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.

RECORD OF CHANGES

5/22/20 – Appendix 10: Updated screenshots with revised forms and added the Receiving County Notifications PowerForm for reporting to the local health department on COVID-19 patient status, disposition, and alerts for COVID-19 patients who will be paroling.

5/20/20“Parole and Discharge to the Community During a COVID-19 Outbreak” is deleted from the “Control Strategies for Contacts to Cases of COVID-19” section. A new section “Inmates Releasing from Institutions During a COVID-19” has been added with revised information.

5/11/20 – Control Strategies for Suspected and Confirmed Cases: added Isolation Rooms and PPE table for ILI/Influenza and COVID-19 cases; added updates involving humane treatment when in isolation; added “Who is a ‘Close Contact’ of a Case”; added recommendation for more than twice a day surveillance for COVID-19 patients if possible; added subsection “Cleaning up After a COVID-19 Case”; added clarification of face coverings versus surgical masks; added information on when patients refuse testing.

5/11/20 – Appendix 11: Added missing content.

5/08/20 – Appendix 9: Revised with new content and made into a fillable PDF.

5/08/20 – Control Strategies for Suspected and Confirmed Cases: Updated algorithm for Evaluation and Treatment for Suspect and Confirmed COVID-19 Cases and updated algorithm for Release from Isolation Criteria for Patients with COVID-19.

5/06/20 – Diagnostic Testing: Added detailed table for increasing testing and how to prioritize testing, clarified section on who to test, and updated algorithm.

5/06/20 – Primary Prevention: Added section on instructions for obtaining resources for outbreak planning.

5/05/20 – Clinical Manifestations: Updated typical signs and symptoms with compilation of latest research

5/04/20 – Appendix 6: Added a column to collect summary information about employee close contacts

5/04/20 – Appendix 7: Changed definition of prolonged close contact from 30 minutes to 10 minutes and changed infectious period to begin 2 days (48 hours) before symptom onset date

5/01/20 – Diagnostic Testing: Added new diagnostic testing algorithm

4/27/20 – Infection Control and PPE: Clarifications and improvements to the Infection Control and PPE guidance.

4/24/20 – Appendix 5: New procedure for requesting access to the PH Outbreak Reporting SharePoint

4/24/20 – Diagnostic Testing: Updated lab test code, Expanded list of symptoms for which to test for COVID-19, Updated information on Rapid Influenza Diagnostic Kits to advise stopping their use due to sporadic influenza prevalence, Updated viral culture media to include saline, Added notes on serology testing and Point of Care COVID-19 test kits

4/24/20 – Public health definitions: The definition of close contact with a confirmed case of COVID-19 has been revised to within 6 feet for a prolonged (generally >10 minutes) period.

4/24/20 – Control Strategies for Suspected and Confirmed Cases: Updates to Criteria for Release from Isolation subsection and new Release from Isolation Algorithm.

4/22/20 – Clinical Manifestation of COVID-19: Updated to include higher occurrence of atypical COVID-19 symptoms and asymptomatic viral shedding and diagnostic study findings typical in COVID-19.

4/21/20 – Transmission: Updated to provide more information on viral particle survival on fomites, asymptomatic shedding and aerosol generating procedures

4/21/20 – Treatment: Updated to include Infectious Disease Society of America guidance on medications

4/20/20 – Primary Prevention: Environmental Infection Control updated clean shared equipment.

4/20/20 – Primary Prevention: Added a new topic with detailed guidance on how facilities can prepare for the pandemic.

Version 2.0 Changes:

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.

The Treatment section was expanded.

Transmission information was updated to highlight possible asymptomatic shedding.

A definition was added for the end of a COVID-19 outbreak.

Updated isolation and quarantine distancing to include space shortages.

Additional clarification was added regarding reporting and notifications.

Additional PPE scenarios were added.

The General Infection Control Precautions section was updated to include supply shortage strategies.

Expanded Contact Investigation section.

Evaluation and Treatment Algorithm for suspect and confirmed COVID-19 patients.

The criteria for release from isolation was changed to require COVID-19 laboratory testing based on updated CDC guidance.

The guidance for when patients are paroling during the outbreak has been expanded.

Environmental control guidance has been expanded.

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.

ACRONYM LIST

AHRQ Agency for Healthcare Research and Quality
AIDS Acquired Immune Deficiency Syndrome
AOD Administrative Officer of the Day
AIIR Airborne infection isolation room
BMI Body Mass Index
CCHCS California Correctional Health Care Services
CDC Centers for Disease Control and Prevention
CDCR California Department of Corrections and Rehabilitation
CDPH California Department of Public Health
CLIA Clinical Laboratory Improvement Amendments
CME Chief Medical Executive
CNE Chief Nurse Executive
COVID-19 Coronavirus Disease 2019
DON Director of Nurses
EHRS Electronic Health Record System
EPA Environmental Protection Agency
HCP Health Care Personnel
HCW Health Care Worker
HIV Human Immunodeficiency Virus
HLOC Higher Level of Care
ICN Infection Control Nurse
ILI Influenza-like illness
LHD Local Health Department
MDI Metered-dose Inhalers
NCPR Nurse Consultant Program Review
NIOSH National Institute for Occupational Safety and Health
NP Nasopharyngeal
OSHA Occupational Safety and Health Administration
OEHW Office of Employee Health and Wellness OEHW
OP Oropharyngeal
PPE Personal protective equipment
PAPR Powered air purifying respirator
PORS Preliminary Report of Infectious Disease or Outbreak form
PHB Public Health Branch
PHN Public Health Nurse
PhORS Public Health Outbreak Response System
QM Quality Management
RIDT Rapid Influenza Diagnostic Test
RSV Respiratory syncytial virus
RT-PCR Reverse Transcription Polymerase Chain Reaction
RTWC Return to Work Coordinator
TAT Turnaround time
URI Upper Respiratory Infection
VCM Viral Culture Media
WHO World Health Organization

PRIMARY PREVENTION - Updated 5/06/2020

TABLE OF CONTENTS

  1. PRIMARY PREVENTION OF COVID-19 WITHIN CDCR
    1. MINIMIZING MOVEMENT
    2. FACE BARRIERS
    3. IDENTIFY OR CREATE SEPARATE SYMPTOMATIC SCREENING AND TESTING AREAS
    4. IDENTIFY AND SEPARATE LOCATIONS FOR AEROSOL GENERATING PROCEDURES (AGP)
    5. EARLY IDENTIFICATION AND LOCATION FOR ISOLATION AND QUARANTINE ROOMS AND FUTURE COHORTS
    6. ASSESSING AND OBTAINING RESOURCES FOR OUTBREAK PLANNING
    7. SOCIAL DISTANCING
      1. HOUSING
      2. EATING
      3. CLASSES AND GROUPS
      4. YARD AND DAY ROOM ACTIVITY
      5. PILL LINES
      6. MEDICAL, DENTAL, AND MENTAL HEALTH APPOINTMENTS
    8. EDUCATION AND HYGIENE
    9. PROTECTING VULNERABLE POPULATIONS
  2. STAFF AND VISITOR PRECAUTIONS AND RESTRICTIONS DURING THE PANDEMIC
    1. RESPIRATORY HYGIENE AND COUGH ETIQUETTE
  3. ENVIRONMENTAL INFECTION CONTROL

PRIMARY PREVENTION OF COVID-19 WITHIN CDCR

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).
  • Educate staff and inmates with fliers and other educational tools. (See educational material at: https://www.cdcr.ca.gov/covid19/population-communications/ and http://lifeline/HealthCareOperations/MedicalServices/PublicHealth/Pages/Coronavirus.aspx under the “CDC/External” tab – CDCR networking is required for access).

MINIMIZING MOVEMENT

There are three main ways the virus can enter the prison:

  1. 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:
    1. Consider stopping all movement of inmates in and out of the prison except for essential legal and medical reasons.
    2. Consider quarantining every inmate entering the prison for 14 days as recommended by the Center for Disease Control (CDC) for prisons and detention facilities.
    3. Consider providing medical and legal visits through telemedicine and teleconferencing.
  2. An employee or contractor brings it in from the outside – either asymptomatic, with mild symptoms, or ill.
    1. Consider having employees telework whenever possible, minimizing the number of people coming from the community into the prison.
    2. 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.
  3. A visitor or volunteer brings it in from the outside.
    1. Consider stopping all visiting and volunteer programs.
    2. 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.
    3. 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.

FACE BARRIERS

  • Begin using face barriers by directive from CCHCS leadership. This is currently the case statewide. (See CALPIA Cloth Face Barrier/Mask memo)
  • 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.
  • Consider universal screening at all housing units or housing units where vulnerable populations have been identified to live, once an outbreak has occurred at your institution.

IDENTIFY AND SEPARATE LOCATIONS FOR AEROSOL GENERATING PROCEDURES (AGP)

  • See the list of AGP in the Aerosol-Generating Procedures memo
  • 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.

Form 213 is available through Lifeline. (Entering ‘213’ in the search space gives you the form below, entering ‘213 resource request’ gives both the form and the Clarification Regarding Utilization of Resource Request Message, Incident Command System, 213 RR; CAL-Cards; and General Procurement Methods in Response to COVID-19 memo – CDCR networking is required for access).

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.

SOCIAL DISTANCING

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.

HOUSING

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.

EATING
  • 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.

PILL LINES
  • 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).
  • Take advantage of the Quality Management COVID-19 Risk Tool (CDCR networking is required for access) for assistance in identifying your vulnerable patients.
  • 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. 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

See COVID-19: Infection Control for Health Care Professionals

  • 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.

For further sanitation information please refer to HCDOM, Chapter 3, Article 8 – Communicating Precautions from Health Care Staff to Custody Staff.

CLINICAL MANIFESTATION OF COVID-19 - Updated 5/05/2020

TABLE OF CONTENTS

  1. INCUBATION PERIOD
  2. TYPICAL SIGNS AND SYMPTOMS
  3. UNUSUAL PRESENTATIONS OF COVID-19
  4. DISEASE COURSE
  5. SPECTRUM OF DISEASE
  6. TYPICAL DIAGNOSTICS IN COVID-19 (HOSPITALIZED PATIENTS)
  7. CLINICAL FACTORS ASSOCIATED WITH PROGRESSION TO SEVERE DISEASE AND RESPIRATORY FAILURE

INCUBATION PERIOD

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.

TYPICAL SIGNS AND SYMPTOMS

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 URIs and the more severe symptoms seen in hospitalized patients. Cases without cough or dyspnea, however, have been described, including presentations where 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.

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.

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

DISEASE COURSE

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 precipitous decline. For this reason, patients with COVID-19 need to be monitored closely for clinical status. 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.

Severe Disease
Approximately 14% of laboratory confirmed patients have severe disease (dyspnea, respiratory rate 2:30/minute, blood oxygen saturation: 93%, and/or lung infiltrates >50% of the lung field within 24-48 hours).

Critical Disease

Approximately 6% of laboratory confirmed patients are critical (respiratory failure, septic shock, and/or multiple organ dysfunction/failure). Older patients and patients with co-morbid conditions (see table 5.1 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)
  • Typical finding on chest X-ray 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.

DIAGNOSTIC TESTING - Updated 5/06/2020

TABLE OF CONTENTS

  1. FIGURE 6.1: ALGORITHM FOR DIAGNOSTIC TESTING
  2. PRIORITIES FOR COVID-19 TESTING
  3. DIAGNOSTIC TESTING FOR SYMPTOMATIC PATIENTS
  4. TESTING INDICATIONS FOR ASYMPTOMATIC PATIENTS
  5. SEVERE TESTING SHORTAGES
  6. RESPIRATORY VIRUS TESTING CONSIDERATIONS
  7. DIAGNOSTIC TEST INFORMATION
  8. RAPID INFLUENZA CLINICAL LABORATORY IMPROVEMENT AMENDMENTS (CLIA) WAIVED DIAGNOSTIC TEST (RIDT)
  9. COVID-19 TESTING
  10. STRATEGIES TO MAXIMIZE SENSTIVITY OF COVID-19 TESTING
  11. SAMPLE SPECIFICATIONS FROM QUEST
  12. PRECAUTIONS FOR SPECIMEN COLLECTION
  13. ROLE OF COVID-19 SEROLOGY TESTING
  14. OTHER DIAGNOSTICS

PRIORITIES FOR COVID-19 TESTING

Please refer to Figure 6.1 Algorithm for Diagnostic Testing and Tables 6.2 and 6.3 for more details on indications for COVID-19 testing. See Diagnostic Test Information for ordering details.

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. 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. Each institution should have a local operating procedure (LOP) for accessing COVID-19 testing through the county.

Institutions with low test rates and few or no cases should work to increase testing to at least 3 tests per 1,000 persons per week (~10/institution/week).

In general, testing should be prioritized for symptomatic patients who are at the highest risk of progression (i.e., over age 65 or medical comorbidities), at risk of having been exposed, or at high risk for transmission to fellow patients (e.g., inmate worker with multiple contacts, resident of dorm housing). Please see Table 6.2 for testing priorities among symptomatic patients.

Testing is also recommended for selected symptomatic patients, particularly in an outbreak. See Table 6.3 for testing priorities among asymptomatic patients.

In addition to education on prevention, patients need education regarding symptoms of COVID-19, availability of testing, and risks of getting infected.

DIAGNOSTIC TESTING FOR SYMPTOMATIC PATIENTS

  • 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.
  • When test supplies are sufficient, 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.
  • 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 recommend for explained symptoms such as typical allergic symptoms in a patient with a known history or other chronic conditions.

TESTING INDICATIONS FOR ASYMPTOMATIC PATIENTS

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 for progression (i.e., over age 65 or medical comorbidities). Repeat or serial testing may be valuable for patients with ongoing risk, and patients being released from isolation or quarantine. See Table 6.3.

In an outbreak setting, testing is recommended for close contacts, those at risk for progression, releases and transfers. Mass testing should be targeted to affected housing and the leading edge of the outbreak (i.e., new housing or new yards identified with cases). Epidemiologists in the Public Health Branch are available for consultation. Expanded testing for public health purposes (e.g., mass testing) should be explored even in the absence of a known outbreak.

SEVERE TESTING SHORTAGES

In the event of severe shortages of testing supplies, symptomatic patients at risk for progression and death are the highest priority. In the event of an outbreak with many symptomatic patients, if all patients cannot be tested due to shortages, testing should be used to identify the extent of the spread of infection in the population. For example, if multiple cases are coming from three separate housing areas, testing 5-10 patients from each area should identify the cause of the outbreak. Patients meeting the clinical case definition who reside in an area with an outbreak of COVID-19 should be isolated and managed as if they have COVID-19.

RESPIRATORY VIRUS TESTING CONSIDERATIONS

  • For patients presenting with symptoms of pneumonia, test for influenza and COVID-19 concurrently. Use RT-PCR for influenza testing for the rest of the 2019-2020 influenza season.
  • Clinicians should use their judgement in testing for other respiratory pathogens, including respiratory syncytial virus (RSV) and coccidioidomycosis (Valley Fever).
  • Repeat testing with NP + OP specimen(s) by PCR is recommended when clinical suspicion is high, but initial PCR testing is negative.

DIAGNOSTIC TEST INFORMATION

  • COVID-19 Testing
    • Order SARS-CoV-2 RNA (COVID-19), Qualitative Nucleic Acid Amplification Test (NAAT). Test Code 39448; preferred specimen is nasopharyngeal. Oropharyngeal swabs are acceptable. Order as ASAP test in EHRS to avoid delays in receiving results. More test details are below
      • NOTE: Full Personal Protective Equipment (PPE) required when obtaining specimens, to include N95 mask, eye protection, gown and gloves.
    • COVID-19 Point of Care (POC) Testing for facilities will be available in the future. Instructions and training will be provided in separate communications. All negative POC tests in symptomatic patients will require a RT-PCR to minimize potential false negatives.
  • Influenza Testing
    • Influenza A/B RNA, Qual, PCR; Test Code 16086; preferred specimen is nasopharyngeal swab.
    • Influenza A and B and RSV RNA Qual Real Time PCR; Test Code 91989; preferred specimen nasal or nasopharyngeal swab.
      • NOTE: Influenza specimen collectors usually use droplet precautions, but because all with ILI must be considered also for COVID-19, PPE for COVID-19 should be used as above.

RAPID INFLUENZA CLINICAL LABORATORY IMPROVEMENT AMENDMENTS (CLIA) WAIVED DIAGNOSTIC TEST (RIDT)

Please refer to RIDT ordering instructions (Appendix 4).

IMPORTANT: Influenza activity is now designated as “sporadic” throughout California and so RIDT should not be used for the rest of spring and summer 2019-2020 season. Use the RT-PCR for influenza testing for the duration of the 2019-2020 season.

  • When influenza is prevalent (transmission designated “Regional” or “Widespread” in your region by CDPH, CDPH Weekly Influenza Report or CDC Weekly Flu View rapid test kits for point of care influenza testing may be used to quickly identify influenza infections.
  • 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 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 Public Health Branch (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.

COVID-19 TESTING

Quest is accepting specimens for SARS-CoV-2 RNA, Qualitative Real-Time RT-PCR testing (Enter “covid” into the order search menu and choose: “CoV-2 RNA QUAL NAAT” in Cerner; 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).

Please refer to the COVID-19 Testing Fact Sheet on Lifeline.

RT-PCR specificity is >98% and sensitivity is 75-80% if done within the first 5 days of symptoms and with proper collection technique (see below).

STRATEGIES TO MAXIMIZE SENSTIVITY 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 shedding is highest early on in the course of the disease, when symptoms tend to be mild (first 5 days).
  • Use NP and OP collection together if possible: For initial diagnostic testing for COVID-19, the preferred specimen is a nasopharyngeal (NP) swab. Only one swab is needed and the NP specimen has the best sensitivity. Oropharyngeal (OP) swabs may also be obtained. NP or OP swabs should be collected in a Viral Culture Media (VCM) tube (green-cap provided by Quest). E-swabs (system kit with swab collection and medium all-in-one) may be used if VCM is not available. If available, M4, M4RT, M5 and M6 transport media and Universal Transport Medium (UTM) are acceptable. Saline can also be used as a transport media. Quest will be supplying red-top tubes with flocked NP swabs for this purpose.
    • Important: Leakage can be a concern. If possible, freeze samples upright at -20°C (-68°F) prior to pick up. This can minimize the leakage risk. Take caution to tighten the cap properly to avoid leakage.
  • Testing both NP and OP further increases sensitivity. If collecting both a NP and OP swab, they both can be put in the same media tube, as long as both tips are in liquid. When testing supplies/swabs are in short supply, OP and NP collection can be performed using the same swab.

    • Please 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 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 sec.) to absorb secretions.
    • Note: If symptomatic, patients may self-swab with an anterior nares collection. Do not use this collection in asymptomatic persons. The patient should be educated that NP is best, however, if NP is too challenging, a nares samples may be collected. ONLY FOAM SWABS can be used for NARES collection, for example: Puritan 6’ Sterile Standard Foam Swab w/ Polystyrene Handle.
  • Nares Collection instructions: Use a single foam swab for collecting specimens from both nares of a symptomatic patient. Insert foam swab into 1 nostril straight back (not upwards). Once the swab is in place, rotate it in a circular motion 2 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 listed in this guide.

    • Please note: Sputum inductions are not recommended as a means for sample collection.

SAMPLE SPECIFICATIONS FROM QUEST

  • Preferred specimen: NP swab or OP swab collected in VCM medium (green-cap) tube. If collecting two swabs, both can be put in one transport medium tube, as long as both tips are in liquid. If available, M4, M4RT, M5 and M6 transport media and UTM are acceptable. Saline can also be used as a transport media in red-top tubes supplied by Quest with NP flocked swabs for the purpose. Separate NP/OP Swab: Collect sample using a separate NP or OP swab for other tests (i.e., influenza test) requiring NP or OP swab. DO NOT COMBINE swabs in one tube for both COVID-19 and influenza test.
  • 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 five days.
  • COVID-19 is not a STAT test and a STAT pick-up cannot be ordered.
  • Turnaround time (TAT), published as 3-4 days, may be delayed initially due to high demand

PRECAUTIONS FOR SPECIMEN COLLECTION

ROLE OF COVID-19 SEROLOGY TESTING

There is currently no role for serology testing for COVID-19 immunity. Antibodies are detectable approximately 11 days after symptom onset. Antibody presence probably does indicate immunity. However, there are concerns with: possible cross-reactivity with other coronaviruses, the duration of immunity is unknown, and what threshold of antibody level confers immunity is unclear.

At this time, serology testing for COVID-19 is not recommended.

OTHER DIAGNOSTICS

Chest X-ray, CT scans, and lab testing (e.g., CBC, D-Dimer, CRP and Procalcitonin) are generally used in the inpatient setting but may assist in diagnosis when there is respiratory decline of uncertain etiology or in predicting progression to respiratory failure (See Clinical Manifestations section).

TREATMENT - Updated 4/21/2020

TABLE OF CONTENTS

  1. TREATMENT AT THE INSTITUTION
  2. TREATMENT OF PATIENTS ADMITTED TO THE HOSPITAL
  3. TREATMENT AFTER HOSPITALIZATION
  4. VACCINES

TREATMENT AT THE INSTITUTION

While certain medications show the potential to have modest benefit, at this point the treatment of COVID-19 is largely supportive. Key treatment considerations are below:

  • Oxygen: use if needed to maintain O2 saturation at or above 92% or near baseline.
  • Note: the use of routine nasal cannula or face tent is preferred to high-flow nasal cannula as the latter has the potential to aerosolize respiratory droplets.

  • Analgesia and antipyretics: consider acetaminophen and/or NSAIDs if needed and not contraindicated.
  • Bronchodilators: if bronchodilators are needed (i.e. reactive airway disease or wheezing and respiratory distress), nebulized medications should be avoided given the potential to aerosolize the virus; metered-dose inhalers (MDIs) are preferred and older clinical data suggest equivalence between MDIs and nebulized medications in patients who are able to use them.
  • IV fluids: IVFs are not needed for most patients but dehydration can occur due to nausea and vomiting or lack of appetite. Those in need for IVF due to inability to take oral hydration or in suspected sepsis should immediately be transferred to a higher level of care (HLOC).
  • Incentive Spirometry: If available. May help maximize lung capacity. No minimum volume required.
  • Corticosteroids: the clinic benefit of steroids is not clear and there is data for other respiratory pathogens suggesting prolonged viral shedding in patients receivingsteroids; currently steroids are not recommended and most US providers are not using them unless clinically indicated for another reason.
  • The CDC endorses no other treatments and NO OTHER TREATMENTS HAVE BEEN SHOWN TO BE SAFE AND EFFECTIVE THROUGH CONTROLLED CLINICAL TRIALS.

TREATMENT OF PATIENTS ADMITTED TO THE HOSPITAL

  • Patients with COVID-19 admitted to the hospital may be treated with a variety of agents.
  • The Infectious Disease Society of America (IDSA) recommends the following regarding use of medications for COVID-19:

TREATMENT AFTER HOSPITALIZATION

Patients may return from the hospital on oxygen and will need close medical attention. They should continue in isolation unless release criteria have been met. Patients may require more frequent surveillance than the scheduled twice a day monitoring depending on the patients clinical course and risk factors.

Patients may also be discharged on experimental medication regimens. Patients may not have been enrolled in a clinical trial while hospitalized, and discharged on treatment that is not recommended. Consult with the hospital attending or infectious disease specialist regarding continuance of the medication(s).

At this time, medications are recommended only if the patient is enrolled in a clinical trial. Providers will need to coordinate with the researchers to ensure adherence to treatment protocols and data collection requirements.

Penal Code 3502.5 states a prisoner may participate in a clinical trial of a drug if it has potential benefit.

Information on registered clinical trials for COVID-19 in the United States is available at ClinicalTrials.gov.

VACCINES

Anticipated to take 12-18 months. Clinical trials currently ongoing by Kaiser Permanente.

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:
    • Nebulizer Treatments
    • Continuous Positive Airway Pressure (CPAP)/ Bilevel Positive Airway Pressure (BiPAP)
    • Oxygen Therapy (high flow)
    • Pulmonary Function Tests (PFTs)
    • Cardiopulmonary Resuscitation (CPR)

The following is not generally considered AGP, but does require additional PPE due to close proximity of the health care staff to patient and risk or sneeze or cough:

  • Respiratory Specimen Collection (e.g., nasopharyngeal swabs)

Guidance for minimizing AGP risk is provided in detail in the Aerosol Generating Procedures Memo dated 4/8/20.

NOTIFICATIONS AND REPORTING

INITIAL NOTIFICATIONS

  • 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.

REPORTING

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. CCHCS Influenza Guidance Document 2019 on Lifeline (CDCR networking is required for access). 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.
  • Refer to the COVID-19 Case and Contact SharePoint Reporting tool (Appendix 5) for step-by-step instructions on using the tool and definitions.

INFECTION CONTROL AND PERSONAL PROTECTIVE EQUIPMENT (PPE) - Updated 4/27/2020

TABLE OF CONTENTS

  1. COVID-19 INFECTION CONTROL PRECAUTIONS
    1. TABLE 11.1: STANDARD, AIRBORNE, AND DROPLET PRECAUTIONS PPE
  2. PERSONAL PROTECTIVE EQUIPMENT (PPE) SCENARIOS FOR INFLUENZA-LIKE ILLNESSES (ILI), INFLUENZA, and COVID-19
    1. STAFF PPE FOR ILI / SYMPTOMATIC PATIENT
    2. STAFF PPE FOR SUSPECTED AND CONFIRMED COVID-19 CASE
    3. STAFF PPE FOR CONFIRMED INFLUENZA CASE
    4. STAFF PPE FOR SURVEILLANCE OF ASYMPTOMATIC CONTACT OF A CASE
    5. PPE FOR CONTACT OF A CONTACT
    6. N95 SHORTAGE GUIDANCE
    7. FACEMASKS, FACE SHIELDS, AND EYE PROTECTION GUIDANCE
    8. GOWNS GUIDANCE
    9. FACE COVERINGS GUIDANCE
    10. TABLE 11.2: RECOMMENDED PPE FOR INCARCERATED/DETAINED PERSONS AND STAFF IN A CORRECTIONAL FACILITY DURING THE COVID-19 RESPONSE

COVID-19 INFECTION CONTROL PRECAUTIONS

As a general principle, staff and inmates should practice standard precautions at all times, and staff should be familiar with different types of transmission-based precautions to protect themselves. See Table 11.1.

TABLE 11.1: STANDARD, CONTACT, DROPLET, AIRBORNE PRECAUTIONS AND PPE USE

TYPES OF PRECAUTIONS. Standard Precautions and Transmission-Based Precautions. Standard - Hand hygiene, cough etiquette, 6 ft. social distance. Use PPE (gloves, mask, gown*, eye protection) for anticipated exposure. All patients. Contact - Standard precautions plus Gown* and gloves for all interactions that may involve contact with patient or patient's environment. Droplet - Standard precautions plus Gown*, one pair nonsterile gloves, mask, and eye protection. Airborne - Standard precautions plus One pair nonsterile gloves, mask: N95 respirator** or PARP, and eye protection. COVID-19 confirmed or suspect or ILI patients (in isolation)

* 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

PERSONAL PROTECTIVE EQUIPMENT (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 period 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

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. A N95 Respirator, gloves, gown, face shield or other eye protection are recommended. A 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.

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.

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.

PPE FOR CONTACT OF A CONTACT

Standard precautions are sufficient for the patient who is a contact of a contact.

For further information on standard, contact, and airborne precautions:
Refer to HCDOM, Chapter 3 Article 8, Communicating Precautions from Health Care Staff to Custody Staff and
https://www.cdc.gov/coronavirus/2019-ncov/infection-control/infection-prevention-control-faq.html

N95 SHORTAGE GUIDANCE

  • N95 and other disposable respirators should not be shared by multiple HCWs. Use personal identification label to minimize potential cross-contamination if re-use.
  • 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.
  • Existing CDC and National Institute for Occupational Safety and Health (NIOSH) guidelines recommend a combination of approaches to conserve supplies while safeguarding health care workers in such circumstances: https://www.cdc.gov/niosh/topics/hcwcontrols/recommendedguidanceextuse.html and https://www.cdc.gov/coronavirus/2019-ncov/hcp/respirators-strategy/index.html.
  • Contingency strategies for optimizing the supply of N95 respirators:
    • Temporarily suspend annual fit-testing of respirators, per interim guidance from 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 prior to 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 reuse of 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:
    • Powered air-purifying respirator (PAPR) which is reusable and 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 manufacturer’s reprocessing instructions prior to re-use.
    • 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 manufacturer’s reprocessing instructions prior to re-use.
  • 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.

GOWNS GUIDANCE

  • 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.

FACE COVERINGS GUIDANCE

  • This guidance is not a substitute for healthcare and custody staff following 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.
  • 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.
  • Discard cloth masks that:
    • No longer cover the nose and mouth
    • Have stretched out or damaged ties or straps
    • Cannot stay on the face
    • Have holes or tears in the fabric

CONTROL STRATEGY FOR SUSPECTED AND CONFIRMED CASES OF COVID-19 - Updated 5/11/2020

TABLE OF CONTENTS

  1. INFLUENZA-LIKE ILLNESS (ILI) CASE AND OUTBREAK IDENTIFICATION
  2. CHECKLIST FOR IDENTIFYING COVID-19 SUSPECTS
  3. ILI/ SUSPECTED COVID-19 STRATEGIC CONTROL STEPS
    1. TABLE 12.1: ISOLATION ROOMS AND PPE
  4. ISOLATION
  5. MEDICAL HOLD
  6. CONTACT INVESTIGATION
  7. MONITORING PATIENTS WITH SUSPECTED OR CONFIRMED COVID-19
    1. FIGURE 12.1: ALGORITHM FOR EVALUATION AND TREATMENT OF SUSPECT COVID-19 CASES
  8. RESPONSE TO A COVID-19 OUTBREAK
  9. CRITERIA FOR RELEASE FROM ISOLATION CONFIRMED COVID-19 CASES
    1. FIGURE 12.2: ALGORITHM FOR RELEASE FROM ISOLATION CRITERIA FOR PATIENTS WITH COVID-19
  10. CRITERIA FOR RELEASE FROM ISOLATION CONFIRMED INFLUENZA CASES
  11. CLEANING SPACES WHERE SUSPECT AND CONFIRMED COVID-19 CASES SPENT TIME

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 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.

Test patients per the Diagnostic Testing prioritization.

Test Refusals:

  • 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. For the control strategy for confirmed cases of influenza, see CCHCS Seasonal Influenza Infection Prevention and Control Guidance (CDCR networking is required for access).

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.
  • 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 for 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). HCWs should use a surgical/procedure mask, unless N95 respirators are in abundant supply.
  • When possible, assign dedicated health care staff 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 PAPR are in abundant supply), gloves, gown, and face shield covering sides and front of face or goggles.
  • 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, custody or HCW will use an N-95 mask for symptomatic patients. Limit number of staff that have contact with suspected and/or confirmed cases.
    • Assess and treat as appropriate soon-to-be released patients with suspected COVID-19 and make direct linkages to community resources to ensure proper isolation and access to medical care. Notify 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. Follow the CCHCS Influenza Guidance document for general ILI and influenza management (CDCR networking is required for access).

ISOLATION

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. provider (see Release from Isolation). 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.
  • As a last resort, when a negative pressure room or a private single room is not available, groups of symptomatic patients can be cohorted in a separate area or facility away from well-patients. Possible areas to cohort patients could be an unused gym or section of a gym or chapel. When it is necessary to cohort patients in a section of a room or area with the general population of well-patients (e.g., dorm section) there should be at least 6 feet (3.6 feet minimum for severe space shortages) between symptomatic patients and the well patient population. However, symptomatic patients with ILI and no diagnosis should maintain social distancing between each isolated individual if at all possible. 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 – Transfer should be avoided due to the potential to introduce infection to another facility; proceed only if no other options are available.

  • If the ideal choice does not exist in a facility, use the next best alternative.

Provide individuals under medical isolation with 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 sick 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. All persons entering the isolation room or areas need to follow the required transmission-based precautions.
  • When possible, assign dedicated health care staff to provide care to suspected or confirmed cases.
  • If a patient with ILI or confirmed COVID-19 or influenza must be moved out of isolation, ensure a surgical or procedure mask is worn during transport. Staff shall wear an appropriate respirator (or surgical mask in times of shortage) during vehicular transport of these patients.
  • Facilities should also ensure that plans are in place to communicate information about suspect and confirmed influenza cases who are transferred to other departments (e.g., radiology, laboratory) or another prison or county jail. Ensure communication and a plan before transfer. (Refer to Inmates Releasing From Institutions During COVID-19 section)

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.

MEDICAL HOLD

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
  • Separate and isolate any symptomatic contacts.
  • Initiate surveillance measures detailed in the monitoring section.

Any persons identified through the contact investigation to have symptoms or test positive for COVID-19, should be immediately isolated and masked and reported to the headquarters PHB: CDCRCCHCSPublicHealthBranch@cdcr.ca.gov.

If COVID-19 case is confirmed, initiate a contact investigation.

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 during the case-patient’s infectious period during which other patients and staff may have been exposed (from 2 days [48 hours] prior to the date of symptom onset to the date the patient was isolated).
  • 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
CLOSE CONTACT
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)
  • Use the COVID-19 Contact Investigation Tool (Appendix 6) and the Index Case-Patient Interview Checklist (Appendix 7) and to guide and document the interview and identification of the case-patient’s close contacts.
    • All symptomatic 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. 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.
  • Initiate and submit a contacts line list to the Public Health Branch (PHB) in the COVID-19 SharePoint: https://cdcr.sharepoint.com/sites/cchcs_ms_phos (see Reporting section – CDCR networking is required for access).
  • 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).

Institutional leadership is responsible for notifying the OEHW and RTWC of the possibility of employees exposed to COVID-19.

MONITORING PATIENTS WITH SUSPECTED OR CONFIRMED COVID-19

  • Patients with suspected or confirmed (symptomatic and asymptomatic) 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. Nursing assessments will include, but are not limited to:
    • Temperature monitoring
    • 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
    • Rapid pulse
    • Rapid breathing
    • Labored breathing
    • 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 of the document.
    • 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 QM COVID-19 Risk Registry 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:
    • Temperature monitoring
    • 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, only if symptoms develop
    • Please refer to the Quality Management (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 ensure that rounding is occurring as required across shifts, as well flags certain symptoms, such as fever.

RESPONSE TO A COVID-19 OUTBREAK

When one or more laboratory confirmed cases of COVID-19 have been reported, surveillance should be conducted throughout the institution to identify close contacts. The institutional PHN and NCPR will confer and implement the investigation. A standardized approach to stop COVID-19 transmission is necessary by identifying people who have been exposed to a laboratory confirmed COVID-19 case.

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 duties in healthcare settings. 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 CME, PHN, CNE, Director of Nurses (DON), 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 Local Health Department 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.

CRITERIA FOR RELEASE FROM ISOLATION CONFIRMED COVID-19 CASES

  1. For individuals with asymptomatic or symptomatic laboratory confirmed COVID-19 under isolation, considerations to discontinue Transmission-Based Precautions include clinical AND testing criteria. Clinical criteria should be met first, then test the patient for COVID-19 related virus by RT-PCR. See Algorithm.
    1. CLINICAL CRITERIA::
      1. At least 5 days after resolution of fever without use of antipyretic medication (if applicable) AND
      2. At least 10 days**(minimum) from after the date of the initial positive test AND
      3. Improvement in illness signs and symptoms
    2. AND once clinical criteria above are met:

    3. TESTING CRITERIA: One negative RT-PCR
      1. If the test is negative, release the patient from isolation with a face covering
      2. If the test is still positive or equivocal, consult the CME, consider re-testing OR use clinical criteria
  2. In cases where there is severe shortage of testing materials/swabs, then the clinical criteria alone may be used:
    1. At least 5 days after resolution of fever without use of antipyretic medication (if applicable) AND
    2. At least 14 days**(minimum) from after the date of the initial positive test AND
    3. Improvement in illness signs and symptoms
  3. **CMEs may choose to lengthen the criteria time for symptom resolution to 14 days or beyond at their discretion.

  4. 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.
    1. 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.
    2. Resolution of cough, is not necessary for release, however people with residual cough should wear a face covering once released, until completely without cough.

Check for updates: https://www.cdc.gov/coronavirus/2019-ncov/hcp/disposition-hospitalized-patients.html

CRITERIA FOR RELEASE FROM ISOLATION CONFIRMED INFLUENZA CASES

Remain in isolation for 7 days from symptom onset and 24 hours after resolution of fever and respiratory symptoms.

CLEANING SPACES WHERE SUSPECT AND CONFIRMED COVID-19 CASES SPENT TIME

(See CDC page on this topic)

  • 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.

Cleaning after aerosol generating procedures: Consult the CDC for updates: https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-faq.html

After discharge, terminal cleaning may be performed by 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.
    • For disinfection, most common EPA-registered household disinfectants should be effective. Choose cleaning products based on security requirements within the facility.
      • Consult a list of products that are EPA-approved for use against the virus that causes COVID-19. 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:
  • Electronics cleaning and disinfection
    • 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

TABLE OF CONTENTS

  1. SURVEILLANCE OF ASYMPTOMATIC CONTACTS OF COVID-19 CASES
  2. QUARANTINE
  3. PATIENT SURVEILLANCE WHILE IN QUARANTINE
  4. RELEASE FROM QUARANTINE

SURVEILLANCE OF ASYMPTOMATIC CONTACTS OF COVID-19 CASES

Patients with exposure to a confirmed or suspected COVID-19 case shall be placed in quarantine. If a suspected COVID-19 case tests negative for COVID-19 and clinicians release the suspected patient from COVID-19 protocols, quarantined patients should also be released.

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 Chief Medical Executive (CME). Quarantine should be implemented for patients who are contacts to a COVID-19 case and are not ill.

  • Quarantined patients shall be placed on medical hold.
  • 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 N-95 respirator or other approved respirator or a surgical/procedure mask in N95 shortage).
  • Quarantine does not include restricting the patient to his own 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 patients not in quarantine.
  • Nursing staff are 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 severe 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.
  • 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) and with 3 days of surveillance recommended after exit from the possible exposure. Out-to-court and medical visits should be evaluated on a case by case basis. With CME or CME designee 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 the patient is in quarantine or was on hold for influenza-like illness (ILI) exposure and they have agreed to see the patient.

Follow the guidance regarding spacing and rooms in the Isolation section of this document.

To reduce the number of health care staff potentially exposed to any new cases of influenza, limit the number of health care staff (when possible) who interact with quarantined patients.

  • In the event of a more severe outbreak, involving multiple suspected or confirmed cases or involving neighboring community, visitor entry and patient visits for well patients may be greatly restricted or even temporarily halted, if necessary.
  • If one or more patients in quarantine develops symptoms consistent with COVID-19 infection, follow recommendations for isolation for 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.

  • All quarantined patients shall be evaluated on a twice daily basis, including weekends and holidays. If staff or resource shortages are severe, once a day testing is the minimum.
  • 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 microorganism) 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 necessitates a provider evaluation:
      • Chills without fever or subjective fever
      • Severe/New/Unexplained fatigue
      • Malaise (difficult to describe unpleasant feeling of being ill)
      • Sore throat
      • Myalgia or Arthralgia
      • Gastrointestinal symptoms such as: nausea, vomiting, diarrhea, or loss of appetite
      • URI symptoms such as nasal or sinus congestion and rhinorrhea
      • Loss of sense of smell or taste
  • 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 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 ILI symptoms must be assessed daily, treated, and isolated as soon as possible to prevent further spread of influenza in the facility.

RELEASE FROM QUARANTINE

For COVID-19, the period of quarantine is 14 days from the last date of exposure of a confirmed case, because 14 days is the longest incubation period seen for similar coronaviruses. 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. Quarantine must be extended by 14 days for every new exposure.

Check for updates From CDC:
https://www.cdc.gov/coronavirus/2019-ncov/faq.html#basics

CONTROL STRATEGY FOR CONTACTS TO CONTACTS

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 DURING COVID-19

TABLE OF CONTENTS

  1. INSTRUCTIONS FOR PATIENTS RELEASING WITH COVID-19 RESTRICTIONS
  2. CASE MANAGEMENT/DISCHARGE NOTIFICATION
  3. ACTIONS UPON RELEASE FOR CONFIRMED OR SUSPECTED COVID-19 CASE
  4. MANDATORY “NOTIFICATION FORM” FOR CONFIRMED OR SUSPECTED COVID-19 CASE
  5. HEALTH EDUCATION INSTRUCTIONS FOR ALL INMATES

INSTRUCTIONS FOR PATIENTS RELEASING WITH COVID-19 RESTRICTIONS

Patients being released from the institutions at any time who are currently quarantined or in isolation for COVID-19, 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 of these patients, which includes discharge notification.

It should be noted that during this time, an unprecedented number of patients are being released who are on quarantine or isolation for COVID-19. The PHN will require additional assistance from nursing staff 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 in advance of patient release:

  • Obtain the following information prior to the patient’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)
    • Identify the mode of transportation for leaving the institution (e.g., private car, public transportation, etc.) in case plans need to be made in advance to safely transport a patient who is on quarantine or isolation for COVID-19
    • Identify other people in the home, residence, or facility who may be at risk for exposure, etc.
    • The LHD should be given an advance notice of the patient’s plan at release so planning can be done to implement effective isolation or quarantine

ACTIONS UPON RELEASE FOR CONFIRMED OR SUSPECTED COVID-19 CASE

When a patient who is a confirmed or suspected COVID-19 case is released to the community, per California Code of Regulations, Title 17, §2500, the following actions shall be completed:

  • 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 Confirmed or Suspected COVID-19 Case” below for the required notification form to complete and the procedure for the notification
  • The patient shall be masked at all times after 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)
      • The discharge notification for the patient will change and the LHD and parole/probation will need to know the updated status before the patient is released

MANDATORY “NOTIFICATION FORM” FOR CONFIRMED OR SUSPECTED COVID-19 CASE

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 inmates who are on medical isolation or quarantine for COVID-19 orders upon release.

The “notification form” (Appendix 9) shall be completed in its entirety, as it includes essential information including the inmate’s COVID-19 status, COVID-19 test results, the inmate’s destination (e.g., a congregate facility such as a drug treatment program), and if applicable, the parole or probation officer’s contact information

  • IMPORTANT: All “notification forms” sent to LHDs, and if applicable, the parole or probation officer, must include a “cc” to the following email address: CDCRCCHCSPublicHealthReleaseNotifications@cdcr.ca.gov
    • 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 CD controller, followed up by sending a fax or confidential email with the “notification form” (Appendix 9)
    • The LHD’s CD controller contact information can be found on Lifeline http://lifeline/HealthCareOperations/MedicalServices/PublicHealth/Pages/Coronavirus.aspx; click on “CDC/External” tab and then select “County Health Departments”
    • 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
    • Notify the parole or probation officer (if applicable)
      • Notification should be made by telephone and followed by sending a confidential email with the “notification form” (Appendix 9) 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 patient doesn’t have a personal health care provider and becomes symptomatic, etc.
  • The patient’s COVID-19 discharge materials should 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

REFERENCES

  1. Influenza and Other Respiratory Viruses Weekly Report. California Influenza Surveillance Program.
    https://www.cdph.ca.gov/programs/cid/dcdc/cdph%20document%20library/immunization/week2019-2009_finalreport.pdf
  2. CDC Tests for COVID-19: https://www.cdc.gov/coronavirus/2019-ncov/about/testing.html
  3. Interim Clinical Guidance for Management of Patients with Confirmed Coronavirus Disease (COVID-19): https://www.cdc.gov/coronavirus/2019-ncov/hcp/clinical-guidance-management-patients.html
  4. Interim Infection Prevention and Control Recommendations for Patients with Suspected or Confirmed Coronavirus Disease 2019 (COVID-19) in Healthcare Settings:
    https://www.cdc.gov/coronavirus/2019-ncov/infection-control/control-recommendations.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fcoronavirus%2F2019-ncov%2Fhcp%2Finfection-control.html
  5. California Department of Corrections and Rehabilitation California Correctional Health Care Services, Health Care Department Operations Manual. Chapter 3, Article 8; 3.8.8: Communication Precautions from Health Care to Custody Staff.
    https://cchcs.ca.gov/wp-content/uploads/sites/60/HC/HCDOM-ch03-art8.8.pdf
  6. Recommended Guidance for Extended Use and Limited Reuse of N95 Filtering Facepiece Respirators in Healthcare Settings:
    https://www.cdc.gov/niosh/topics/hcwcontrols/recommendedguidanceextuse.html
  7. United States Department of Labor, Occupational Safety and Health Administration
    https://www.osha.gov/laws-regs/regulations/standardnumber/1910/1910.134
  8. Public Health Outbreak Response System (PhORS) http://phuoutbreak/
  9. Interim Guidance for Discontinuation of Transmission-Based Precautions and Disposition of Hospitalized Patients with COVID-19 https://www.cdc.gov/coronavirus/2019-ncov/hcp/disposition-hospitalized-patients.html
  10. Centers for Disease Control Coronavirus Disease 2019 (COVID-19) Healthcare Professionals: Frequently Asked Questions and Answers
    https://www.cdc.gov/coronavirus/2019-ncov/hcp/faq.html
  11. Centers for Disease Control Coronavirus Disease 2019 (COVID-19) Healthcare Professionals: Frequently Asked Questions and Answers About: When can patients with confirmed COVID-19 be discharged from the hospital?
    https://www.cdc.gov/coronavirus/2019-ncov/faq.html#basic
  12. List N: Disinfectants for Use Against SARS-CoV-2: https://www.epa.gov/pesticide-registration/list-n-disinfectants-use-against-sars-cov-2
  13. Dr. David Sears, UCSF Clinical Guidelines for Evaluation and Treatment of Suspected and Confirmed Cases of COVID-19 in Correctional Facilities
  14. Interim Guidance on Management of Coronavirus Disease 2019 (COVID-19) in Correctional and Detention Facilities https://www.cdc.gov/coronavirus/2019-ncov/community/correction-detention/guidance-correctional-detention.html
  15. Forst, Arnold, COVID-19 (SARS-CoV-2) epidemic www.louisvillelectures.org/imblog/2020-coronavirus/forest-arnold

APPENDIX 1: CORONAVIRUS DISEASE 2019 (COVID-19) CHECKLIST

1. RECOGNITION, REPORTING, AND DATA COLLECTION
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).

APPENDIX 2: DROPLET PRECAUTIONS CHECKLIST

APPENDIX 3: HOW TO DOFF AND DON PPE

Sequence for Donning Personal Protective Equipment (PPE)

APPENDIX 4: HOW TO ORDER RAPID INFLUENZA DIAGNOSTIC TESTING IN THE EHR

APPENDIX 5: COVID-19 CASE AND CONTACT SHAREPOINT REPORTING TOOL - Updated 4/27/2020

APPENDIX 6: COVID-19 INDEX CASE - PATIENT CONTACT INVESTIGATION TOOL - Updated 5/04/2020

APPENDIX 7: COVID-19 INDEX CASE - PATIENT INTERVIEW CHECKLIST - Updated 5/04/2020

TABLE OF CONTENTS

  1. INTERVIEW CHECKLIST

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) to identify individuals who had close contact (within 6 feet and prolonged [generally ≥10 minutes]) with the patient or direct contact with any of the patient’s secretions while infectious.

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:

Interview Objectives

  • 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

Pre-Interview Activities

  • 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.

INTERVIEW CHECKLIST

Personal Information

  • Full name
  • Aliases

Symptoms / Onset Date

  • Cough (new onset or worsening)
  • Shortness of breath (dyspnea)
  • Fever >100.4°F (38°C)
  • Subjective fever (felt feverish)
  • Other symptoms

Contact Information
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
  • Family visits
  • Visitors

Routine Activities and Assignments

  • Work
  • Vocational training
  • Educational classes
  • Dining areas
  • Library time
  • Group activities
  • Regular appointments (medical, dental, legal)
  • Committee presentation
  • Religious, worship or spiritual activities
  • TV room / day room
  • Exercise
  • Sports team participation
  • Other

Notes
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

  1. Receive Notification from institution(s), name and contact information of suspected positive COVID-19 patient.
  2. Nurse Consultant gathers available information on the patient
    1. Nurse Consultant contacts the patient for interview
      1. Patient provides evidence of Positive test if available
      2. Patient provides dates of symptom onset
      3. Patient provides the dates of the work schedule.
    2. Determine initial dates of the infectious period
      1. Review patient interview
    3. Contact the local Public Health Department to determine positive status if needed
      1. Confirm the status of Patients test
      2. Refine infectious period if necessary
  3. Determine if this referral is a valid positive case for COVID-19
    1. Verified positive continue on as a case
    2. Verified negative; conclude the investigation

PART 2 VERIFIED POSITIVE COVID-19 CASE

  1. Develop plan for investigation
    1. Prepare contacts list based on the refined infectious period
    2. Prioritize contacts
    3. Conduct contact assessments
  2. Determine need to expand or conclude an investigation based on evaluation of the information gathered.
    1. Expand investigation
      1. Repeat steps in Part 1 (steps 1-3 for each contact)
    2. Conduct contact assessments
      1. 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

APPENDIX 10: COVID-19 POWERFORM INSTRUCTIONS; SCREENING, ISOLATION, AND QUARANTINE SURVEILLANCE - Updated 5/22/2020

APPENDIX 11: LOCAL HEALTH DEPARTMENT CONTACT LIST