be treated as if they tested positive. They should be placed in medical isolation. See more details in the Isolation section.
See checklist below for active means to identify ILI already within an institution.
CHECKLIST FOR IDENTIFYING COVID-19 SUSPECTS
Examine laboratory testing results for positive COVID-19 and other communicable diseases requiring public health action.
Examine COVID-19 tests ordered in the last 24 hours to identify patients with ILI who may be COVID-19 infected.
Examine treatment and triage area (TTA) logs for patients who had respiratory symptoms.
Coordinate with Utilization Management (UM) nurse on patients who are out to medical with ILI/pneumonia.
Review the daily movement sheet to identify patients that may have been sent out to a higher level of care (HLOC) due to ILI/respiratory symptoms.
Attend daily Patient Care (PC) clinic huddles, as time permits, to identify any patients being seen that day with complaints of ILI symptoms.
Establish a sustainable process by which Public Health and Infection Control staff are notified of patients that are put on precautions for ILI after hours.
ILI/SUSPECTED COVID-19 STRATEGIC CONTROL STEPS
Immediately mask patients when COVID-19 is suspected. Surgical or procedure masks are appropriate for patients. If there is a shortage of surgical/procedure masks, have the patients use a cloth face covering, tissue, and/or bandana when coughing.
Patients should be placed in an airborne infection isolation room (AIIR) as soon as possible (this can be ordered in the electronic health records system [EHRS]). If AIIR is not immediately available, the patient shall be placed in a private room with the door closed. Appropriate signage indicating precautions and required PPE to enter should be visible outside the patient’s room. A summary of isolation room type recommendations is below.
Standard, contact, and airborne precautions plus eye protection should be implemented immediately (see Infection Control and Personal Protective Equipment section). Health Care Workers (HCWs) should use a surgical/procedure mask, unless N95 respirators are in abundant supply.
When possible, assign dedicated health care staff and equipment to provide care to suspected or confirmed cases.
Ensure staff caring for confirmed cases or involved in intra-facility transporting of cases and inmate workers if they are to come within 6 feet of confirmed case patients, utilize appropriate PPE: use procedure/surgical masks, (unless N95 respirator or powered air purifying respirator (PAPR) are in abundant supply), gloves, gown, and face shield covering sides and front of face or goggles.
Provide education to the patient about their test result. Help allay fears, teach them about the symptoms of COVID-19, what isolation is like, how their housing might be affected, and what to expect with surveillance rounding. Providers may want to specifically order a nursing education session in the EHRS as well.
Limit movement of designated staff between different parts of the institution to decrease the risk of staff spreading COVID-19 to other parts of the facility. To assist staff, traffic patterns may need to be changed or guided with demarcations.
Patients shall only be transported for emergent medically necessary procedures or transfers, and shall wear a surgical or procedure mask during transport. During vehicle transport of patients with COVID-19 infection, custody or HCW will use an N95 mask as part of needed PPE, rather than a surgical or procedure mask. Limit the number of staff that have contact with suspected and/or confirmed cases. Personnel escorting the patient within the facility should also wear an N95.
Assess and treat as appropriate. Soon-to-be released patients with suspected COVID-19 need direct linkages to community resources to ensure proper isolation and access to medical care. Notify the local health department (LHD) of patients to be released who have suspect or confirmed cases and are still isolated.
IMPORTANT: Suspect cases, patients from facilities with large outbreaks, and COVID-19 case patients should not be released without the coordination of CDCR discharge planning and LHD guidance. See the Inmates Releasing from Institutions During COVID-19 section.
Once COVID-19 has been ruled out clinically and by testing, airborne precautions can be stopped.
Promptly separate patients who are sick with fever or lower respiratory symptoms from well patients. Patients with these symptoms should be isolated until they are no longer infectious and have been cleared by the health care provider (see Release from Isolation). Patients who test negative, but for whom there is still clinical suspicion of COVID-19 infection, should remain in isolation while re-testing and decision making is underway. Also, promptly isolate asymptomatic but test-confirmed cases.
NOTE: For Patients with COVID-19 symptoms that refuse testing: People who refuse testing after showing symptoms should be treated as if they tested positive. They should be placed in medical isolation in celled housing. They should NOT be placed in cohorts (double-celled or in dorm housing) with other people who are symptomatic, pending a test result, or confirmed positive following testing.
Medical isolation conditions should be as similar to regular housing as possible.
The preference is for isolation in a negative pressure room; second choice would be isolation in private room with a solid, closed door.
When a negative pressure room or a private single room is not available, groups of patients can be cohorted in a separate facility away from well patients. Possible areas to cohort patients could be an unused gym or chapel.
As a last resort, when no other options are available for separating cases from contacts, it may be necessary to cohort patients in a section of a room or area. There should be at least 6 feet between patients and the rest of the residents. Tape can be placed on the floor to mark the isolation section with a second line of tape 6 feet away to mark the well patient section which can provide a visual sign and alert well employees and patients to remain outside of the isolation section unless they are wearing appropriate PPE.
In order of preference, individuals under medical isolation should be housed:
Separately, in single cells with solid walls (i.e., not bars) and solid doors that close fully
Separately, in single cells with solid walls but without solid doors
As a cohort, in a large, well-ventilated cell with solid walls and a solid door that closes fully. Employ social distancing strategies.
As a cohort, in a large, well-ventilated cell with solid walls but without a solid door. Employ social distancing strategies.
As a cohort, in single cells without solid walls or solid doors (i.e., cells enclosed entirely with bars), preferably with an empty cell between occupied cells. (Although individuals are in single cells in this scenario, the airflow between cells essentially makes it a cohort arrangement in the context of COVID-19.)
As a cohort, in multi-person cells without solid walls or solid doors (i.e., cells enclosed entirely with bars), preferably with an empty cell between occupied cells. Employ social distancing strategies. Use tape to mark off safe distances between patients.
Safely transfer individual(s) to another facility with available medical isolation capacity in one of the above arrangements.
NOTE: Transfers should be avoided due to the potential to introduce infection to another facility; proceed only if no other options are available and employ testing strategies if available
If the ideal choice does not exist in a facility, use the next best alternative.
Provide individuals under medical isolation with extra soap, tissues and, if permissible, a lined, no-touch, trash receptacle. Instruct them to:
Cover their mouth and nose with a tissue when they cough or sneeze.
Dispose of used tissues immediately in the lined trash receptacle.
Wash hands immediately with soap and water for at least 20 seconds. If soap and water are not available, clean hands with an alcohol-based hand sanitizer that contains at least 60% alcohol (where security concerns permit). Ensure that hand washing supplies are continually restocked.
Patients with ILI of unknown etiology should be isolated alone. If they cannot be isolated alone, they should be isolated with other sick patients from the same housing unit or other ILI patients of unknown etiology. When cohorting ILI patients, if at all possible, separate patients 6 feet from each other, with 3.6 feet minimum if space is limited.
Patients with confirmed COVID-19 or influenza can safely be isolated in a cohort with other patients who have the same confirmed diagnosis.
Correctional facilities should review their medical isolation policies, identify potential areas for isolation, and anticipate how to provide isolation when cases exceed the number of isolation rooms available. (See subsection in Primary Prevention on this topic)
If possible, the isolation area should have a bathroom available for the exclusive use of the identified confirmed positive cases. When there is no separate bathroom available, patients that are symptomatic and asymptomatic with a positive test, should wear a surgical or procedure mask when outside the isolation room or area, and the bathroom should be sanitized frequently (ideally 3 to 4 times daily).
A sign should be placed on the door or wall of an isolation area to alert employees and patients that all persons entering the isolation room or areas must follow the required Transmission-Based Precautions.
When possible, assign dedicated health care staff to provide care to patients with suspected or confirmed cases.
If a patient with ILI or confirmed COVID-19 or influenza must be moved out of isolation, ensure an N95 respirator is worn during escort and vehicular transport (or surgical mask in times of shortage).
Patients who are in quarantine or isolation may develop medical, mental health, or dental symptoms, and communicate this either via a 7362, via talking with a correctional officer (C.O.) or HCW, or a staff member or other inmate may observe a problem. Depending on the type and severity of the problem and the physical layout of the prison, there are a number of possibilities for evaluation. General principles are to limit as much as possible the exposure of other people to the patient, and the number of places he or she passes through. Each institution and group of health care staff should develop a plan for various contingencies, including the possibility of setting up temporary exam rooms, tents, or other areas within or just outside each housing area. This should include evaluating whether a 7362 or a reasonable accommodations request could be postponed or temporarily addressed without a visit.
Thus, if possible, the inmate would be evaluated at cell front. If the evaluation required more privacy or a physical exam, the next best place would be an exam room within or just outside the same housing. If more equipment were needed, the next best would be the yard clinic or the treatment and triage area (TTA). If the problem were obviously severe enough that the patient needed to go to the emergency room (ER) or hospital, having the ambulance or state vehicle pick the patient up directly from the room or housing area would be ideal, as long as medical treatment and stabilization wasn’t needed first, in which case moving to the TTA would be necessary. If it is a mild problem, then a visit to evaluate it should be postponed until after the isolation or quarantine has ended. If it is a moderate or severe problem, and the patient needs to be brought to a yard clinic or TTA, they must wear a mask and be escorted directly to the exam/treatment room that has a closed door, with no interaction with other inmates and no time spent in a waiting room. The escorting staff member and the evaluating health care staff must wear appropriate PPE, and appropriate disinfection of the room to include high-touch surfaces must be done after the visit.
To the greatest extent possible, individuals who are under medical isolation should be provided access to the same necessities and privileges that would otherwise normally be available.
Patients under medical isolation for suspected or confirmed COVID-19 should continue to have access to the following activities (see below). However, facilities must ensure staffing, and the ability to adhere to all recommended infection control precautions (see Infection Control Precautions and PPE Scenarios) and physical distancing guidelines when implementing these daily activities:
Showering/bathing must be permitted at least every other day, or more often if possible (per CCR 15, § 1226)
Spending time outside of isolation, including yard and day room time
Phone calls and access to personal property
When feasible, accessing the canteen
Strategies to minimize unnecessary movements outside of isolation include conducting surveillance rounds and providing meals and medications at the cell/room door should be instituted.
Patients with confirmed COVID-19 who are isolated as a cohort may participate as a group for yard time, day room time, while dining, and in medication and canteen lines, as long as they are masked and adhering to physical distancing from well persons.
Providing access to the above necessities and time outside of isolation to the extent that is feasible and safe is important for reducing disincentives for symptomatic patients to seek medical attention.
When a patient with a suspected case of COVID-19 is identified:
The patient should be isolated and placed on a medical hold.
All patients housed in the same unit, and any other identified close contacts, should be placed on a medical hold as part of quarantine measures.
If the contact with the case that occurred likely posed a high risk of transmission (see Close Contact table below), consideration can be given to a preliminary contact investigation as if it was a confirmed case, time and resources permitting.
If a COVID-19 case is confirmed, initiate a contact investigation.
Contact investigation for suspected COVID-19 cases should not be initiated while Influenza and COVID-19 test results are pending, except in consultation with the PHB (e.g., highly suspicious suspect case or multiple suspect cases with known contact to a confirmed case).
A contact investigation should be conducted for all confirmed cases of COVID-19.
Determine the dates of the case-patient’s infectious period during which other patients and staff may have been exposed. For symptomatic patients, this is from 2 days (48 hours) prior to the date of symptom onset to the date the case-patient was isolated. For asymptomatic case-patients, the infectious period should be considered 2 days prior to the date of the positive test.
Interview the case-patient to identify all close contacts based on exposure (within 6 feet for >10 minutes) during the infectious period, without the use of PPE:
Identify all activities and locations where exposure may have occurred (e.g., classrooms, group activities, social activities, work, dining hall, day room, church, clinic visits, yard, medication line, and commissary line).
Determine the case-patient’s movement history, including cell/bed assignments and transfers to and from other institutions or outside facilities.
Identify close contacts associated with each activity and movement.
Within 6 feet and prolonged (generally ≥10 minutes) contact with a confirmed case of COVID-19 during the infectious period, without the use of PPE
Examples (ranked in order of descending risk):
Cellmate of a patient with confirmed COVID-19
Residing in the same dormitory pod or small housing unit (up to 8 beds) as the confirmed case
Occupying adjacent beds in a large dormitory or ward with the confirmed case
Inmate worker/volunteer caring for a patient with confirmed COVID-19 without PPE
Being directly coughed or sneezed upon (even though may be transient encounter)
Close contact during activities (e.g., in classrooms, groups, social activities, work, church, clinic visits, medication line, and commissary line) with the patient with confirmed COVID-19
Linkage to a high risk group defined by public health during an outbreak (e.g., an affected dorm, housing unit, or yard)
Resident transferring from a facility with sustained COVID-19 transmission in the last 14 days
Sharing common spaces (e.g., yard, shower, dining hall, day room)
All asymptomatic patients with a known exposure to a confirmed case should be placed in quarantine. If an asymptomatic patient is offered testing while in quarantine and refuses, they will continue in quarantine. Refer to the Release from Quarantine section. They should not be placed in cohorts with people who are symptomatic, pending a test result, or confirmed positive following testing.
Determine the last date of exposure for each of the contacts for the purpose of placing them in quarantine for a full incubation period (14 days). If a contact is subsequently exposed to another confirmed COVID-19 case, the quarantine period should be extended for another 14 days after the last exposure.
Use the COVID-19 SharePoint contacts line list to track the date of last exposure, date the quarantine began, and the end date for quarantine.
Asymptomatic contacts should be monitored for symptoms two times daily, unless severe staffing or resource issues necessitate once daily.
Any contact who develops symptoms consistent with COVID-19 should be immediately isolated. (See Isolation section below)
Institutional leadership is responsible for notifying the Office of Employee Health and Wellness (OEHW) and the Return to Work Coordinator (RTWC) of the possibility of employees exposed to COVID-19.
MONITORING PATIENTS WITH SUSPECTED OR CONFIRMED COVID-19
Symptomatic patients with suspected or confirmed COVID-19 require a minimum of twice-daily nursing assessments. However, strong consideration should be given to an increased frequency of assessments beyond twice-a-day because COVID-19 patients tend to decline precipitously (and after improvement) and silent hypoxemia (patient not experiencing undue dyspnea, but blood oxygenation is declining) may contribute to this. More than twice-a-day surveillance may be prudent for patients who are at high risk of severe COVID-19 disease. Nursing assessments will include, but are not limited to:
Pulse oximeter monitoring
Blood pressure checks
Respiratory rate and heart rate
Monitor patients for complications of COVID-19 infection, including respiratory distress and sepsis:
Fever and chills
Low body temperature
Low blood pressure
Low oxygen saturation (highest association with the development of pneumonia)
Persistent pain or pressure in the chest
Bluish lips or face
Altered mental status or confusion, inability to arouse
Patients with abnormal findings should be immediately referred to a provider for further evaluation.
Keep in mind the risk factors for severe illness: older age and those with medical conditions described in the High Risk Conditions section.
Patients at high risk of progression, rapid deterioration, and death should be assessed by a nurse and monitored for complications as described above, with consideration of increasing frequency beyond twice daily while in isolation.
Please refer to the Lifeline Quality Management (QM) COVID-19 Risk Registry (CDCR networking is required for access) to identify patients with medical conditions that place them at high risk for severe COVID-19 disease.
Patients tend to deteriorate rapidly and may occur after a day of feeling better. Studies show patients tend to decline and need hospital admission around the 8th day after exposure.
Patients with laboratory-confirmed COVID-19 who do not present with symptoms (e.g., tested as asymptomatic contacts at higher risk due to close contact with a symptomatic confirmed case) require isolation and twice daily nursing assessment including:
Development of symptoms (e.g., chills, subjective fever, shaking chills, fatigue, malaise, sore throat, myalgia or arthralgia, gastrointestinal [GI] symptoms including loss of appetite, upper respiratory infection [URI] symptoms, and loss of sense of smell or taste)
Pulse oximeter monitoring
Please refer to the QM COVID-19 Monitoring Registry (CDCR networking is required for access), which tracks patients with either confirmed or suspected of COVID-19. The COVID-19 Monitoring Registry helps health care staff stay apprised of COVID-19 testing results and ensures that rounding is occurring as required across shifts, as well flags certain symptoms, such as fever.
When one or more laboratory-confirmed cases of COVID-19 have been reported, screening and surveillance should be conducted throughout the institution to identify close contacts. The institutional Public Health Nurse (PHN) and Nurse Consultant Program Reviewer (NCPR) will confer and implement the investigation. A standardized approach of identifying people who have been exposed to a laboratory confirmed COVID-19 case is necessary to prevent COVID-19 transmission. Refer to Testing Considerations for COVID-19 Outbreaks.
Containment: Stopping transmission will require halting movement of exposed patients. The goal is to keep patients who are ill, or who have been exposed to someone who is ill, from mingling with patients from other areas of the prison, from food handling, and from duties in healthcare settings or duties that move in a widespread way (e.g., mail carrier, janitor). Close as many affected buildings/units as needed to confine the outbreak. Remind patients not to share eating utensils, food, or drinks. Stop large group meetings such as religious meetings and social events. Patients who are housed in the same affected building/unit may have pill line or yard time together.
Communication within the Institution: Establish a central command center to include the Chief Medical Executive (CME), PHN, Chief Nurse Executive (CNE), Director of Nurses (DON), Infection Control Nurse (ICN), Warden, and key custody staff. Call for an Exposure Control meeting with the Warden, CME, Facilities Captains, Department Heads, and Employee Union Representatives to inform them of outbreak, symptoms of disease, number of patients affected, and infection control measures.
Reporting and Notification: As soon as outbreak is suspected, contact your Statewide Public Health Nurse Consultant by telephone or email within 24 hours. Initiate and submit a contacts line list to the PHB in the COVID-19 SharePoint: https://cdcr.sharepoint.com/sites/cchcs_ms_phos (CDCR networking is required for access). Report outbreak by telephone to the LHD as soon as possible to assist with contact investigation, if needed. If your facility is considering halting all movement in and out of your institution, please consult with the PHB warmline at (916) 691-9901.
Tracking: For the duration of the outbreak, collect patient information systematically to ensure consistency in the data collection process. Assign back-up staff for days off, to be responsible for tracking cases and reporting. Additional staff and/or registry staff may be needed.
CRITERIA FOR RELEASE FROM ISOLATION CONFIRMED COVID-19 CASES
For individuals with asymptomatic or symptomatic laboratory-confirmed COVID-19 under isolation, considerations to discontinue Transmission-Based Precautions include clinical AND testing criteria. See Algorithm 12.2.
The Center for Disease Control (CDC) suggests congregate settings such as prisons, consider a test-based strategy, in general. Also, specifically, consider testing criteria for immunocompromised persons and when release is relatively high risk (e.g., the patient: has a job with a high risk of transmission, is releasing to the community, is high-risk, or is releasing to dorm or congregate housing or a setting where high-risk patients reside.
When clinical criteria alone are to be used:
At least 5 days after resolution of fever without the use of antipyretic medication (if applicable) AND
At least 14 days**(minimum) from after the date of the initial positive test AND
Improvement in illness signs and symptoms
If using testing criteria, clinical criteria should be met first, then test the patient for COVID-19 related virus by RT-PCR.
TESTING CRITERIA: One negative RT-PCR
If the test is negative, release the patient from isolation with a face covering
If the test is still positive or equivocal, consult the CME, consider re-testing OR use clinical criteria
Point-of-care (POC) testing could also be done immediately before release
MAXIMUM TIME IN ISOLATION: 21 DAYS
Ultimately, clinical judgment and suspicion of active SARS-CoV-2 infection determine whether to continue or discontinue empiric Transmission-Based Precautions. Hence, an evaluation by a medical provider is strongly recommended before release, to ensure the patient meets the clinical release criteria.
Being a congregate, high-risk setting, there are concerns in releasing isolated patients who continue to have a positive SARS-CoV-2 test, and thus could still potentially be infectious after clinical criteria have been met.
Detecting viral RNA via PCR does not necessarily mean that an infectious virus is present. Viral shedding studies show that prolonged shedding is not likely to be infectious. CDC analysis and review of literature shows that viral shedding beyond 9 days from the onset of symptoms does not grow in viral culture.
For patients who continue to have a positive SARS-CoV-2 test, a maximum of 21 days will conservatively be well outside the infectious timeframe in theliterature.
This recommendation will prevent most, but possibly not prevent all instances of secondary spread. The risk of transmission after recovery is likely substantially less than that during illness, and the viral load found is orders of magnitude less than that in the first 5 days.
The statistically estimated likelihood of recovering replication-competent virus approaches zero by 10 days from the onset of symptoms.
Also, as the likelihood of isolating replication-competent virus decreases, anti-SARS-CoV-2 IgM and IgG can be detected in an increasing number of persons recovering from the infection.
Further, following recovery from clinical illness, many patients no longer have detectable viral RNA in upper respiratory specimens. Among those who continue to have detectable RNA, concentrations of detectable RNA 3 days following recovery are generally in the range at which replication-competent virus has not been reliably isolated by CDC in unpublished data.
Infectious virus has not been cultured from urine or reliably cultured from feces in multiple studies; these potential sources pose minimal, if any, risk of transmitting infection, and any risk can be sufficiently mitigated by good hand hygiene.
RE-TESTING PREVIOUSLY POSITIVE PATIENTS AFTER RECOVERY FROM COVID-19: WHEN IT IS NOT NEEDED
Although more research is needed, current literature suggests at least short-term immunity after the resolution of infection. For individuals who tested positive for SARS-CoV-2 and have met the above criteria for release from isolation (see exceptions below), repeat testing by RT-PCR is not recommended by CDPH until after 3 months from the date of symptom onset. For asymptomatic patients, the 3 months starts from the date of the initial positive test.
These patients are not contagious.
In the absence of symptoms and below exceptions, any tests that are conducted and are positive can be considered a false positive.
Additionally, CDPH states these individuals do not need to be quarantined after exposure if that exposure occurs within that 3-month window.
It is safe to house them in isolation, quarantine, or general population.
They do not need to be tested for routine public health surveillance or before transfers.
They still need to wear a mask for conformity and in the case of new symptom development. (See below on face coverings).
Clinical judgment should always be used; exceptions to this rule are detailed below
RE-TESTING PREVIOUSLY POSITIVE PATIENTS AFTER RECOVERY FROM COVID-19: WHEN IT IS NEEDED
Time elapsed since release from the date of symptom onset for the initial infection is >3 months or for asymptomatic patients, 3 months from the date of the initial positive test.
Time elapsed since date of symptom onset is <3 months, and a previously infected individual with prior resolved COVID-19 develops new symptoms consistent with COVID-19; in these cases, sending a molecular test for SARS-CoV-2 can be included alongside a routine laboratory and microbiologic workup.
Time elapsed since the date of symptom onset is <3 months, and the individual is severely immunocompromised (i.e., ongoing chemotherapy, hematologic malignancy, bone marrow transplant recipient, on immunosuppressive therapy).
Time elapsed since the date of symptom onset is <6-8 weeks, and the individual is a resident in a skilled nursing facility level of care. Re-testing after 6-8 weeks may be appropriate per CDC guidance.
FACE COVERINGS AFTER RELEASE FROM ISOLATION
Given studies showing highly variable prolonged viral shedding after resolution of symptoms, all patients should wear a face covering and continue social distancing after release from isolation. The timeframe for this has not been specified by the CDC. At this time, CCHCS is recommending a minimum of 2 weeks. If a facility-wide order for social distancing and universal face coverings are in place, continue for 2 weeks from release or as long as the universal order persists, whichever is longer.
IMPORTANT: Consider the potential for harassment of patients released from isolation into the general population, especially if wearing masks but the general population is not using them. Work with custody leadership to mitigate stigma-related risk as much as possible before release.
Resolution of cough, is not necessary for release, however people with residual cough should wear a face covering once released, until completely without cough.
Thoroughly clean and disinfect all areas where the confirmed or suspected COVID-19 case patients spent any time. Note – these protocols apply to suspected cases as well as confirmed cases, to ensure adequate disinfection in the event that the suspected case does, in fact, have COVID-19. Refer to the Definitions section for the distinction between confirmed and suspected cases.
Close off areas used by the infected individual. If possible, open outside doors and windows to increase air circulation in the area. Wait as long as practical, up to 24 hours under the poorest air-exchange conditions (consult CDC Guidelines for Environmental Infection Control in Health-Care Facilities for wait time based on different ventilation conditions), before beginning to clean and disinfect, to minimize potential for exposure to respiratory droplets.
Clean and disinfect all areas (e.g., cells, bathrooms, and common areas) used by the infected individual, focusing especially on frequently touched surfaces.
After discharge, terminal cleaning may be performed by Environmental Services (EVS) personnel. They should delay entry into the room until a sufficient time has elapsed for enough air changes to remove potentially infectious particles. We do not yet know how long SARS-CoV-2 remains infectious in the air. Regardless, EVS personnel should refrain from entering the vacated room until sufficient time has elapsed for enough air changes to remove potentially infectious particles (more information on clearance rates under differing ventilation conditions is available). After this time has elapsed, EVS personnel may enter the room and should wear a gown and gloves when performing terminal cleaning. A surgical mask (if not already wearing for source control) and eye protection should be added if splashes or sprays during cleaning and disinfection activities are anticipated or otherwise required based on the selected cleaning products. Shoe covers are not recommended at this time for personnel caring for patients with COVID-19.
Hard (non-porous) surface cleaning and disinfection
If surfaces are dirty, they should be cleaned using a detergent or soap and water prior to disinfection.
Follow the manufacturer’s instructions for all cleaning and disinfection products (e.g., concentration, application method, and contact time, etc.).
Diluted household bleach solutions can be used if appropriate for the surface. Follow the manufacturer’s instructions for application and proper ventilation, and check to ensure the product is not past its expiration date. Never mix household bleach with ammonia or any other cleanser. Unexpired household bleach will be effective against coronaviruses when properly diluted. Prepare a bleach solution by mixing:
– 5 tablespoons (1/3 cup) bleach per gallon of water or
– 4 teaspoons bleach per quart of water
Soft (porous) surface cleaning and disinfection
For soft (porous) surfaces such as carpeted floors and rugs, remove visible contamination, if present. and clean with appropriate cleaners indicated for use on these surfaces. After cleaning:
If the items can be laundered, launder items in accordance with the manufacturer’s instructions using the warmest appropriate water setting for the items and then dry items completely.
For electronics such as tablets, touch screens, keyboards, and remote controls, remove visible contamination, if present.
Follow the manufacturer’s instructions for all cleaning and disinfection products.
Consider use of wipeable covers for electronics.
If no manufacturer guidance is available, consider the use of alcohol-based wipes or spray containing at least 70% alcohol to disinfect touch screens. Dry surfaces thoroughly to avoid pooling of liquids.
Additional information on cleaning and disinfection of communal facilities such can be found on CDC’s website.
Ensure that staff and incarcerated/detained persons performing cleaning wear recommended PPE. (See PPE CHART)
Food service items. Cases under medical isolation should throw disposable food service items in the trash in their medical isolation room. Non-disposable food service items should be handled with gloves and washed with hot water or in a dishwasher. Individuals handling used food service items should clean their hands after removing gloves.
Laundry from COVID-19 cases can be washed with other individuals’ laundry.
Individuals handling laundry from COVID-19 cases should wear disposable gloves, discard after each use, and clean their hands after.
Do not shake dirty laundry. This will minimize the possibility of dispersing virus through the air.
Launder items as appropriate in accordance with the manufacturer’s instructions. If possible, launder items using the warmest appropriate water setting for the items and dry items completely.
Clean and disinfect clothes hampers according to guidance above for surfaces. If permissible, consider using a bag liner that is either disposable or can be laundered.
Consult cleaning recommendations to ensure that transport vehicles are thoroughly cleaned after carrying a confirmed or suspected COVID-19 case.
CONTROL STRATEGIES FOR CONTACTS TO CASES OF COVID-19 - Updated 7/17/2020
Asymptomatic patients who may have been exposed to a confirmed or suspected COVID-19 case shall be placed in quarantine. These patients are at risk of already being infected or becoming infected as a result of their exposure. Thus, they need to be separated from the confirmed cases to avoid re-exposure and from the general population of unexposed individuals. The duration of quarantine is 14 days from the date of last exposure.
If a suspected COVID-19 case tests negative and clinicians release the suspected patient from COVID-19 isolation, quarantined patients should also be released.
WHO SHOULD BE IN QUARANTINE
The criteria for imposing quarantine in a correctional facility will remain a dynamic process with possible re-direction and re-strategizing of disease control efforts based on recommendations from the local health department (LHD), California Department of Public Health (CDPH), CCHCS Public Health Branch (PHB), and the Chief Medical Executive (CME).
Prior to initiating quarantine, patients should receive a full symptom screen and temperature check. If the patient screens positive, s/he should be immediately isolated, given a surgical mask, and moved to an isolation-designated location for medical evaluation.
Quarantine should be implemented for the following asymptomatic patients:
Contacts to a COVID-19 case, including close contacts, housing contacts, work-related contacts, and yard contacts
Inmates arriving at a reception center from a county jail
Patients returning from out-to-court with an overnight stay
Patients returning from an emergency department after any length of time or returning from a community hospital after an overnight stay
Inmates arriving from another correctional institution or healthcare facility, including the Department of State Hospitals (DSH)
Contacts to either staff or another inmate with COVID-19 should be tested at the beginning of quarantine, in the middle of quarantine, and prior to release from quarantine.
Other high risk quarantined patients (e.g., patients coming from a jail or county with a large outbreak) may also be tested at the beginning of quarantine (if there is no test in the past 7 days), in the middle of quarantine, and prior to release from quarantine.
Reception center facilities should test inmates arriving from jail within the first 24 hours of quarantine.
The Rapid SARS-CoV-2 antigen point of care (POC) test can be used if available.
If the POC is positive, the patient should be immediately isolated, given a surgical mask, and moved to an isolation-designated location for medical evaluation
If the POC is negative, testing with RT-PCR should be offered to improve the sensitivity and reduce the risk of a false negative.
Inmates with a negative test result need to be quarantined for 14 days.
Arrivals to all facilities should be tested within the first 24 hours of quarantine.
If positive, the patient should be isolated.
If negative, the patient must still complete the 14 days of quarantine and meet the release criteria below.
If testing during quarantine is refused, re-offer testing every 3-5 days.
MINIMIZING TRANSMISSION IN QUARANTINE
Minimizing the size of groups quarantined together reduces the risk of widespread transmission. If one person becomes infectious, fewer people are exposed.
Quarantine cohorts should be as small as possible (2-8 persons) to minimize spread.
Cohorts with different exposure dates should be separated.
Cohorts with different types of exposures should be separated, including those coming in from jails or transferring between institutions.
Serial testing and healthcare surveillance is used to identify those infected so that they can be moved to isolation.
QUARANTINE PRECAUTIONS AND CONDITIONS
Quarantined patients shall be placed on a medical hold.
The transport of patients in quarantine should be limited. If transport becomes necessary, assign dedicated staff to the extent possible. Patients under quarantine, and those transporting quarantined patients, must use appropriate personal protective equipment (PPE). Quarantined patients should wear a surgical or procedure mask; transport staff should wear an N95 respirator or other approved respirator.
Quarantine does not include restricting the patient to his/her cell for the duration of the quarantine without opportunity for exercise or yard time. Quarantined patients can have yard time as a group but should not mix with non-quarantined patients.
Quarantined patients may be given meals in the chow hall as a group;
If they do not congregate with other non-quarantined patients,
are the last group to get meals, and
the dining room can be cleaned after the meal.
If these parameters cannot be met in the chow hall, the patients shall be given meals in their cells.
Movement in or out of the quarantined area should be restricted for the duration of the quarantine period. When transport and non-essential movement is allowed; limit patient transports outside of the facility, permitting transport only for medical or legal necessity (e.g., specialty clinics, outside medical appointments, mental health crisis, or out-to-court).
Out-to-court and medical visits should be evaluated on a case-by-case basis. With the CME or CME designee’s approval, a quarantined or held patient may keep the necessary appointments or transfers, provided that the court, medical provider, and/or clinic have been notified that the patient is in quarantine or was on hold due to COVID-19 exposure, and they have agreed to see the patient.
Patients who are in quarantine or isolation may develop medical, mental health, or dental symptoms and communicate this by submitting a 7362, talking with a correctional officer (CO) or health care worker (HCW), or a staff member or other inmate may observe a problem. Depending on the type and severity of the problem and the physical layout of the prison, there are a number of possibilities for evaluation. General principles are to limit as much as possible the exposure of other people to the patient, and the number of places he or she passes through. Each institution and group of health care staff should develop a plan for various contingencies, including the possibility of setting up temporary exam rooms, tents, or other areas within or just outside each housing area. This should include evaluating whether a 7362 or a reasonable accommodation request could be postponed or temporarily addressed without a visit.
Thus, if possible, the inmate would be evaluated cell front. If the evaluation required more privacy or a physical exam, the next best place would be an exam room within or just outside the same housing. If more equipment were needed, the next best would be the yard clinic or the treatment and triage area (TTA). If the problem was obviously severe enough that the patient needed to go to the emergency room (ER) or hospital, having the ambulance or state vehicle pick the patient up directly from the room or housing area would be ideal, as long as medical treatment and stabilization are not needed first, in which case moving to the TTA would be necessary. If it is a mild problem, then a visit to evaluate it should be postponed until after the isolation or quarantine has ended. If it is a moderate or severe problem, and the patient needs to be brought to a yard clinic or TTA, they must wear a mask and be escorted directly to the exam/treatment room that has a closed door, with no interaction with other inmates and no time spent in a waiting room. The escorting staff member and the evaluating health care staff must wear appropriate PPE, and appropriate disinfection of the room to include high-touch surfaces must be done after the visit.
To reduce the number of health care staff potentially exposed, limit the number of health care staff (when possible) who interact with quarantined patients.
If one or more patients in quarantine develop symptoms consistent with COVID-19, follow recommendations for isolation of the ill patient(s). Separate the ill-quarantined patients from the well-quarantined patients immediately.
PATIENT SURVEILLANCE WHILE IN QUARANTINE
Correctional nursing leadership is responsible for assigning nursing teams to conduct surveillance to identify new suspected cases. Surveillance rounds and the evaluation of well patients who have been exposed must be done in all housing units that have housed one or more patients with suspected or confirmed COVID-19.
Nursing staff is advised to conduct twice-daily surveillance on quarantined patients for the duration of the quarantine period to identify any new cases. The minimum surveillance frequency is once per day if staffing or resource shortages occur.
If new case(s) are identified, the symptomatic patient must be masked, isolated, and evaluated by a health care provider as soon as possible.
Use the new COVID-19 electronic Surveillance Rounds form tool in the electronic health record system (EHRS) and the COVID-19 Screening Powerform (see instructions in Appendix 10). Temperatures and any symptoms must be recorded to identify illness (temperature >100° F [37.8° C], cough). List symptoms (see below list) not on the EHRS tool checklist in the free text box:
Note: Influenza (and other microorganisms) surveillance still uses the “Surveillance Round” in EHRS (Adhoc > All Items > CareMobile Nursing Task > Surveillance Round)
The only vital sign for quarantine is the temperature
Keep a very low threshold for symptoms, including those listed below. Any symptoms of illness necessitate a provider evaluation:
Chills without fever or subjective fever
Loss of sense of smell or taste
Gastrointestinal symptoms such as nausea, vomiting, diarrhea, cramping, or loss of appetite
Malaise (a difficult to describe, unpleasant feeling of being ill)
Myalgia or Arthralgia
Upper respiratory infection (URI) symptoms such as nasal or sinus congestion and rhinorrhea
“COVID Toe(s)” – painful digit(s) due to microthrombosis
New/unexplained muscle weakness
Patients with symptoms should be promptly masked and escorted to an isolation-designated clinical area for medical follow up as soon as possible during the same day symptoms are identified, including weekends and holidays.
Educate all patients about signs and symptoms of respiratory illness, possible complications, and the need for prompt assessment and treatment. Instruct patients to report respiratory symptoms at the first sign of illness. See patient education handouts on the CCHCS Coronavirus Webpage (CDCR networking is required for access).
Surveillance may uncover patients in housing units with upper respiratory symptoms, without fever, and who do not meet the case presentation for COVID-19. Consult with the treating provider and/or CME to determine if these patients should be isolated.
Each correctional facility should ensure the public health nurse (PHN), or designee, is aware of any patients with an influenza-like illness (ILI), and any suspected or confirmed COVID-19 cases. PHNs should be notified by phone and via the EHRS Message Center.
The 7362 Patient-Generated Request for Care System should not be relied on for alerting clinicians of symptomatic patients in housing units under quarantine. New patients with symptoms must be assessed daily, treated, and isolated as soon as possible to prevent further spread in the facility.
For COVID-19, the period of quarantine is 14 days from the date of the last exposure to a confirmed case.
Quarantine must be extended by 14 days for every new exposure.
No sooner than day 12 of 14 of quarantine, and within 2 days prior to release, all patients should be tested and have a negative result.
If a patient tests positive, they must be isolated and given a surgical mask immediately.
If a patient refuses testing for release, continue quarantine for another 7 days before release. Re-offer testing. If the patient ultimately agrees to the test, and the results are negative, they may be released before the seven days are up.
Someone who has been released from COVID-19 quarantine is not considered a risk for spreading the virus to others because they have not developed illness during the incubation period.
The CDC does not recommend testing, symptom monitoring, quarantine, or special management for people exposed to asymptomatic people who have had high-risk exposures to COVID-19, e.g., Contacts to Contacts.
INMATES RELEASING FROM INSTITUTIONS – COVID-19 TESTING AND NOTIFICATION
Review the transfer/release list in advance in order to schedule testing.
Schedule testing accordingly to have the test results before release.
If the patient “refuses” testing OR the test results are “pending,” the patient is still released on their legal release date.
Regardless of the patients’ COVID-19 status post-testing (including patients that refused testing and patients whose test results are pending) all patients being released require specific notifications to the local health department (LHD), Division of Adult Parole Operations (DAPO – parole), and/or Post Release Community Supervision (PRCS – probation) before the patient is released. The public health nurse (PHN) is responsible for the case management for each of these patients, which includes discharge notification.
It should be noted that during this time, due to early COVID-19 releases, an unprecedented number of patients are being released. The PHN will require additional assistance to accommodate the increased workload, including patient education and coordination of the discharge notification process with the LHD and, if applicable, the parole or probation officer.
CASE MANAGEMENT/DISCHARGE NOTIFICATION
The following are case management and discharge notification responsibilities conducted by the PHN or designee in advance of patient release:
Obtain the following information prior to the inmate’s release date, so arrangements can be made:
The county to which the patient will be released (if paroling, it will be the county of the patient’s last legal residence).
The type of housing planned for the patient upon release (e.g., private home, congregate setting, or no housing destination).
The mode of transportation for leaving the institution (e.g., private car, public transportation, etc.) in the event that plans need to be made in advance to safely transport a patient who is on quarantine or isolation for COVID-19.
Other people identified in the home, residence, or facility who may be at risk for exposure, especially if the patient being released is on COVID-19 restrictions.
The LHD should be given advance notice of the patient’s plan at release so planning can be done to implement, if needed, effective isolation or quarantine.
ACTIONS UPON RELEASE FOR ALL PATIENTS
Written notification shall be sent to the appropriate parties (i.e., the LHD and if applicable, parole or probation). See the section Mandatory “Notification Form” for ALL Patients Released” below for the required notification form to complete and the procedure for the notification.
The patient shall wear a cloth face covering upon exiting the institution.
The patient shall be screened for COVID-19 symptoms, including a temperature check. Refer to the COVID-19 Screening PowerForm (Appendix 10)
The purpose of screening upon release is to make sure the status of the patient has not changed (e.g., if an asymptomatic quarantined patient develops symptoms, that patient’s precautions will need to change from quarantine to isolation).
If the discharge notification for the patient changes, the LHD, parole/probation, and transportation officers, if applicable, will need to know the updated status before the patient is released.
MANDATORY “NOTIFICATION FORM” FOR ALL PATIENTS RELEASED
The “Inmate Release: COVID-19 Status and Test Results Notification for Local Health Department and Parole/Probation” form (Appendix 9) must be completed for ALL patients upon release.
The “notification form” (Appendix 9) shall be completed in its entirety, as it includes essential information including the patient’s COVID-19 status, COVID-19 test results, the patient’s destination (e.g., a congregate facility such as a drug treatment program), and if applicable, the parole or probation officer’s contact information.
Labeling and Sending “Notification Forms”:
All forms should be saved as a PDF and labeled as follows: Institution, Last Name, First Name, Current Date (e.g., San Quentin Smith John 2020-05-27).
All forms going to non-CCHCS email addresses (e.g., outside agencies) must be sent with NO personal identifying information (PII) in the subject line, and [Encrypt] must be written in the subject line. The forms contain confidential and sensitive information.
A copy of the notification form must always be sent to the “notification email” even if the form was faxed to the outside agencies (e.g., LHD).
Initial notification should be made by telephone to the LHD’s communicable disease (CD) controller, followed up by sending a confidential fax or email (include [Encrypt] in the email subject line), with the “notification form” (Appendix 9).
The notification to the LHD should be made during business hours and, if possible, with advance notice.
Due to the COVID-19 early releases, the PHN may not have a chance to obtain this information and share it with the LHD before the release. In cases of delayed-release information to the PHN, the PHN shall proceed with the necessary notifications upon discovery of the release.
Notify the parole or probation officer (if applicable):
Notification should be made by telephone and followed by sending an email (include [Encrypt] in the email subject line), with the “notification form” (Appendix 9) attached, to the appropriate officer.
HEALTH EDUCATION INSTRUCTIONS FOR ALL INMATES
Provide COVID-19 educational information for all inmates regardless of status.
For patients with COVID-19 restrictions, review:
The need to continue medical isolation or quarantine upon release.
The signs and symptoms of clinical deterioration.
The contact number of LHD if the patient doesn’t have a personal health care provider and becomes symptomatic.
The patient’s COVID-19 discharge materials shall include specific dates written on the documentation for when their specific infection control precautions began and will end (e.g., Quarantine: Your 14 days of quarantine began on (date) ___/___/___ and will end on (date) ____/___/____. If you get sick, notify your health care provider or the local public health department).
Document all notifications made and education provided in the Electronic Healthcare Record System (EHRS) via the Public Health PowerForm and other PowerForms as needed.
a. Be on alert for patients presenting with fever or symptoms of respiratory illness.
b. Report suspect cases to institutional leadership, local health department, and the Public Health Branch.
2. INFECTION PREVENTION AND CONTROL MEASURES
a. Isolate symptomatic patients immediately in airborne infection isolation room (AIIR). Implement Standard, Contact, and Airborne Precautions, plus eye protection.
b. Educate staff & patients about outbreak. Emphasize importance of hand hygiene, respiratory etiquette,and avoiding touching eye, nose, or mouth. Post signage about the outbreak in high traffic areas.
c. Increase available of hand hygiene supplies in housing units and throughout the facility.
d. Separate patients identified as contacts from other patients and implement quarantine as appropriate.
e. Increase cleaning schedule for high-traffic areas and high-touch surfaces (faucets, door handles, keys,telephones, keyboards, etc.). Ensure available cleaning supplies.
3. CARING FOR THE SICK
a. Implement plan for assessing ill patients. Limit number of staff providing care to ill patients, if possible.
b. Ensure Personal Protective Equipment is available and accessible to staff caring for ill patients.
4. POSSIBLE ADMINISTRATIVE CONTROLS DURING OUTBREAKS
a. Institute screening for respiratory symptoms.
b. Encourage patients to report respiratory illness.
c. Halt patient movement between affected and unaffected units.
d. Screen for respiratory illness in patient workers in Food Service and Health Services; exclude fromwork if symptomatic.
e. Minimize self-serve foods in Food Service (e.g., eliminate salad bars).
f. Do controlled movement by unit to chow hall (cleaning between units), or feed on the units.
g. Temporarily discontinue group activities, e.g., recreation, chapel, activity therapy groups, education.
h. Schedule daily status meetings involving custody and medical leadership; other stakeholders shouldattend as appropriate.
i. Do controlled movement by unit to pill line, or administer medication on the units.
j. Encourage ill staff to stay home until symptoms resolve and/or they are cleared to return to work bytheir provider.
k. Post visitor notifications regarding outbreak. Advise visitors with respiratory symptoms to not enter thefacility (If large outbreak, consider suspending visits).
l. During large outbreaks, consider halting patient movement in and out (in consultation with local healthdepartment).
Prior to the index case-patient interview, a review of the case presentation or physician conference should take place. The interviewer should be prepared to gather a detailed account of the case-patient’s movements and activities during their infectious period (from 2 days [48 hours] prior to symptom onset to isolation, if symptomatic). For asymptomatic case-patients, the infectious period should be considered 2 days prior to the date of the positive test.
The index case-patient interview should take place as soon as possible after laboratory confirmation of COVID-19. If the patient is at an outside hospital, coordination with the local health department (LHD) or hospital should occur, to ensure timely completion of the interview so that close contacts can be identified and placed in quarantine.
Use the COVID-19 Index Case-Patient Contact Investigation Tool and this Interview Checklist to guide and document the interview. Initiate the contacts line list in the COVID-19 SharePoint:
Confirmation of medical information (e.g., symptoms and onset date)
Determination of the infectious period
Determination of where the patient spends time
Identification of all close contacts during the infectious period
Providing patient education and answering the patient’s questions
Conveying the importance of sharing information about close contacts to help stop the spread
Review medical record and consult with physician as necessary for case presentation
Establish a preliminary infectious period
Collect housing, movement history, and work or program assignments from SOMS
Determine if the patient is expected to be released from CDCR within the next 30 days
Arrange interview time, space, and interpreter, if needed
Defining the Infectious Period
The infectious period during which others may have been exposed to COVID-19 starts 2 days (48 hours) before the onset of symptoms and ends when the patient was isolated or hospitalized at an outside facility. For asymptomatic case-patients, the infectious period should be considered 2 days prior to the date of the positive test.
Symptoms / Onset Date
Cough (new onset or worsening)
Shortness of breath (dyspnea)
Fever >100.4°F (38°C)
Subjective fever (felt feverish)
Identify and list contacts exposed for each group and activity. Document approximate duration of exposure during the activity.
Friends and Family
Friends the patient spends the most time with
Cell/dorm mates patient spends the most time with
Routine Activities and Assignments
Regular appointments (medical, dental, legal)
Religious, worship or spiritual activities
TV room / day room
Sports team participation
Any other relevant information
APPENDIX 8: EMPLOYEE CASE VERIFICATION AND CONTACT INVESTIGATION
COVID-19 Patient Positive Verification and Contact Investigation
PART 1 Initial steps to determine valid COVID -19 CASE
Notification to employee, health to begin an investigation
Receive Notification from institution(s), name and contact information of suspected positive COVID-19 patient
Nurse Consultant gathers available information on the patient
Nurse Consultant contacts the patient for interview
Patient provides evidence of positive test if available
Patient provides dates of symptom onset
Patient provides the dates of the work schedule.
Determine initial dates of the infectious period
Review patient interview
Contact the local Public Health Department to determine positive status if needed
Confirm the status of patients test
Refine infectious period if necessary
Determine if this referral is a valid positive case for COVID-19
Verified positive continue on as a case
Verified negative; conclude the investigation
PART 2 VERIFIED POSITIVE COVID-19 CASE
Develop plan for investigation
Prepare contacts list based on the refined infectious period
Conduct contact assessments
Determine need to expand or conclude an investigation based on evaluation of the information gathered
Repeat steps in Part 1 (steps 1-3 for each contact)
Conduct contact assessments
Complete all report forms and forward to appropriate staff.
APPENDIX 9: MEMO TEMPLATE FOR NOTIFICATION OF COVID-19 CASES AND CONTACTS RELEASED TO THE COMMUNITY
The purpose of this sample LOP is to identify decision points and assist in documenting the processes needed to implement COVID-19 testing with your local county department of public health, local county or outside reference testing lab, or both.
The issues surrounding each decision point within the testing procedure, followed by proposed LOP language will be presented. The proposed LOP language must be adapted to your local circumstances.
Note: Lab order processing through Quest should be the first choice of institutions. Most institutions will receive results sooner from Quest, and the Quest results will post directly into the Electronic Health Record System (EHRS) and the Quality Management (QM) registries. This speed will allow institutions to move more quickly to evaluate and track positive cases and prevent the spread of COVID-19.
Who is responsible for creating this LOP? Who is responsible for the oversight of this process?
Who will be assigned responsibility for the various tasks associated with the testing process: ordering, obtaining & maintaining testing supplies, scheduling, specimen collection, specimen transmission/delivery to the reference lab, result transmission & recording in EHRS, etc.?
The institution Public Health Nurse (PHN) will be responsible for creating the process for, and exercising oversight over the COVID-19 testing of inmates by the county-designated laboratory. The institution PHN will be the main point of contact between the institution and the county and their lab testing entity.
Responsibility over the various tasks of the testing process will be outlined in the components of the procedure below. Problems with exercising the various assigned tasks should flow through the institution PHN.
Who will be allowed to order the county COVID-19 tests?
What order should be entered into the EHRS for the county COVID-19 tests? How do we ensure the correct order is chosen? Is there an appropriate collection priority to choose?
Will a simultaneous “ordering” or notification process have to be followed with the county, or outside lab? Does the county place a daily volume limit on testing due to capacity issues?
Treating providers and nursing staff designated by the treating providers or institution PHN may order the county COVID-19 tests.
County COVID testing orders for the designated inmate should be recorded in EHRS with a “Misc Test Other–COVID19” order. Ordering providers may simply search for the order by typing “COVID”. Do not use the “Quest Misc Test” or “Misc Test Other” orders to record in EHRS.
When selecting the EHRS order collection priority please choose “ASAP” to not delay testing.
A proper requisition will be completed by specimen collection staff at the time of the collection, and will accompany the specimen through the transmission/delivery process.
The institution PHN will notify the county-designated lab of incoming specimens exceeding a designated notification threshold.
OBTAINING & MAINTAINING SUPPLIES
What specific testing supplies/kits are required by the county lab? Which transport media are allowed? Which type of collection method is accepted (are anterior nares and mid-turbinate accepted?)
Who will order the testing supplies and requisition from the county lab or vendor?
How will the testing supplies be delivered to the institution? Who will accept delivery of the supplies at the institution; does custody need to be notified of incoming lab supplies? If there is no delivery, how will testing kits arrive at your institution?
Do the testing supplies/kits have to be ordered through the county, or an approved county vendor? Will alternative versions of the required supplies be allowed from alternative vendors?
Where will county-related testing kits be stored? Is there a system in place to ensure county testing supplies incompatible with existing Quest testing kits are maintained in a separate location?
Is there a communication system in place to alert ordering providers and specimen collection staff of testing kit shortages?
Recommended media are Nasopharyngeal (NP) swab in Viral Transport Medium (VTM) and Oropharyngeal (OP) swab in VTM or Universal Transport Medium (UTM) for upper respiratory symptoms. (Name of lab) does not currently process any other media for COVID-19 testing.
Testing supplies are ordered by the institution PHN the day before they are needed. Testing supplies are then delivered the next day by 8 am via courier, excluding Sundays. Deliveries will be accepted at the treatment and triage area (TTA). Custody will need to be alerted of the expected delivery at the time supplies are ordered.
(Name of public health lab) will process samples from the list of pre-approved alternate vendors found here: (county lab website).
Samples shall be stored in the refrigerator located in/at (location) until pickup by the courier service. Refrigerator AAA shall only hold Quest testing kits and refrigerator BBB shall only hold county-related test kits. For tests needed on Sundays, custody shall pick up testing supplies from (alternate test supply location) to return by 8 am. Kits must be logged at the TTA.
To facilitate communication in the case of testing kit shortages, all testing kits shall be logged in the TTA upon arrival and a daily update email will be sent to ordering providers and specimen collection staff to apprise them of the amount of tests on-hand.
Can we test asymptomatic patients?
Does the lab require a pre-review of the patient for approval to test?
Does the lab require a form for processing? Who will fill out the form request? How do we obtain the form? Who will review the completed form?
Prior to collection, nursing shall contact (name of lab, phone number) and ask for permission to test for COVID-19. A nurse or epidemiologist will evaluate and then provide a person of interest number (PUI#).
Prior to collection, the assigned nurse will fill out form (form name) found at (public health lab website). Completed forms shall be emailed to (lab name and email) for processing.
Patients shall be triaged according to symptom severity daily, with priority for confirmed contacts. Refer to the Diagnostic Testing section (hyperlink) for more information.
Where will the samples be collected?
How will the samples be collected and labeled? How so do we ensure that the correct requisition and labels are on specimens? Who collects the labels?
Will the samples be labeled individually as well as the lot?
Does the lab have a maximum amount of tests that they can process? What if the number of patients needing testing exceeds the county lab’s daily limit?
Specimens can be collected at the institution’s designated collection site, lab, or bedside if needed (e.g., central treatment center [CTC]).
Nursing staff will swab the patient and ensure the sample is labeled and has the appropriate requisition form. Staff places the specimen in the plastic bag in the designated refrigerator for delivery to (name of lab). Swabs should be refrigerated until transfer. A specimen requisition form MUST accompany all specimens. Note: It is critical that providers document travel history and symptoms on the form.
Samples should be labeled individually as well as a lot label for the institution.
(Name of lab) has agreed to process 200 tests per day. Patients shall be triaged according to symptom severity daily, with priority for confirmed contacts.
SPECIMEN PROCESSING AND TRANSPORT
Does the lab provide a courier service, and what days and times will the courier be provided? Where will the courier service pick the specimens up? Does the courier travel to the facility location?
Who is responsible for contacting the lab for courier pick-up?
(Lab name) will pick up specimens on Mondays-Fridays with the final courier pick-up at 3 pm. All samples will be obtained by 2:30 pm. There will be one courier pick-up on Saturdays at noon, all samples will be obtained by 11:30 am. (Name of lab) does not process exams after hours and Sundays.
Institutional lab staff should be responsible for contacting the lab for courier services and confirming the location of pickup.
The lab supervisor will designate staff for delivering specimens if courier service is not provided and ensure the staff has ample time to deliver the specimen before the lab closes.
How long will it take for results to come back?
Does the lab have an online portal for results? Will staff have access to Public Health web portals for test results?
Once results are available, how will the information get into EHRS (e.g., scanned, manually entered, etc.)? Will the results be in an easily accessible and consistent location?
Will the labs fax the results to the institution? If so, does the lab have the TTA’s fax machine number?
Who will send the information to Headquarters (HQ) as well as the institution for tracking?
Test results will be available within 48 hours at (name of lab) portal located at (web portal address). (Designated person/unit) will print the test results and place in an interoffice envelope addressed to Health Information Management (HIM), who will scan into EHRS within 24 hours with the label “COVID-19 exam results”. If the designated person/unit is not the lab, the test results will also be sent to the lab for order completion.
COVID test results will be scanned by HIM into the appropriate section/folder in EHRS.
Institution lab staff will ensure the outside lab has the TTA’s fax number.
Lab results will be forwarded to the institution PHN for tracking and sending the results to HQ. The PHN will ensure quarantine or isolation is ordered for nurse tasking and surveillance as indicated.
Clinical Lab Scientist staff will complete the order in EHRS using a unique designated process for the “Misc Test Other–COVID19” lab order. (Note: Please contact Trang Bui or the CDCRCCHCSLabQuestions@cdcr.ca.gov mailbox for questions on this process.)
APPENDIX 13: COVID SCREENING AND TESTING MATRIX FOR PATIENT MOVEMENT
Point-of-care (POC), rapid SARS Antigen Testing kits for identifying infections with the COVID-19-related virus have been ordered and should be arriving at your facility in 1-2 weeks. The test is an immunofluorescence SARS-CoV antigen assay that is point-of-care and Clinical Laboratory Improvement Amendments (CLIA)-waived. The test cassettes are to be used with the SOFIA-2 devices previously sent to you for the Rapid Influenza Diagnostic Testing (RIDT) in March 2020.
When facilities start to use the analyzer, they will need to alert the California Department of Health (CDPH) that point-of-care COVID-19 testing is commencing at the facility. Please notify CDPH Lab Services at LFSCOVID@cdph.ca.gov.
Which institutions can use the test?
Institutions who have valid/current CLIA, Certificate of Waiver, and California Clinical Laboratory registration.
Who should be tested?
All incoming inmates (e.g., jail intakes) to CDCR that come through the reception center (RC) should be offered testing.
All new arrivals should be placed into quarantine for 14 days and tested within 24 hours of arrival.
Patients who refuse testing will be treated the same as the tested patients. Re-offer testing to those who refuse every 3 to 5 days.
All incoming patients will be quarantined for a minimum of 14 days, regardless of testing negative or declining to be tested.
High-risk patients for which an immediate knowledge of infection status is critical. This includes, but is not limited to:
Custody related transfers to another institution, especially before busing with other inmates and staff.
Healthcare-related transfers to a higher level of care (HLOC) or mental health-related/crisis transfers.
Patients releasing to the community if there is insufficient time to perform a PCR test.
Other transfers such as out-to-court, before outside dialysis, same day infusions or procedures, and before appointments with external clinics and medical centers.
Who should not be tested with this platform?
Antigen POC tests are generally not for mass testing for outbreak situations, routine public health surveillance, or other routine testing of vulnerable populations or workers. However, there may be times when the PCR test results will not be available in time for decisions, or if immediate repeat testing for confirmation following a prior PCR is indicated.
Who can use the analyzer?
Only the following personnel will be able to perform the test: trained Licensed Vocational Nurses (LVNs), Psychiatric Technicians (PTs), Registered Nurses (RNs), Supervising Registered Nurses (SRN)IIs, SRNIIIs, Chief Nurse Executives (CNEs), and medical providers.
How is the sample collected?
The kits require brand-specific test cassettes and reagents. The kits come with an anterior nares (AN) or “nasal” swab. The specimen can be collected by health care staff, or the patient may be amenable to supervised self-swabbing with AN collection. Please refer to the COVID-19 Interim Guidance for technique and more information on self-swabbing.
If nasopharyngeal (NP) samples are to be collected, any nylon-flocked NP swabs that you have at your facility will work, and additional non-brand specific NP swabs have been ordered. Polyester-flocked NP swabs will not work on this platform.
What type of specimen medium is accepted by the test cassettes?
**Important**No viral medium is used. USE A DRY SWABWITHOUT MEDIA OR SALINE for the test. Use sterile tube containers for dry swab transport when the analyzer station is far from the patient. Test performance is significantly better with dry swab than when the swab is diluted with viral medium.
What personal protective equipment (PPE) is required for specimen collection?
For nasal specimens that are self-collected swabs, and for which the supervising health care personnel (HCP) remains 6 feet away during the collection, only a surgical mask and gloves are needed.
Ideally, for nasal specimens that are collected by HCP, use an N95 respirator, eye protection, gloves, and a gown. A surgical face mask is an acceptable alternative during shortages, as the N95 should be prioritized for higher risk aerosol-generating procedures.
When collecting respiratory specimens with an NP collection method, HCP in the room should wear an N95 or higher-level respirator (or facemask if a respirator is not available), eye protection, gloves, and a gown. The collection should be performed in a designated isolation examination room with the door closed, or an isolated outdoor location if a room is not available. In times of severe PPE shortages, a surgical/procedure mask can be used in lieu of the N95. Further adaptions for PPE shortages can be found on the CDC website https://www.cdc.gov/coronavirus/2019-ncov/hcp/ppe-strategy/index.html.
How many tests can be run on the analyzer?
Testing through the analyzer should be performed as soon as possible after collection. The specimen is only usable for 2 hours in a dry tube after collection.
The analyzer can conservatively handle 15 tests in an hour calculating with a full minute between result output and the next entry. Take caution in moving faster to increase capacity, to avoid mistakes.
We recommend limiting the inoculated cassette samples in or awaiting analyzer use to 5 tests at a time. While the first cassette is incubating inside the analyzer for the required 15 minutes, up to four cassettes can be incubating and lined up ready for analyzer entry. Each cassette can then be sequentially entered immediately after the preceding cassette comes out. Additional samples should not be inoculated until <4 samples are waiting. This will avoid sample deterioration, which occurs 30 minutes after the cassette has been inoculated with the sample.
If the number of cassettes is insufficient for patient volume or the physical layout of your facility requires additional analyzers, please let your Regional Nurse Executive know.
How do I interpret the test results? What if the test result is positive?
These tests are highly specific, and when positive, the test can confirm a COVID-19 case with confidence. Place a surgical mask on the patient and immediately separate them from the quarantined area and take them to an isolation-designated location for medical evaluation.
All positive tests need to be reported to the local health departments.
What if the test result is negative or reads “invalid”?
The lower the prevalence of circulating virus, the lower the sensitivity of the test. If there is a high risk of exposure, high risk of transmission to others, or a high level of concern, a negative test should be followed up by a sample for RT-PCR.
An “invalid” result means the sample timed-out (≥30 minutes elapsed after the swab was mixed with reagent and the sample inoculated onto the cassette, but before the cassette was entered into the device) or was an otherwise unreadable sample. The sample must be repeated for the antigen test, or another sample sent for RT-PCR.
How are the results charted?
A POC order and tasking trigger for charting, similar to that for the RIDT, has been created. Order “COVID-19 Rapid Test POC” in the electronic health record system (EHRS) and chart results using the task list tab > Schedule patient care tab > double click on the Influenza like illness POC results task > the PowerForm will pop up > Document and sign the PowerForm > Task and the order will be complete.
A POC order and tasking trigger for charting, similar to that for the RIDT, has been created. Order “COVID-19 Rapid Test POC” in the electronic health record system (EHRS) and chart results in the form located in “Adhoc/Nursing Forms/COVID-19 Rapid POC.” Please refer to the Testing for COVID-19 and Other Respiratory Pathogens section of the guidance document for more information. A Webinar is also available through Lifeline ECHOS/EHRS Project > ECHOS Learning Team > Nurse Webinars tab.
Will there be training?
There is training provided by the manufacturer. There are excellent training step-by-step handouts and videos at the Quidel training website on use, calibration, and control checks. Also, you may request a virtual demonstration in real-time with a question and answer session with Quidel personnel if desired. Email email@example.com if interested in real-time training.
For free additional control kits for training, call Quidel Customer Service at 1-800-874-1517.
Note: The analyzer needs to be connected to a Quidel cloud-based storage for data called “Virena”. HIPAA-compliant, de-identified patient information is sent back to the manufacturer for research purposes. Setting the device to connect to Virena is done simply by turning on the wireless (or Ethernet) setting on the device menu. Instructions on how to connect to Virena can be found at https://connectme.quidel.com/docs/virena/configuration-instructions, and general information on Virena is available at https://www.quidel.com/immunoassays/virena.
The analyzer requires monthly calibration.
How can I get help if I have trouble with the analyzer?
Call Quidel Sofia Customer Service at 800-874-1517, option 2, then option 1; Monday-Friday 6 AM to 5 PM Pacific time; or email: firstname.lastname@example.org.
Will CDCR get other tests for the COVID-19-related virus in the future?
Yes. The testing platforms with high performance for detecting infection and for serology testing are under constant evaluation. Changes in testing policy and new platforms or types of tests may be instituted at any time based on the science and guidance that continues to evolve.
APPENDIX 15: PROVIDER SCRIPT – OFFERING CELL HOUSING TO PATIENTS AT HIGH RISK OF SEVERE COVID-19