COVID-19 and Seasonal Influenza: Interim Guidance for Health Care and Public Health Providers

This guidance is intended for use by employees of California Correctional Health Care Services (CCHCS) and the California Department of Corrections and Rehabilitation (CDCR). The purpose is to provide an integrated approach to preventing, monitoring, and containing outbreaks of acute respiratory infection caused by SARS-CoV-2 (the virus that causes COVID-19) and influenza viruses. This guidance is based on standards and recommendations put forth by the federal Centers for Disease Control and Prevention (CDC) and the California Department of Public Health (CDPH). It includes information on pharmaceutical and non-pharmaceutical prevention strategies, including infection control, respiratory protection, and vaccination; testing and treatment; and outbreak management strategies including isolation, quarantine and mass testing. For additional information, please see CDC’s “Interim Guidance on Management of Coronavirus Disease 2019 (COVID-19) in Correctional and Detention Facilities” and “Seasonal Influenza Vaccination Resources for Health Professionals: Information for the 2021-22 Influenza Season.” Links are given to publicly-available information when possible; however, some links require CDCR network access. This guidance is continuously updated; the latest revisions are summarized in the “Record of Changes.”

RECORD OF CHANGES


9/02/21Environmental Infection Control: Added information about cleaning, such as table on “Cleaning Procedures for Specific Surface Types.”

8/27/21Prevention, Preparedness, and Reopening: Updated to include recommendations on re-opening programs that involve gatherings.

8/27/21Appendix 23: Planning Checklist for Safe Gatherings has been added.

8/27/21 – Appendix 1 – COVID-19 Outbreak Response Checklist for Institutional Leaders and Public Health Providers, Appendix 15 – Provider Script – Offering Cell Housing to Patients at High Risk of Severe COVID-19, and Appendix 18 – COVID-19 Operational Preparedness for Facility Leadership and Incident Command were removed.

8/27/21Appendix 16: Replaced link to May 10, 2021, memo with Appendix from that memo reformatted to fit onto single page.

8/27/21 – Introduction: Updated link to CDC influenza information.

8/10/21 – Introduction: Clarified audience for and scope of interim guidance, added links, explained need for CDCR network access for some links.

7/28/21Inmates Releasing From Institutions – COVID-19 Testing, Notification, Health Education, And Vaccine Instructions: Revised to reflect deletion of Appendix 9.

7/28/21 – Appendix 9: Deleted “Memo Template for Notification of COVID-19 Cases and Contacts Released to the Community” as notification of release is now made electronically to local health departments.

ARCHIVED RECORD OF CHANGES

6/29/21Vaccination: Updated information concerning Johnson & Johnson (Janssen) vaccine, patients with rheumatologic/autoimmune diseases, COVID-19 vaccine compatibility with other vaccines, and myocarditis/pericarditis.

6/23/21Appendix 13: Replaced with updated (6/18/2021) Screening and Testing Matrix for Patient Movement.

6/09/21Appendix 13: Replaced with updated (6/2/2021) Screening and Testing Matrix for Patient Movement.

5/24/21Appendix 16: Replaced 7/16/2020 “COVID-19 REQUIRED PPE CHECKLIST” poster with link to 5/10/2021 memo on PPE (CDCR networking is required for access).

5/21/21Treatment: Removed mention of respiratory pathogens other than SARS-CoV-2 and influenza viruses; explained why bamlanivimab monotherapy should no longer be used; added details about bamlanivimab/etesevimab combination therapy; deleted mention of in-hospital treatment; added cross-reference to Clinical Manifestations chapter concerning “Long COVID”/ “PASC.”

4/26/21Appendix 13: Replaced with updated (4/26/2021) Screening and Testing Matrix for Patient Movement.

4/16/21Vaccination: Explained “pause” in use of Johnson & Johnson (Janssen) COVID-19 vaccine; added material on pregnancy, lactation, and mammography; clarified that COVID-19 vaccines can be given to people who have had COVID-19.

4/08/21
Infection Control and Personal Protective Equipment: Updated and clarified N95 requirements for inmate workers and staff; added KN95s as an option whenever surgical masks are worn; clarified expectations for eye protection; added PPE expectations for confirmed COVID-19 cases, and updated links to the new Recommended PPE for Staff and Inmates memo.
Control Strategies for Contacts to Cases: Clarified expectations that a patient should be quarantined immediately (i.e., as soon as possible, and no later than 24 hours) after they are recognized as a close contact; changed frequency of nursing surveillance on quarantined patients from “twice” to “at least once” daily.
Control Strategies for Suspected and Confirmed Cases: Clarified the meaning of “immediately” for isolating patients as “as soon as possible, and no later than 24 hours after recognition.”

3/19/21: Moved the following appendices from the Interim Guidance to the Lifeline COVID-19 Resources page under the Internal Resources tab (for historical purposes only, they will not continue to be updated): Bamlanivimab Resource Packet (Appendix 4), Sample LOP (Appendix 12), Rapid Point of Care Antigen Test Information (Appendix 14), CCHCS COVID-19 Testing: NAAT and POC Antigen Explained (Appendix 17), and Case Entry Form for Re-Infection Evaluation (Appendix 21).

3/09/21Vaccination: Updated the narrative and Table 3.1 with information on the Johnson & Johnson vaccine; updated Table 3.2 to mirror the 3/5/21 CDC’s Interim Clinical Considerations for Use of COVID-19 Vaccines Currently Authorized in the United States table; added that those who have had COVID-19 in the last 90 days can receive the vaccine prior to 90 days as long as their acute infection has resolved; and added the definition of fully vaccinated (14 days after the last recommended dose of COVID-19 vaccine).

3/02/21Notifications and Reporting and Appendix 5: Removed requirement for resolving confirmed cases in SharePoint.

2/26/21 – Control Strategies for Suspected and Confirmed Cases: Added a paragraph emphasizing the importance/need for educating patients when released from isolation about the 90-day presumed immunity period, infectiousness, development of symptoms, safety for return to housing, and that they will not need quarantine or surveillance testing, but still may need to test prior to transport.

2/23/21 – Treatment: Updated to clarify there is no monthly requirement for COVID-19 post-hospitalizations follow-ups.

2/22/21 – Appendix 22 mRNA Vaccine Administration Errors and Deviations (Appendix 22): Added an appendix with CDC recommendations for administration errors and deviations of site/route, intervals, mixed series, dosage, storage and handling, diluent, and age.

2/22/21 – Inmates Releasing from Institutions – COVID-19 Testing, Notification, Health Education, and Vaccine Instructions: Updated to include the protocol and educational materials (including a blank vaccination card) for patients releasing who have either started the COVID-19 vaccine series and need a 2nd dose or have not been vaccinated, including instructions of where to find the educational materials in CERNER and the statewide website where patients can find vaccine locations.

2/19/21 – Testing: Updated guidance for expanded weekly testing for inmate workers including culinary, PIA, healthcare environments, porters and janitors, and plant operations; updated guidance on surveillance testing – testing for groups without ongoing outbreaks or quarantines, clarified the definition of an exposed contact; updated guidance on CDPH reinfection data to reflect that exposure/contact investigation information will no longer be a requirement for every re-positive, but rather will be an inquiry on an as needed basis; clarified guidance regarding broad-based institution-wide testing; and revised Table 6.3 for consistency with updated testing guidance.

2/19/21 – Summary of the Infectious Diseases Society of America (IDSA) Testing Recommendations (Appendix 8): Add an appendix summarizing the IDSA’s 12/23/20 recommendations for NAAT and RNA testing and specimen collection.

2/19/21 – Treatment: Clarified that if MCAB therapy is given after the first COVID-19 vaccine dose, a 90-day waiting period before the second COVID-19 vaccine dose is indicated.

2/19/21Vaccination and Control Strategies for Contacts to Cases: Revised to clarify that inmate-patients who are vaccinated must still be quarantined if they are exposed to COVID-19.

2/18/21 – Recommendation for Pharmacologic Management of Patients with COVID-19 Based on Disease Severity table (Table 8.2): Updated monoclonal antibody treatment (MCAB) section Table 8.2 to reflect the updated (2/11/21) NIH Recommendations for Pharmacologic Management table.

2/18/21 – Control Strategies for Suspected and Confirmed Cases: Clarified the definition of exposed contact for contact investigations.

2/17/21 – Treatment: Added the bamlanivimab/etesevimab drug combination to the list of EUA approved monoclonal antibody treatments; added a link to the Bamlanivimab Resource Packet (Appendix 4); added the recommendation that patients who have received monoclonal antibody treatments wait 90 days before getting vaccinated, and that those who are already vaccinated can receive monoclonal antibody treatments at any time after vaccination if they test positive and are symptomatic.

2/09/21 – CCHCS COVID-19 Vaccines – Information and Side Effects (Table 3.1): Updated the table to reflect that the second dose of Moderna, like Pfizer, may be given up to 4 days early if necessary, both the Moderna and Pfizer should be given within 6 weeks from the first dose, and that early doses do not need to be repeated (the two dose regimen is adequate).

2/08/21 – Bamlanivimab Resource Packet (Appendix 4): Added the 1/28/21 EUA Update Summary to the packet.

2/05/21 – Vaccination: Added links to the Vaccine Clinic Information and Vaccine Provider Toolkit, available on the COVID-19 Vaccine Lifeline webpage (CDCR networking is required for access).

2/04/21 – COVID-19 and Seasonal Influenza PowerForm Instructions; Screening, Isolation, and Quarantine Surveillance (Appendix 10): Clarified language that the surveillance power form is to be used for patients experiencing influenza symptoms, and added-Droplet precautions as another order to be placed when placing the surveillance round order for the patient presenting with influenza like illness.

1/27/21 – Treatment: Added the importance of appropriate medical care and frequent follow up after release from isolation.

1/19/21 – Bamlanivimab Resource Packet (Appendix 4): Created an appendix with materials for monoclonal antibody use including instructions on how to order, consent form, supply checklist, referral form, and more.

1/19/21 – Treatment: Added link to the COVID-19 Monitoring Registry with new Bamlanivimab qualifying identification and changed text to reflect abundance of the medication and liberalization of use to all three tiers.

1/19/21 – Vaccination and Table 3.4: Added information on vaccinating immunocompromised patients; updated the narrative and Table 3.4 to align with CDC guidelines including now vaccinating COVID-19 asymptomatic quarantined persons regardless of exposure status; added direction on COVID-19 testing prior to vaccination.

1/15/21 – Testing: Updated information regarding CDPH re-infection study criteria.

1/13/21 – Vaccination section: Updated COVID-19 vaccine information and added recommendations on TB testing and COVID-19 vaccine.

1/13/21 – COVID-19 Screening and Testing Matrix for Patient Movement (Appendix 13): Eliminated pre-transfer quarantine unless the patient is unable to quarantine at the receiving location or refuses; Added the movement quarantine requirement of POC test within 24 hours if a pre-transfer POC was not done; decreased the maximum cohort size for movement quarantine to 4 persons; Patients with symptoms, positive POC, or positive PCR/active cases do not move; Specified that patients with a COVID-19 risk score of 3 or more must be housed in celled-housing and limits the available institutions where they can be transferred.

1/06/21 – Treatment: Added information on bamlanivimab allotment and updated to include on-site infusion administration.

1/06/21 – Triage of Persons Presenting for mRNA COVID-19 Vaccination table (Table 3.2): Added pregnancy and lactation conditions, added the presence of a “moderate/severe illness” into the precaution column.

1/04/21 – Triage of Persons Presenting for mRNA COVID-19 Vaccination (Table 3.2): Added additional information to the table and included the ingredients in the COVID-19 vaccines.

12/29/20 – Vaccination: Added information on vaccine side effects to help differentiate side effects from symptoms of infection and added information on anaphylactic reactions including statistics, how to minimize the risk, and a link to CDC guidance on Preparing and Potential Management of Anaphylaxis at COVID-19 Vaccination Sites.

12/29/20 – Reported Symptoms of Influenza, COVID-19, and Respiratory Syncytial Virus (RSV) table (Table 5.1): Added information on vaccine side effects to help differentiate side effects from symptoms of infection.

12/29/20 – Control Strategies for Suspected and Confirmed Cases: Added information on vaccine side effects to help differentiate side effects from symptoms of infection.

12/23/20 – Control Strategies for Suspected and Confirmed: Added a recommendation for ambulatory oxygen saturation check to uncover silent hypoxia and expanded release from isolation criteria.

12/22/20 – COVID-19 Case and Contact SharePoint Reporting Tool (Appendix 5): Eliminated the reporting of re-positive tests >90 days; added instructions for resolving cases in patients returning after release/parole with active COVID; added instructions for deleting records.

12/22/20 – Vaccination: Added information on COVID-19 vaccination including a table on triaging persons presenting for the Pfizer vaccine and a table with information and side effects.

12/21/20 – Primary Prevention and Preparedness: Added information on COVID-19 immunization to the narrative and Table 2.1.

12/18/20 – Clinical Manifestations: Added information from NIH and CDC updates on long-term sequelae of COVID-19.

12/15/20 – Treatment: Added a section on Monocloncal Antibody Treatment to the narrative and Table 8.1.

12/15/20 – Control Strategies for Suspected and Confirmed Cases: Clarified that all suspect and confirmed COVID-19 patients (patients in isolation), whether asymptomatic or symptomatic, should receive a full set of vitals twice a day.

11/20/20 – Public Health Definitions: Updated COVID-related definitions and added influenza-related definitions.

11/16/20 – COVID-19 and Influenza Specimen Collection and Test Ordering Information (Appendix 19): Updated test specifications for the COVID combo test, SARS-CoV-2 and Influenza A &B (test code 31688) and added rejection criteria for test codes 31687 and 31686.

11/16/20 – Testing: Integrated influenza, updated to reflect all positive COVID-19 POCs need PCR confirmation; clarified exposed versus non-exposed testing; updated employee testing to refer to new employee testing website and memo; clarified testing types and definitions; added a new table on influenza and COVID-19 co-testing (Table 6.3), simplified and updated Table 6.1 to reflect all positive POCs need to be followed up with a PCR.

11/04/20 – Control Strategies for Suspected and Confirmed Cases: Integrated influenza; clarified isolation categories; clarified types and populations for isolation; updated the definition of close contact to be 10 minutes and cumulative; N95s for all persons working in and around isolation: ILI, suspect COVID-19, confirmed COVID-19 and suspected influenza; emphasized need for care and monitoring while in isolation for influenza and COVID-19.

11/03/20 – Inmates Releasing from Institutions – COVID-19 Testing and Notification: Revised guidance to reflect that Appendix 9 notification forms only need to be submitted for inmates releasing from isolation or quarantine.

11/03/20 – Vaccination: Expanded information on influenza vaccination and added Influenza Vaccination Related to COVID-19 Quarantine and Isolation table (Table 3.2).

10/29/20 – Recommendations for Safer Movement Between Jails and Prisons to Prevent COVID-19 Introductions (Appendix 20): Added a link to the Transfer of COVID-19 Resolved Patients memo.

10/29/20 – Control Strategies for Contacts to Cases: Added definitions for single-person quarantine space and cohort quarantine space; updated verbiage from “should” to “shall” in regards to re-testing previously negative patients in quarantine; added hyperlinks to patient education materials.

10/28/20 – COVID-19 Index Case-Patient Interview Checklist (Appendix 7): Added information on creating a contact line list and instructions on reporting and follow-up.

10/23/20NEW COVID-19 and Influenza Specimen Collection and Test Ordering Information (Appendix 19): Added an appendix with information on: Strategies to Maximize Sensitivity of COVID-19 and Influenza Testing; Specimen Collection; EHRS Test Ordering and Test Considerations for COVID-19 and Influenza; and Other Respiratory Virus Testing Considerations.

10/21/20 – Environmental Infection Control: Integrated influenza and consolidated environmental infection control related content from other sections.

10/21/20 – Notifications and Reporting: Removed requirements to report COVID-19-related events to PhORS; added requirement for reporting outbreaks of influenza to PhORS.

10/19/20 – Primary Prevention and Preparedness: Added a link to the CDPH All Facilities Letter (AFL) Summary including recommendations to prevent and manage influenza outbreaks in skilled nursing facilities (SNFs) during the COVID-19 pandemic.

10/15/20 – COVID-19 Operational Preparedness for Facility Leadership and Incident Command (Appendix 18): Added a link to the COVID-19 Management Assessment and Response Tool (CMAR) for Correctional and Detention Facilities.

10/15/20 – CCHCS COVID-19 Testing – NAAT and POC Antigen Explained (Appendix 17): Added performance data and turn-around times; updated guidance to concur with the Movement Matrix.

10/14/20 – Treatment: Expanded information on Treatment of COVID-19 at the Institution including Antivirals, Dexamethasone, and Vitamins; added Bronchodilators back into Table 8.1; and added new Oct 2020 NIH Recommendation for Pharmacologic Management of Patients with COVID-19 Based on Disease Severity table (Table 8.2).

10/12/20 – Case Entry Form for Re-Infection Evaluation (Appendix 21): Added space for outcome of contact investigations.

10/12/20 – Transmission: Expanded information on airborne transmission.

10/12/20 – Vaccination: Added links to supportive CCHCS influenza documents and added information on prioritizing influenza vaccines.

10/07/20 – Control Strategies for Contacts to Cases: Integrated guidance for ILI and influenza quarantines; clarified the definition of contact to include cumulative addition to 10 minutes and is irrespective of wearing a mask; added that patients within 12 weeks of their prior infection, and patients out to court or hospitals <24 hours, do not need quarantine; updated PPE for COVID-19 and influenza quarantine; added surveillance rounding for influenza; clarified that influenza quarantine does not have any asymptomatic testing and release is time based only; clarified that release from COVID-19 quarantine testing should be RT-PCR.

10/07/20 – Infection Control and Personal Protective Equipment (PPE): Added the following sections: Background; Care of Reusable Respirators, Facemasks, Face Shields, and Eye Protection Guidance; COVID-19 Transmission from Paper Surfaces; and Handling the Property of Deceased Inmates/Patients Who Died from COVID-19.

10/06/20 – COVID-19 Case and Contact SharePoint Reporting Tool (Appendix 5): Added instructions for reporting a documented false positive SARS-CoV-2 PCR result.

10/06/20 – Appendix 10: COVID-19 and Influenza PowerForm Instructions; Screening, Isolation, and Quarantine Surveillance: Added information on Influenza Surveillance Rounding.

10/05/20 – Testing for COVID-19 and Other Respiratory Pathogens: Expanded and updated the section on Potential Re-infections including information on false positives and CDPH’s research criteria.

10/05/20 – Appendix 21: Case Entry Form for Re-Infection Evaluation: Added a fillable form to report initial and potential re-infection information for PHB and/or CDPH evaluation for further investigation.

10/02/20 – Clinical Manifestations: Added a section on Clinical Manifestations, Incubation, and Infectivity of Influenza; added a section on Clinical Manifestations of Other Respiratory Pathogens; added a Comparison Between Seasonal Influenza and SARS-COV-2 table; added an Adult Groups at High-risk for Serious Influenza Complications table.

10/02/20 – Appendix 20: Recommendations for Safer Movement Between Jails and Prisons to Prevent COVID-19 Introduction: Added a new appendix with information on general vehicular transportation precautions and recommendations.

9/21/20 – Primary Prevention and Preparedness: Added a section on Pandemic Preparedness, clarified basic principles of prevention strategies that will ultimately be used to guide re-opening, and added Core Principles table.

9/18/20 – Vaccination: Created a new section for vaccination and updated the CCHCS Formulary Vaccines for the 2020-2021 Influenza Season table

9/16/20 – Treatment: Integrated influenza, included new validated risk calculator for COVID-19 hospitalization, added surveillance for signs of influenza complications, updated treatment and chemoprophylaxis guidelines for influenza based on CDC and CDPH updates, added treatment of tuberculosis links.

9/14/20 – Public Health Definitions: Created a single suspect case definition (combining high and low suspect), aligned outbreak definitions with CDPH (with a note about CDCR’s definition), added definitions for re-positive and false positive.

9/11/20 – Transmission: Added transmission for influenza and included information on aerosol transmission.

9/11/20 – Clinical Manifestation’s Table 5.1: Removed COVID-19 prevalence column and added symptoms for influenza and respiratory syncytial virus.

9/10/20 – COVID-19 Case and Contact SharePoint Reporting Tool: Added instructions for resolving cases, reporting re-positives, and reporting false positives. Added instructions for searching and filtering lists. Updated definitions. Updated the data dictionary

9/02/20 – Primary Prevention and Environmental Infection Control: Added Transportation, Ventilation, and Vaccination sections, added information to the Education subsection.

9/02/20 – Added Appendix 18: COVID-19 Operational Preparedness for Facility Leadership and Incident Command

9/02/20 – Clinical Manifestations of COVID-19: Added Infectious Period and Immune Period sections, added Figure 5.1: Incubation, Infectious Period, and Test Positivity for SARS-CoV-2, updated Table 5.2: Persons at High Risk for Severe Morbidity and Mortality from COVID-19.

8/24/20 – COVID Screening and Testing Matrix for Patient Movement (Appendix 13): Updates and supersedes the May 22, 2020 version.

8/21/20 – Control Strategy for Suspected and Confirmed Cases of COVID-19: Significantly revised release from isolation protocols and algorithm to emphasize clinical based criteria and lessoned the time for resolution of fever to 3 days instead of 5 and need for a medical provider evaluation before release, added information on extended convalescent period for patients with severe/critical illness or releasing to fire camp, and added more information on transport of symptomatic individuals/suspect cases or cases.

8/19/20 – Clinical Manifestations: Added information on the sequela of COVID-19, immunity, potential re-infections, retesting after recovery, and multisystem inflammatory syndrome in children (MIS-C)

8/12/20 – COVID-19 RAPID POINT OF CARE ANTIGEN TEST INFORMATION SHEET (Appendix 14): Added information on firmware updates, calibration, and self-ordering of test kits.

8/11/20 – Treatment and Vaccines for COVID-19 and Influenza: Updated to include the use of alternative steroid medications if dexamethasone is unavailable, expanded information on the necessity of rehabilitation after severe illness, and added the CDC clinician management assistance hotline.

8/03/20 – Testing for COVID-19 and Other Respiratory Pathogens: Added: when to use antigen point-of-care (POC) testing, information to rejection criteria for Quest Nucleic Acid Amplification Test (NAAT), link for information on how to self-order antigen test kits, considerations for testing strategies, when to follow up negative POC tests, link to information on critical inmate worker screening, section on testing of expedited releases and other discharges to community, section on when re-testing previously positive patients and employees is needed, guidance on handling potential false positives, corrected POC charting workflow, and changed duration of repeat testing during outbreaks to every 3-7 days, depending on risk.

8/03/20 – COVID-19 Testing: NAAT and POC Antigen Explained (Appendix 17): Added information comparing Quest NAAT testing and Antigen testing.

7/31/20 – Control Strategy for Suspected and Confirmed Cases of COVID-19: Added information on false positives and when to test after infection resolution, point of care (POC) testing, ordering antigen POC test cassettes, and Quest Nucleic Acid Amplification Test (NAAT) rejection criteria. Changed serial testing of potentially exposed persons who are not quarantined to be retested every 3-7 days and guidance on testing of expedited releases.

7/22/20 – Clinical Manifestations of COVID-19: Added a section on immunity.

7/21/20 – Required PPE Checklist (Appendix 16): Added a checklist of required PPE.

7/17/20 – Control Strategies for Contacts to Cases of COVID-19: Updated the section to reflect the current testing guidance for testing every 7 days in quarantine, added subsections in the “quarantine“ section, added descriptions of quarantined conditions related to the size of quarantine and reducing transmission.

7/17/20 – Primary Prevention and Environmental Infection Control: Added links to the Screening Critical Inmate Workers memo.

7/16/20 – Treatment of COVID-19 and Influenza: Updated supportive treatments to include oral rehydration and antitussives, updated indications for dexamethasone to include any patients requiring oxygen supplementation and new NIH recommendations regarding its use in hospitalized patients.

7/16/20Control Strategy for Suspected and Confirmed Cases of COVID-19 AND Appendix 7: Updated the definition of the infectious period for asymptomatic case-patients who are SARS-CoV-2 positive.

7/13/20 – Provider Script (Appendix 15): Added Provider Script for Offering Cell Housing to Patients at High Risk of Severe COVID-19.

7/09/20 – COVID-19 Case and Contact SharePoint Reporting Tool (Appendix 5): Updated to reflect that reporting of COVID-19 contacts to CCHCS HQ is no longer required.

7/08/20 – Control Strategy for Suspected and Confirmed Cases of COVID-19: Added information on evaluating medical problems of patients in quarantine and isolation.

7/07/20 – COVID-19 Rapid Point-of-Care Antigen Test Information Sheet (Appendix 14): Added frequently asked questions on Antigen Tests.

7/06/20 – Infection Control and Personal Protective Equipment (PPE): Added recommendation for N95 respirator use for staff that escort suspect or confirmed cases and for staff spending extended periods of time with quarantined individuals, and added links to recent PPE memos.

7/02/20 – Testing for COVID-19 and Other Respiratory Pathogens (previously Diagnostic Testing): Expanded use of rapid POC testing and how to order, removed types of sample collection hierarchy per CDC’s removal of NP as preferred specimen.

6/30/20 – Clinical Manifestations: Added Differential Diagnosis section.

6/29/20 – Control Strategy for Suspected and Confirmed Cases of COVID-19: Clarified that asymptomatic cases of COVID-19 require pulse oximetry monitoring, but not blood pressure monitoring. Updated release from isolation criteria to have a choice in test-based or clinical-based criteria not dependent solely on testing shortages, and added a 21 day maximum for time in isolation to curtail the problem of persistent positives.

6/22/20 – Treatment: Added the updated National Institutes of Health Medication Treatment Guidelines, information on potential use of SIRS criteria, notes on advanced care planning and additional medication considerations, expanded information on influenza, RSV, and Cocci treatment.

6/15/20 – Control Strategies for Contacts to Cases: Updated the list of who should be placed in quarantine, added testing recommendation in the first 24 hours of quarantine, added expanded list of symptoms to monitor for, updated release from quarantine to reflect exit testing and extended quarantine for test refusers.

6/09/20 – Clinical Manifestations: Added expanded symptoms for the aged and immunocompromised, added lab parameters reflecting increased risk for DVT, and updated the laboratory predictors of in the severe disease table (Table 5.2).

6/02/20 – Diagnostic Testing: Added extensive new information on SARS-CoV-2 testing including who to test, how to prioritize testing during clusters and outbreaks, how to mass test, asymptomatic testing and how to prioritize, who needs routine serial testing, employee testing, testing during quarantine and release from quarantine, public health surveillance testing, vulnerable population testing, how many to test, testing of transfers, and new information on mid-turbinate patient self-testing and technique.

6/01/20Added Appendix 12 – Sample Local Operating Procedure (LOP) for COVID-19 County Testing.

6/01/20 – Inmates Releasing from Institutions During COVID-19: Title updated to Inmates Releasing from Institutions – COVID-19 Testing and Notification; Revised to include:

  1. All patients being released from the institutions, regardless of the patients’ COVID status, shall be offered COVID-19 testing one week before release with notification of the results sent to LHDs and DAPO and/or PRCS
  2. All “Appendix 9” notification forms are required to be “cc’ed” to a newly established public health notification email box.

5/22/20Added Appendix 13 – COVID Screening and Testing Matrix for Patient Movement.

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

TRANSMISSION - Updated 10/12/2020

TABLE OF CONTENTS

  1. SARS-CoV-2
  2. INFLUENZA

Both SARS CoV-2 and influenza are transmitted through infectious respiratory particles and secretions in the air and on surfaces. Although influenza is less infectious than SARS CoV-2, both can cause large outbreaks and significant morbidity and mortality. Primary prevention strategies are formed based on modes of transmission.

SARS-CoV-2

SARS-CoV-2, the virus that causes COVID-19, is transmitted by close contact from person-to-person through respiratory droplets and aerosols, airborne transmission over long distances, and contact with contaminated surfaces.

The virus is thought to spread mainly from person-to-person via droplet transmission:

  • Between people in close contact with one another (within about 6 feet) through respiratory droplets produced when an infected person coughs, sneezes, or talks.
    • These droplets can land in the mouths or noses of people nearby or possibly be inhaled into their lungs.
  • COVID-19 may be spread by an asymptomatic person.

The virus spreads easily between people. In general, the more closely a person interacts with others, and the longer that interaction, the higher the risk of COVID-19 spread. Viral shedding is highest around the time of symptom onset and lessens after the first 5 days of symptoms.

The Centers for Disease Control (CDC) uses the term “airborne transmission” to describe infections capable of being transmitted through exposure to infectious, pathogen-containing, small droplets and particles suspended in the air or carried by dust over long distances (>6 feet) and persist in the air for long times (typically hours). There is no evidence of efficient spread (i.e., routine, rapid spread) of SARS-CoV-2 to people far away or who enter a space hours after an infectious person was there. Circumstances under which airborne transmission of SARS-CoV-2 appears to have occurred include:

  • Enclosed spaces within which an infectious person either exposed susceptible people at the same time or to which susceptible people were exposed shortly after the infectious person had left the space.
  • Prolonged exposure to respiratory particles, often generated with expiratory exertion (e.g., shouting, singing, exercising) that increased the concentration of suspended respiratory droplets in the air space.
  • Inadequate ventilation or air handling that allowed a build-up of suspended small respiratory droplets and particles.

Airborne transmission is not currently thought to be a major driver of the pandemic. SARS-CoV-2 has been shown to remain viable in aerosols for sustained periods. Aerosol-generating procedures (AGPs) 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. AGPs require distinct engineering controls to prevent occupational transmission of infectious pathogens like SARS-CoV-2. Guidance for minimizing AGP risk is provided in detail in the Aerosol Generating Procedures Memo dated 4/8/20.

It may be possible that a person can get COVID-19 by touching a surface or object that has the virus on it and then touching their mouth, nose, or possibly eyes. This is not thought to be the primary transmission source, but we are still learning more about how this virus spreads.

Contact or surface transmission occurs 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 (ICUs) to have a high positivity rate throughout the hospital; on floors, computer mice, trashcans, sickbed handrails, and patient masks. Thus, there are clearly viable virus particles on fomites, but infectiousness and the amount of virus necessary to cause disease by this modality are 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 undoubtedly contagious, the infectiousness of fecal specimens is 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.

At this time, the risk of COVID-19 spreading from animals to people is considered to be low.

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 average 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. This post-recovery shedding’s infectiousness 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.

INFLUENZA

People infected with influenza can spread it to others up to about 6 feet away. Most experts think that influenza viruses spread mainly by droplets made when people with influenza cough, sneeze, or talk. These droplets can land in the mouths or noses of people nearby or possibly be inhaled into their lungs. Less often, a person might get influenza by touching a surface or object that has the influenza virus on it and then touching their mouth, nose, or possibly eyes.

People with influenza are most contagious in the first 3 to 4 days after their illness begins. Most healthy adults may be able to infect others beginning 1 day before symptoms develop and up to 5 to 7 days after becoming sick. Children and some people with weakened immune systems may be contagious for longer than 7 days.

Symptoms can begin about 2 days (but can range from 1 to 4 days) after the virus enters the body. The virus can be transmitted before people know they are sick, as well as while they are sick. Infected people may be asymptomatic but still be contagious.

  • People with influenza are most contagious in the first 3 to 4 days after their illness begins.
  • Some otherwise healthy adults may be able to infect others beginning 1 day before symptoms develop and up to 5 to 7 days after becoming sick.
  • Some people, especially young children and people with weakened immune systems, might be able to infect others with influenza viruses for an even longer time.

For more information on COVID-19 and influenza transmission, see the CDC on How COVID-19 Spreads and CDC How Flu Spreads.

PREVENTION, PREPAREDNESS, AND REOPENING - Updated 8/27/2021

TABLE OF CONTENTS

  1. PREVENTION AND PREPAREDNESS
    1. TABLE 2.1 CORE PRINCIPLES OF COVID-19 PREVENTION
  2. REOPENING PROGRAMMING
    1. PHYSICAL DISTANCING
    2. FACE COVERINGS
    3. COVID-19 VACCINATION
    4. TESTING
    5. VENTILATION
    6. HAND HYGIENE
    7. CLEANING AND DISINFECTING
    8. DURATION OF CONTACT
    9. SCHEDULING
    10. MOVEMENT/MIXING
    11. TRANSPORTATION
    12. COVID-19 SYMPTOM SCREENING
    13. STAFFING
    14. VENDORS/CONTRACTORS/VOLUNTEERS/OTHERS
    15. SIGNAGE
  3. APPENDIX 13: COVID SCREENING AND TESTING MATRIX FOR PATIENT MOVEMENT
  4. APPENDIX 20: RECOMMENDATIONS FOR SAFER MOVEMENT TO PREVENT COVID-19 INTRODUCTION
  5. APPENDIX 23: PLANNING CHECKLIST FOR SAFE GATHERINGS

This section covers the core principles of primary prevention, pandemic preparedness, and safe reopening. Primary prevention involves all people within the institution: staff, visitors, and incarcerated persons. The introduction of COVID-19 or influenza can quickly cause large outbreaks. Preparing in advance and implementing prevention strategies prior to the introduction is key to containment. This requires planning, education of everyone who lives, works or visits a confinement facility, leadership engagement and coordination, supportive policies, and teamwork.

PREVENTION AND PREPAREDNESS

The core principles of COVID-19 prevention are summarized in the table.

Table 2.1: Core Principles of COVID-19 Prevention. Based on information contained in the CCHCS COVID-19 and Seasonal Influenza Guideline and CCHCS Memos. Please click on the image to open PDF for full table details.

Institutional preparedness is critical for implementing prevention strategies and ensuring an effective response to outbreak threats. Since each institution has a unique physical layout and different missions, the actual application of the guidelines requires creative thinking about how to make things work best at that institution.

The CDCR/CCHCS Aerosol Transmissible Disease Exposure Plan is available to assist institutions in preparing for and responding to ATD risk.

The CCHCS Outbreak Management Tool is available to help institutions manage COVID-19 outbreaks.

REOPENING PROGRAMMING

The CCHCS Roadmap to Reopening memo provides helpful details as institutions move toward reopening programming.

Programs and events that involve groups of people coming together increases the risk of COVID-19 outbreaks, thus it is imperative that programs institute and maintain measures to minimize risk. See: CDC Guidance for Organizing Large Events and Gatherings.

Appendix 23 provides a planning tool for supporting safe gatherings. The information below is intended to provide guidance for each prevention strategy. More stringent measures may be necessary to minimize risk such as within healthcare areas, dorm settings, kitchens, etc. Program planners must identify and implement measures to minimize infection risk in settings that pose additional risk.

Individuals with suspected or confirmed COVID-19 infection and those who have been exposed to COVID-19 should be excluded from group activities. Patients who are at high risk of severe complications from COVID-19 should be offered alternative ways to participate. N95 masks should be made available for indoor gatherings.

PHYSICAL DISTANCING

  • When possible utilize remote/telework, tele-education, telemedicine, video-visiting, video-programming/meetings instead of group meetings.
  • In any setting, the goal is to ensure all persons have the ability to maintain 6 feet of distance from each other:
    • Outdoor setting is highly preferred
    • If using an indoor setting, use the largest room possible and ventilate as much as possible (See Ventilation section below)
  • Reduce capacity in all rooms as much as possible by:
    • Limiting class/group size (based on ability to have people 6 feet apart)
    • Divide groups into smaller groups
    • Reconfigure space to ensure tables/chairs are at least 6 feet apart and are at least 6 feet from foot traffic
  • Use tape on the ground/floor to indicate distances that chairs or tables should be placed.
  • Use physical barriers (e.g., Plexiglass, plastic sheeting) in areas where contact closer than 6 feet is needed such as canteen window.
  • Modify foot traffic patterns to have single entry and exit points.
  • Use only stairs when possible and limit the number of people on the stairs at the same time. Allow only one direction of stair traffic at a time.
  • Staff and incarcerated persons should enter through doors that are propped open or automated, if possible. Hand sanitizer should be available for those who must touch door handles.
  • Any area where incarcerated persons line up should also be clearly marked for appropriate physical distancing.
  • Close small rooms and alcoves where people might congregate, including staff breakrooms if unable to control occupancy.
  • Where possible, create outdoor break areas with shade covers and seating that ensures physical distancing.

FACE COVERINGS

  • Use of face coverings is known to be one of the most effective way to decrease COVID-19 spread.
  • Reopening programs/activities must meet the CDCR requirements for facial coverings.
  • N95 face masks are required under certain conditions and should be made available for indoor activities.
  • Do not allow singing, yelling, shouting, chanting or other loud verbal behavior in any indoor setting (e.g., religious ceremonies should have recorded music).
  • Avoid eating in groups. Removal of masks to drink should be brief.

COVID-19 VACCINATION

  • Vaccination against COVID-19 is an important strategy to prevent COVID-19 illness and probably decreases disease transmission. A person is considered fully-vaccinated 14 days after the final dose of a vaccine regimen.
  • Encouraging staff and participants to be fully vaccinated against COVID-19 can be helpful to ensure safer groups.

TESTING

  • There are several testing strategies that could be employed to resume programming. Examples include:
    • Point-of-care testing prior to participation in a group setting
    • PCR testing prior with results available before group participation
  • All participants are expected to follow current testing policies, including regular testing for surveillance.

VENTILATION

  • When possible, arrange for events/groups to be held outdoors with physical distancing maintained.
  • If indoors, open windows/doors as much as possible.
  • Use locations with maximum ventilation.
  • Fans should be used with caution as they can disperse the virus more in a closed setting.
  • Check ventilation to determine if it is shared with other areas, especially if COVID-19 infected patients are housed in those areas.
  • Increase number of air exchanges of the ventilation system if possible.
  • Clean ventilation intake and returns daily as indicated.
  • Upgrade the ventilation filter if possible.
  • Install air filtration equipment if possible.
  • Where possible, ensure indoor space is vacant and open for at least 30 minutes between uses.
  • For more information, see ASHRAE on Ventilation During the COVID-19 Pandemic

HAND HYGIENE

  • Stress the importance of frequent handwashing and provide for hand hygiene in every location:
    • Hand sanitizer (at least 60% ethanol or 70% isopropanol) or
    • Soap and water can be used (water does not need to be hot)
    • Scrub for at least 20 seconds with soap and water and then rinse
  • Require hand hygiene when entering and exiting any public space.
  • Gloves are generally only needed when there is physical contact with a person with COVID-19.
  • Where possible, handling any object or surface should be minimized. If handling an object is necessary for group members, measures should be taken to decrease risk of contamination.

CLEANING AND DISINFECTING

  • Keeping surfaces and areas clean and decontaminated is important to decrease risk of infection.
  • For details on cleaning/disinfecting areas, please refer to the section titled “ENVIRONMENTAL INFECTION CONTROL.”

DURATION OF CONTACT

  • Risk of infection is higher when cumulative contact is more than 10 minutes in any 24-hour period.
  • As much as possible, minimize the amount of time in direct contact with other persons, especially if closer than 6 feet.

SCHEDULING

  • Ensure time is allowed to clean area between uses and to avoid two groups of people from interacting during entering/existing.
  • As much as possible, schedule housing units/buildings together for group activities to limit cross-exposure.
  • Consider staggering the schedule of activities to minimize groups sizes.

MOVEMENT/MIXING

TRANSPORTATION

COVID-19 SYMPTOM SCREENING

  • Screening for symptoms prior to joining the group activity should be done for all participants including staff, incarcerated persons, and internal people (contractors, volunteers, vendors, etc).
  • All persons who report having one or more symptoms of COVID-19 or show signs such as coughing should not be allowed to join the group.

STAFFING

  • All staff must be educated about the risks of various behaviors as well as the protective measures they can take to minimize risk of infection.
  • Staff should also remind incarcerated persons about the risks of infection and preventive measures.
  • Activities/groups should involve as few staff as possible to manage the activity so that inadvertent virus exposure (from an asymptomatic infected person) can be minimized.
  • Staff who work in isolation or quarantine areas, or facilities with active outbreaks should be tested prior to participating in group activities.
  • Facilities, groups, programs, etc. shall keep a log of staff and external people who enter an area or are part of a group. This is crucial for contact tracing to mitigate outbreaks.

VENDORS/CONTRACTORS/VOLUNTEERS/OTHERS

  • Any external person entering a facility is to follow the same guidelines as staff and submit proof of vaccination or a negative test per current policy.

SIGNAGE

  • Signs should be placed in multiple areas reminding everyone how to prevent spread of COVID-19 and of the requirements:
    • Face coverings must be worn at all times.
    • Physical distancing of at least 6 feet should be maintained at all times.
    • Hand hygiene is required.
    • Any symptoms of possible COVID-19 must be reported immediately. List of symptoms should be displayed.
    • Any temporary occupancy limitation.

Proposals that involve deviations from current policy should be reviewed and approved by institutional leadership and if needed, regional healthcare executives.

VACCINATION - Updated 6/29/2021

TABLE OF CONTENTS

  1. COVID-19 VACCINES
    1. SAFETY AND SIDE EFFECTS
    2. TABLE 3.1 CCHCS COVID-19 VACCINES: INFORMATION AND SIDE EFFECTS
    3. PRECAUTIONS AND CONSIDERATIONS
    4. OTHER VACCINE COMPATIBILITY
    5. QUARANTINE AND INFECTION CONTROL
    6. DETAILS CONCERNING THE MRNA VACCINES (PFIZER AND MODERNA)
    7. TABLE 3.2 TRIAGE OF PERSONS PRESENTING FOR mRNA COVID-19 VACCINATION
    8. DETAILS CONCERNING THE ADENOVIRUS VECTOR VACCINE (JOHNSON & JOHNSON OR JANSSEN OR J&J)
    9. TUBERCULOSIS (TB) SCREENING AND COVID-19 VACCINES
  2. INFLUENZA VACCINATION
    1. TABLE 3.3 CCHCS FORMULARY VACCINES FOR THE 2020-2021 INFLUENZA SEASON
    2. TABLE 3.4: INFLUENZA AND COVID-19 VACCINATION RELATED TO COVID-19 QUARANTINE AND ISOLATION

This section covers pharmaceutical prevention interventions for COVID-19 and influenza A and B. As of March 1, 2021, there are three vaccines to prevent COVID-19. As new options become available, this section will be updated. Information on COVID-19 vaccination changes frequently, and this section will be updated accordingly. For influenza, both vaccination and chemoprophylaxis have proven effectiveness.

1. COVID-19 VACCINES

As of March 1, 2021, three COVID-19 vaccines, one from Pfizer (partnered with BioNTech), one from Moderna, and one from Johnson & Johnson (Janssen Biotech), have been granted Emergency Use Authorization (EUA) by the Federal Food and Drug Administration (FDA). Other clinical trials are currently ongoing by several entities. Details of other clinical trials can be found on the Regulatory Affairs Professionals Society (RAPS) website at RAPS COVID-19 Vaccine Tracker.

CCHCS has developed a Frequently Asked Questions document to answer many common questions related to the COVID-19 vaccines. Also, on Lifeline, several resources for clinicians and other stakeholders can be found at COVID-19 Vaccine Information. Many helpful documents can be found under the main tabs. More detailed information about the vaccines is discussed below.

The three vaccines have been found to be very effective. Details for each vaccine’s effectiveness are shown below.

The three vaccines have many similarities and some differences. The similarities will be described below, with the differences discussed subsequently.

SAFETY AND SIDE EFFECTS

From the published data, the COVID-19 vaccines appear to be very safe. Their safety profile is similar to many of the standard vaccines given to the general public. The rate of significant adverse events (including mortality) was no different than expected in the general population.

The COVID-19 vaccines have known side effects based on the reactogenicity of the vaccines. These effects are expected from the vaccines and are part of the developing immunity against COVID-19. Side effects typically seen after COVID-19 vaccination include fatigue, headache, muscle and joint pains, chills, nausea, and fever. While the vast majority of side effects are mild, a small percentage of patients experience more significant symptoms. Patients may need rest and over-the-counter treatment (e.g., acetaminophen) to manage side effects. Non-specific post-vaccination symptoms (e.g., fatigue, headache, and body aches) may be mistaken for COVID-19 symptoms. See Table 5.1. Differentiating between vaccine side effects and COVID-19 infection is important to avoid unnecessarily isolating patients with only post-vaccination symptoms from activities AND to avoid inadvertently allowing infected patients to spread the infection. Symptoms typical of COVID-19 infection that are NOT typical post-vaccination side effects include cough, shortness of breath, rhinorrhea, sore throat, diarrhea, and loss of taste/smell. Patients who develop any of these symptoms or fever within 3 days of receiving a dose of the COVID-19 vaccine (or at any other time) should be isolated and tested in accordance with the Control Strategies for Suspected and Confirmed Cases.

Please see Table 3.1 for details on vaccine storage, use, and expected side effects.

As with any vaccine, there is the potential for an anaphylactic reaction after receiving the vaccine. While it appears that anaphylactic reactions are more common with COVID-19 vaccines compared to other vaccines, from early data, anaphylaxis from the COVID-19 vaccines is rare (about 4.5 cases of anaphylaxis per a million recipients of the mRNA vaccines – not enough information published on the Johnson & Johnson vaccine). The risk of an anaphylactic reaction can be minimized by taking precautions with those who have had prior anaphylaxis or other prior allergic reactions. See Table 3.2. Since anaphylactic reactions are serious and can be life-threatening, the Centers for Disease Control and Prevention (CDC) recommends that vaccination clinics/sites have a plan to manage an anaphylactic reaction and have appropriate medications and supplies available throughout the vaccination process. A list of recommended supplies/medications as well as CDC recommendations for recognition and management of anaphylaxis can be found at the CDC Interim Considerations: Preparing for the Potential Management of Anaphylaxis at COVID-19 Vaccination Sites. Adverse events subsequent to vaccine administration should be reported to the Vaccine Adverse Event Reporting System (VAERS).

Table 3.1: CCHCS COVID-19 Vaccines: Information and Side Effects. Please click on the image to open PDF for full table details.

PRECAUTIONS AND CONSIDERATIONS

There is limited information about vaccine provision in those with certain issues, but based on recommendations published by the CDC, there are several considerations/precautions related to the COVID-19 vaccines. Specific details related to the vaccines about allergies and specific conditions are listed on the Triage of People Presenting for COVID-19 Vaccination (Table 3.2). Details for all three vaccines are shown here:

  • Individuals suffering from acute severe illness may need vaccine deferral or further risk assessment prior to vaccination and monitoring after vaccination.
  • Individuals undergoing anticoagulant therapy or those with a bleeding disorder may receive the COVID-19 vaccine.
  • Immunocompromised persons, including individuals receiving immunosuppressant therapy (e.g., post-transplantation, chemotherapy, etc.), may have a diminished immune response to the vaccine. There is no available data about the concomitant use of immunosuppressants. Those patients on immunosuppressant therapy or who have immunocompromising or autoimmune conditions may receive the COVID-19 vaccines along with counseling. Re-vaccination after regaining immune competence is not recommended at this time, nor is post-vaccination antibody testing to assess immunity.
  • Currently, no data has been published on the safety or efficacy of vaccination in persons who received monoclonal antibodies or convalescent plasma as part of COVID-19 treatment. Therefore, vaccination should be deferred for at least 90 days to avoid interference of the COVID-19 treatment with vaccine-induced immune responses. For more information on vaccine-related issues with monoclonal antibody treatment, please see the Treatment section of this Guidance.
  • Pregnancy: Since the COVID-19 disease has been known to have adverse effects on pregnancy and pregnancy is not a contraindication to vaccination, pregnant women should have an informed discussion with their healthcare provider prior to receiving the vaccine. Patients should also be monitored after vaccination.
  • Lactation: Breastfeeding is not a contraindication to vaccination, and the vaccines are not thought to be a risk to the breast-feeding infant. A breast-feeding patient should have additional counseling and be monitored.
  • Mammograms: People who have received a COVID-19 vaccine can have lymphadenopathy in the underarm near where they got the shot. This swelling is a normal reaction to the vaccine but may cause a false reading on a mammogram. Some experts recommend getting a mammogram before being vaccinated or waiting four to six weeks after getting the final dose of vaccine.
  • For patients with rheumatologic and/or autoimmune diseases, the American College of Rheumatology has developed a Clinical Guidance Summary for management of the COVID-19 vaccine administration. It is found on the link attached here.

All staff and patients will be offered the COVID-19 vaccine. All potential recipients of the vaccine should be provided information about the vaccine, its side effects, and cautions/contraindications. Healthcare staff should make ongoing efforts to educate patients who refuse vaccination about the benefits of the vaccine.

OTHER VACCINE COMPATIBILITY

According to the CDC, as of May 14, 2021, COVID-19 vaccines and other vaccines can be administered without regard to timing. This includes simultaneous administration of COVID-19 vaccines and other vaccines on the same day, as well as coadministration within 14 days (or later). When deciding whether to coadminister another vaccine(s) with COVID-19 vaccines, providers should consider whether the patient is behind or at risk of becoming behind on recommended vaccines, their risk of vaccine-preventable disease (e.g., during an outbreak or other exposure), and the reactogenicity profile of the vaccines. Interested providers can find more specific information about the coadministration of vaccines on the CDC page: Interim Clinical Considerations for the use of COVID-19 Vaccines.

QUARANTINE AND INFECTION CONTROL

Because of the increased risk for outbreaks in CDCR facilities, patients in quarantine may be vaccinated against COVID-19 in order to avoid delays and missed opportunities for vaccination. This includes patients who have had an exposure and are awaiting COVID-19 test results. They may be vaccinated if they have no symptoms consistent with COVID-19.

Until a body of research shows that COVID-19 vaccines prevent virus transmission, the primary benefit of vaccination is to prevent individual COVID-19 illness. On February 10, 2021, the CDC released a recommendation that (under certain conditions) those who have been fully vaccinated (defined as 14 days after the last recommended dose of COVID-19 vaccine) do not need to be quarantined if exposed to COVID-19. Due to the congregate-living nature of CCHCS’ population, CCHCS continues to mandate that anyone (regardless of vaccination status) exposed to a COVID-19 case will be quarantined and managed based on the Control Strategies for Contacts to Cases section of this Guidance.

During vaccination clinics, precautions should be taken to limit mixing exposed individuals with other patients or staff (except those essential for the provision of vaccination services, who should employ appropriate infection and control procedures).

DETAILS CONCERNING THE MRNA VACCINES (PFIZER AND MODERNA)

Both the Pfizer-BioNTech and Moderna vaccines utilize messenger RNA (mRNA). Summarized from the CDC: The vaccine gives instructions for our cells to make a harmless piece of what is called the “spike protein” found on the surface of the COVID-19 virus. After injection of the mRNA vaccine, the immune cells use the mRNA (instructions) to make the protein piece. The cell then breaks down the instructions. Next, the cell displays the protein piece on its surface. The immune system then recognizes that the protein does not belong there and develops an immune response by making antibodies to the protein and thus to COVID-19. (See CDC – Understanding mRNA COVID-19 Vaccines for a further description).

  • Effectiveness: The Pfizer-BioNTech vaccine is 95% effective in preventing symptomatic COVID-19 disease occurring at least 7 days after completion of the two-dose vaccination series. The Moderna vaccine is 94% effective in preventing symptomatic COVID-19 disease occurring at least 14 days after completion of the two-dose vaccination series.
  • Dosing: Both Pfizer-BioNTech and Moderna vaccines require two doses to develop adequate immunity. Protection against COVID-19 may not be effective until at least 7-14 days after the second dose. The vaccines are not interchangeable, and the second dose is to be of the same vaccine as the first dose. If a COVID-19 vaccine from a different manufacturer is given inadvertently, no additional doses are recommended. At this time, booster doses are not recommended after the two-dose primary series.
  • Contraindication: Prior history of hypersensitivity to a previous dose of an mRNA COVID-19 vaccine or any of the vaccine components.
  • Myocarditis/Pericarditis: Rare cases of myocarditis and pericarditis have been reported after mRNA COVID-19 vaccination. Most have occurred predominantly in male adolescents and young adults 16 years of age and older. Should a younger patient present with chest pain, shortness of breath, and/or palpitations, myocarditis and pericarditis should be considered.
Table 3.2: Triage of People Presenting for COVID-19 Vaccination. Please click on the image to open PDF for full table details.

See Table 3.2 for further information about certain conditions and the provision of mRNA vaccines.

DETAILS CONCERNING THE ADENOVIRUS VECTOR VACCINE (JOHNSON & JOHNSON OR J&J)

The Johnson & Johnson vaccine contains a non-harmful adenovirus vector that, after entering human cells, expresses the “spike protein” found on the surface of the COVID-19 virus. The body’s immune system then develops antibodies to the spike protein, thus developing an immune response to COVID-19.

  • Effectiveness: The Johnson & Johnson vaccine is 67% effective in preventing moderate to severe/critical COVID-19 disease occurring at least 14 days after vaccination and 66% effective in preventing moderate to severe/critical disease at least 28 days after vaccination. (Moderate COVID-19 was defined as having any of the typical symptoms of COVID-19, having minor changes in oxygenation, increases in breathing or heart rate, or development of pneumonia or deep vein thrombosis in someone with a positive COVID-19 test. Severe/critical disease was defined as having clinical signs of severe systemic illness, respiratory failure, shock, kidney or liver failure, neurologic dysfunction, intensive care unit admission, or death in someone with a positive COVID-19 test.)

    Additionally, the vaccine was approximately 77% effective in preventing severe/critical COVID-19 occurring at least 14 days after vaccination and 85% effective in preventing severe/critical COVID-19 occurring at least 28 days after vaccination.

  • Dosing: Unlike the two mRNA vaccines, the Johnson & Johnson vaccine is only one dose. No repeat or booster dose is necessary.
  • Contraindication: Prior history of a severe allergic reaction (e.g., anaphylaxis) to any component of the Johnson & Johnson COVID-19 Vaccine.
  • Blood clots: There have been some reports of thrombosis with thrombocytopenia in patients receiving the Johnson & Johnson vaccine. Healthcare professionals should be alert to the signs and symptoms of thrombosis with thrombocytopenia in such individuals. Recipients of the Johnson & Johnson vaccine should be instructed to seek immediate medical attention if they develop shortness of breath, chest pain, leg swelling, persistent abdominal pain, neurological symptoms (including severe or persistent headaches or blurred vision), or petechiae beyond the site of vaccination.
  • Mixing vaccine doses: A vaccine recipient is not to mix doses between the Johnson & Johnson vaccine and the mRNA vaccines.

More information on the Johnson & Johnson vaccine will be added to the Guidance as more is published by the FDA, CDC, or Johnson & Johnson.

TUBERCULOSIS (TB) SCREENING AND COVID-19 VACCINES

Although the COVID-19 vaccines are not live-virus vaccines, not enough is yet known of the potential impact of these vaccines on immune response to say conclusively whether these vaccines could have a potential effect on tuberculin skin test (TST) or interferon-gamma release assay (IGRA) results during the first 4 weeks after COVID-19 vaccination.

  • For patients who require baseline TB testing (for entry into facilities) at the same time they are to receive a COVID-19 mRNA vaccine, the CDC recommends:
    • Perform TB symptom screening.
    • If using IGRA, draw blood prior to COVID-19 mRNA vaccination.
    • If using TST, place prior to COVID-19 mRNA vaccination.
    • If COVID-19 mRNA vaccination has already occurred, defer TST or IGRA until 4 weeks after completion of 2-dose COVID-19 mRNA vaccination.
  • Should a facility need to do TB testing to investigate a possible TB outbreak, the decision to test individuals for TB (around the timing of a COVID-19 vaccine) depends on the risk factors for contracting TB and contracting COVID-19. Local health authorities will make specific recommendations as needed for outbreak situations.
  • All potential recipients of COVID-19 mRNA vaccination who may need a TST/IGRA should weigh the risks and benefits of delaying TST/IGRA with their healthcare providers.

Resources:
Since COVID-19 vaccination information changes frequently, for updated information about COVID-19 vaccine development and other COVID-19 vaccine-related issues, visit the CDC website on Frequently Asked Questions about Vaccines.

A large collection of vaccine-related information for CCHCS providers is located on the Lifeline COVID-19 Vaccine page, under the “Clinical” tab – Vaccine Provider Toolkit (CDCR networking is required for access).

For CCHCS staff involved in COVID-19 vaccination clinics, there are several useful resources available on the Lifeline COVID-19 Vaccine page, under the “Clinical” tab – Vaccine Clinic Information (CDCR networking is required for access).

The above information is taken from CDC, FDA, Pfizer-BioNTech, Moderna, and Johnson & Johnson documents and can be accessed here:

2. INFLUENZA VACCINATION

See CCHCS information on the 2020-2021 influenza season in the Influenza Vaccination Campaign 2020-2021 memo, including Tips from the Field – Influenza Campaign Recommendations and Standing Orders for Administering Influenza Vaccine to Adults.

It is imperative to have all patients vaccinated against influenza annually, if not contraindicated. Prioritize influenza vaccination for those ≥65 years of age and those with high-risk comorbid conditions, including pregnancy. Use the ducat system to bring these vulnerable patients in to discuss the importance of influenza vaccination. Essential inmate workers who are critical to the continuity of the institution’s essential functions are considered a priority as well.

Please see Table 3.3 for details on vaccine use and contraindications. Consider a patient education session with healthcare staff for patients who refuse vaccination. All employees should be strongly encouraged to get a seasonal influenza vaccine as well. Vaccination begins every fall and extends as long as influenza is circulating.

Table 3.3: CCHCS Formulary Vaccines for the 2020-2021 Influenza Season. Adapted from the CDPH and CDC Guidelines. Please click on the image to open PDF for full table details.

Healthcare personnel who serve as vaccinators should wear appropriate personal protective equipment (PPE) to prevent any possible COVID-19 transmission.

Since there are no data to inform optimal timing of influenza vaccination in persons with COVID-19 or who are recovering from COVID-19 related to influenza vaccine effectiveness, the following recommendations follow the CDC Guidance on Immunization Services During the COVID-19 Pandemic. CCHCS is following CDC recommendations for correctional settings. See Table 3.4.

Table 3.4: Influenza and COVID-19 Vaccination Related to COVID-19 Quarantine and Isolation. Please click on the image to open PDF for full table details.

Patients who receive the influenza vaccine may develop possible mild side effects; some of these symptoms (e.g., headache, low-grade fever, and muscle aches) may be mistaken for COVID-19 symptoms. Patients must be educated on the side effects of the vaccine prior to vaccination.

Since minimizing influenza cases system-wide can decrease the probability of outbreaks, the influenza vaccine should be administered to all eligible patients regardless of any upcoming movements/transfers within or between facilities. When administered, it should be documented in the electronic health records system (EHRS) to decrease the possibility of unnecessary re-vaccination.

Resources

More information can be found on the CDC website for Influenza Vaccination, the California Department of Public Health (CDPH) Recommendations for the Prevention and Control of Influenza in California Skilled Nursing Facilities During the COVID-19 Pandemic, and the Infectious Disease Society of America (IDSA) 2018 Guidelines.

Information on the strains used in the 2020-2021 influenza season can be found in the CDC Prevention and Control of Seasonal Influenza with Vaccines: Recommendations of the Advisory Committee on Immunization Practices – United States, 2020–21 Influenza Season.

ENVIRONMENTAL INFECTION CONTROL - Updated 9/02/2021

TABLE OF CONTENTS

  1. CLEANING AND DISINFECTING SURFACES
  2. CLEANING SPACES WHERE SUSPECT AND CONFIRMED COVID-19 or INFLUENZA CASES SPENT TIME
  3. CLEANING AFTER AEROSOL-GENERATING PROCEDURES (AGPs)
  4. LAUNDRY
  5. CLEANING VEHICLES

Both SARS-CoV-2 and influenza can be transmitted through contact with contaminated surfaces in the environment. Disinfection of high-touch surfaces and physical environments reduces the risk of transmission. The following recommendations for environmental disinfection apply to both COVID-19 and influenza.

CLEANING AND DISINFECTING SURFACES

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

Thoroughly clean and disinfect all areas where the confirmed or suspected COVID-19 or influenza case-patients spent any time. Note: these protocols apply to suspected cases and confirmed cases to ensure adequate disinfection in the event that the suspected case does have COVID-19. Refer to the Public Health 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 the potential for exposure to respiratory droplets.
    • Influenza A has been shown to last for 10 seconds for larger particles (100 microns) up to 62 minutes for 5 microns. We do not yet know how long COVD-19 remains infectious in the air. Regardless, environmental services (EVS) personnel should refrain from entering the vacated room until sufficient time has elapsed for enough air changes to remove potentially infectious particles.
  • Clean and disinfect all areas (e.g., cells, bathrooms, and common areas) used by the infected individual, focusing especially on frequently touched surfaces.
  • After a thorough cleaning of the area, any room/space is to be left unoccupied for 90 or more minutes prior to re-entry.
  • For further instructions on cleaning specific surface types, see Table: Cleaning Procedures for Specific Surface Types.
Table: Cleaning Procedures for Specific Surface Types. Based on information contained in the CCHCS COVID-19 and Seasonal Influenza Guideline and CCHCS Memos. Please click on the image to open PDF for full table details.

CLEANING AFTER AEROSOL-GENERATING PROCEDURES (AGPs)

LAUNDRY

  • Laundry from COVID-19 cases can be washed with other individuals’ laundry.
  • Place contaminated linen in a clear water-soluble bag and then into a leak-resistant soiled linen bag (usually yellow). Ensure the bag is securely tied to prevent leakage. The contaminated laundry must be clearly labeled as “contaminated/soiled.”
  • Laundry workers should wear appropriate PPE (e.g., gloves and protective garments) while handling the soiled linen.
  • Clean and disinfect clothes hampers according to the guidance above for surfaces. If permissible, consider using a bag liner that is either disposable or can be laundered.
  • Laundry guidance can be found at CDC Cleaning and Disinfecting Your Facility section Clean and Disinfect Specific Types of Surfaces.

CLEANING VEHICLES

RESOURCES
For further sanitation information, please refer to:

CLINICAL MANIFESTATIONS - Updated 12/18/2020

TABLE OF CONTENTS

  1. DIFFERENTIAL DIAGNOSIS FOR INFLUENZA LIKE ILLNESS (ILI)
    1. TABLE 5.1 REPORTED SYMPTOMS COVID-19, INFLUENZA, AND RESPIRATORY SYNCYTIAL VIRUS
    2. TABLE 5.2 COMPARISON BETWEEN SEASONAL INFLUENZA AND SARS-COV-2
  2. CLINICAL MANIFESTATIONS OF COVID-19
    1. COVID-19 INCUBATION AND INFECTIOUS PERIOD
    2. FIGURE 5.1 INCUBATION, INFECTIOUS PERIOD, AND TEST POSITIVITY FOR SARS-COV-2
    3. SYMPTOMS OF COVID-19
    4. PRESENTATIONS AND DISEASE COURSE OF COVID-19
    5. SPECTRUM OF COVID-19 DISEASE
    6. TABLE 5.3: PERSONS AT HIGH RISK FOR SEVERE MORBIDITY AND MORTALITY FROM COVID-19
    7. TYPICAL DIAGNOSTICS IN COVID-19 (HOSPITALIZED PATIENTS)
    8. CLINICAL FACTORS OF COVID-19 ASSOCIATED WITH PROGRESSION TO SEVERE DISEASE AND RESPIRATORY FAILURE
    9. TABLE 5.4: LABORATORY FINDINGS ASSOCIATED WITH SEVERE COVID-19 DISEASE AND DISEASE PROGRESSION TO RESPIRATORY FAILURE
    10. SEQUELAE AFTER SEVERE COVID-19 ILLNESS
    11. COVID-19 IMMUNITY AND POTENTIAL RE-INFECTION
    12. SARS-CoV-2 ASSOCIATED MULTISYSTEM INFLAMMATORY SYNDROME IN CHILDREN (MIS-C)
    13. RECOMMENDATIONS FOR SUSPECTED MIS-C
  3. CLINICAL MANIFESTATIONS, INCUBATION, AND INFECTIVITY OF INFLUENZA
    1. SPECTRUM OF INFLUENZA DISEASE
    2. CLINICAL FACTORS OF INFLUENZA ASSOCIATED WITH PROGRESSION TO SEVERE DISEASE, RESPIRATORY FAILURE, AND OTHER COMPLICATIONS
    3. TABLE 5.5 ADULT GROUPS AT HIGH RISK FOR SERIOUS INFLUENZA COMPLICATIONS
    4. LABORATORY FINDINGS ASSOCIATED WITH INFLUENZA
    5. SEQUELAE AFTER SEVERE INFLUENZA ILLNESS
    6. INFLUENZA IMMUNITY AND POTENTIAL RE-INFECTION
  4. CLINICAL MANIFESTATIONS OF OTHER RESPIRATORY PATHOGENS
    1. RSV
    2. COCCI
    3. TUBERCULOSIS

This section covers the clinical manifestations of COVID-19 and influenza illness. Influenza-specific guidance and links for clinical information on other respiratory pathogens are located at the end of this section.

DIFFERENTIAL DIAGNOSIS FOR INFLUENZA LIKE ILLNESS (ILI)

Patients presenting with ILI could have COVID-19 or other known viral causes of pneumonia, depending on regional prevalence, such as influenza viruses and respiratory syncytial virus (RSV). Other common viral causes include: parainfluenza virus, adenovirus, rhinovirus, and human metapneumovirus. Common bacterial causes to consider are mycoplasma pneumonia, chlamydia pneumonia, and legionellosis. Coccidioidomycosis is an important fungal infection to keep in mind. In addition, non-infectious diseases such as vasculitis, dermatomyositis, and cryptogenic organizing pneumonia (formerly bronchiolitis obliterans with organizing pneumonia) should be considered.

Testing will be necessary to diagnose viral symptoms, as the symptoms of the common respiratory ailments can be similar and overlap. This is particularly true with influenza and RSV. Please refer to Table 5.1 and the Testing section for more information.

Table 5.1: Reported Symptoms of Influenza, COVID-19, and Respiratory Syncytial Virus (RSV). Please click on the image to open PDF for full table details.

Also, refer to Table 5.2 for a comparison summary of the different viral and clinical characteristics and other parameters of influenza and SARS-CoV-2 virus.

Table 5.2: Comparison Between Season Influenza and SARS-CoV-2. Please click on the image to open PDF for full table details.

The possibility of co-infection of influenza and COVID-19 should also be kept in mind. Studies have shown variability in frequency, ranging from 0.9% to 8% for influenza, but up to 20% for any respiratory virus. Some studies suggest having influenza and COVID-19 coinfection is a risk factor for severe disease, but others have shown no increased risk.

RSV season coincides with the influenza season, and coccidioidomycosis and tuberculosis are always a concern in endemic areas or transfers from endemic areas.

CLINICAL MANIFESTATIONS OF COVID-19

COVID-19 INCUBATION AND INFECTIOUS PERIOD

Please refer to Figure 5.1 for a summary of the relative time frames for incubation, infectiousness, and viral shedding for the coronavirus, SARS-CoV-2, which causes COVID-19 illness.

Figure 5.1: Incubation, Infection Period, and Test Positivity for SARS-COV-2. Please click on the image to open PDF for full table details.

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.

Patients are infectious before they realize they have the SARS-CoV-2 virus. The infectious period begins 2 days before symptom onset and ends 10 days after symptom onset for symptomatic patients. For asymptomatic patients, the infectious period can be considered over after 10 days from the initial positive test date.

SARS-CoV-2 viral nucleic acid testing can be positive for a prolonged time after recovery, through 90 days from the onset of symptoms for some, but viral culture confirming actively infectious virus has not been able to be cultured beyond day 10 from the onset of symptoms for immunocompetent people. Infectiousness may vary depending on whether the host is immunocompetent versus immunocompromised and on other factors, such as severity of illness, that are still under scientific investigation. Refer to the section on viral shedding in the Testing section.

SYMPTOMS OF COVID-19

Please refer to Table 5.1 for the symptoms of COVID-19, as well as influenza and RSV. Discussions on the differential diagnosis, influenza, and RSV are located at the end of this section.

Given that some patients can be entirely asymptomatic, despite infection, the range of symptoms in outpatients is exceedingly broad, but often falls along the spectrum between mild upper respiratory infections (URIs) and the more severe symptoms seen in hospitalized patients (see severe and critical disease below). Cases without cough or dyspnea, however, have been described, including presentations where gastrointestinal (GI) symptoms were the presenting complaint, fever was the only complaint, or a loss of the sense of smell (anosmia) or taste (dysgeusia) was the presenting feature. Fever is not always present.

PRESENTATIONS AND DISEASE COURSE OF COVID-19

Some examples of presentations of COVID-19 include, but are not limited to:

  • Classic: Fever, cough, fatigue, +/- dyspnea
  • GI predominant presentation: Nausea, vomiting, diarrhea
  • Loss of the sense of smell (anosmia) or taste (dysgeusia)
  • URI presentation: Rhinorrhea, sore throat, headache
  • In the aged and immunocompromised: Reduced alertness, reduced mobility, delirium, and absence of fever in addition to the atypical symptoms above

Asymptomatic cases are common. An Annals of Internal Medicine June 2020 review of the literature assessed a conservative asymptomatic rate of 30%, but stated it may be as high as 40-45%.

The disease tends to start indolently, with varying symptoms as above. Patients’ respiratory status may start to worsen, sometimes along with fevers, followed by marked improvement, only to then have a steep decline. For this reason, patients with COVID-19 need to be monitored closely for clinical status. Patients who are older or have comorbid conditions need especially heightened vigilance. Dyspnea has a median of 7 days after illness onset, sepsis – 9 days, acute respiratory distress syndrome (ARDS) with intensive care unit (ICU) admission and need for mechanical ventilation – 15 days.

Also, keep a high index of suspicion for COVID-19 involvement presenting as a new onset of thromboembolic disease, myocarditis, pericarditis, pleuritis, and other inflammatory conditions.

SPECTRUM OF COVID-19 DISEASE

Formal definitions from the National Institutes of Health (NIH) regarding definitions for the severity of disease for clinical decision-making, are found in the Treatment section. Percentages are based on national data.

Mild to Moderate Disease
Approximately 80% of laboratory-confirmed patients have mild to moderate disease, which includes non-pneumonia and mild pneumonia cases. Most people infected with the COVID-19 related virus have mild disease and recover.

Severe Disease
Approximately 14% of laboratory-confirmed patients have severe disease (dyspnea, respiratory rate ≥30/minute, blood oxygen saturation: 93%, and/or lung infiltrates >50% of the lung field within 24-48 hours). These patients need hospitalization. Older patients and patients with co-morbid conditions (see Table 5.3) are at higher risk of severe COVID-19 illness.

Critical Disease
Approximately 6% of laboratory-confirmed patients are critical (respiratory failure, septic shock, thromboembolic disease, and/or multiple organ dysfunction/failure). Older patients and patients with co-morbid conditions (see Table 5.3) are at higher risk of mortality and morbidity with COVID-19.

Patients who are over the age of 65 and have co-morbid conditions are at risk for significant morbidity and mortality from COVID-19 illness. See Table 5.3 which describes who is at risk for severe COVID-19.

Table 5.3: Persons at High Risk for Severe Morbidity and Mortality from COVID-19. Please click on the image to open PDF for full table details.

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 C-reactive protein (CRP; 81-86%)
    • Low procalcitonin (90-95%, unless severe disease develops)
    • High D-dimer, fibrinogen (and CRP) in those found with deep venous thrombosis (DVT) on admission
    • High lactic acid dehydrogenase (LDH) in those with critical disease
  • Typical chest X-ray findings in COVID-19:
    • Patchy ground-glass opacities, which tend to be predominantly peripheral and basal
    • The number of involved lung segments increases with more severe disease
    • Over time, patchy ground-glass opacities may coalesce into more dense consolidation
    • Infiltrates may be subtle
  • Chest X-ray findings which aren’t commonly seen, and might argue for an alternative or superimposed diagnosis:
    • Pleural effusion is uncommon (seen in only ~5%)
  • COVID-19 doesn’t appear to cause nodules, masses, cavitation, or lymphadenopathy

CLINICAL FACTORS OF COVID-19 ASSOCIATED WITH PROGRESSION TO SEVERE DISEASE AND RESPIRATORY FAILURE

Amongst hospitalized patients, the following clinical parameters have been shown to be statistically associated with respiratory demise:

Table 5.4: Laboratory Findings Associated with Severe COVID-19 Disease and Disease Progression to Respiratory Failure. Please click on the image to open PDF for full table details.

SEQUELAE AFTER SEVERE COVID-19 ILLNESS

COVID-19 illness appears to be particularly prone to persistent symptoms, even in mild cases and in the young and/or physically fit. Case reports and new studies are emerging about the long-term sequelae of COVID-19. A recent study showed that 87% had at least one persistent symptom 2 months after hospitalization. Data from another study suggested 10-15% of people do not recover quickly, including some with only mild disease. The variability in affected organs during illness also equates to variability in lingering symptoms and disease states after the illness.

One study showed that 35% of patients in all age ranges are not in their usual health after 2 weeks. 20% of young patients (age 18-34) with no comorbid conditions do not achieve their usual health after a median of 16 days from testing.

Research on over 200 outpatients demonstrated that more than half of individuals had symptoms consistent with severe fatigue a median of 10 weeks after their initial illness and almost one-third of those previously employed had not returned to work. Fatigue was not associated with initial disease severity, inflammatory markers, or immune response.

High rates of anxiety and depression have been reported on self-questionnaires and are more common in patients who are under 60 years of age.

Research has shown impaired pulmonary function 1 month after discharge and cardiac involvement over 2 months after diagnosis.

In other small studies, the most frequently reported persistent symptoms are fatigue, dyspnea, chest pain, arthralgia, and persistent cough. The inability to concentrate, dizziness, cognitive dysfunction, headaches, vision changes, persistent loss of hearing, taste, or smell, impaired mobility, extremity numbness, tremors, myalgia, memory loss, sleep dysregulation, palpitations, rashes and alopecia, and mood changes have also been reported, many persisting beyond 3 months from the acute illness. Patients may struggle with respiratory, cardiac, kidney, neurologic, or mental health problems after recovery from the acute illness.

Needing ICU-level care, needing ventilator support and/or thromboembolic events, acute renal failure, and multi-organ system involvement increases the risk of continued medical problems after acute resolution. A study from Germany showed more than 75% of people had abnormal cardiac findings and that myocarditis, pleuritis, and/or pericarditis was present in a significant number of patients. Patients requiring dialysis and persistent renal dysfunction have also been described. The concern is also rising for ongoing elevated systemic inflammation and blood clotting. Patients who had cardiac involvement while hospitalized with COVID-19 may have significant cardiac damage, ongoing myocarditis, and arrhythmias. Larger studies are underway to help understand more on this topic.

The etiology of COVID-19 long-term sequelae is thought to be multifactorial and may be related to organ damage during the acute phase, inflammation, ongoing viral activity, inadequate antibody response, and physical state prior to infection. Currently, there is no case definition for post-acute COVID-19 syndrome (also referred to as long COVID or long haulers), and no specific time frame has been established to define late sequelae of COVID-19. However, the Centers for Disease Control and Prevention (CDC) recently proposed defining late sequelae as sequelae that extend beyond 4 weeks after the initial infection.

Providers will need to listen to patients and be vigilant when seeing patients in follow up after COVID-19, even when the COVID course was mild. New symptoms can represent organ inflammation or dysfunction, be incapacitating, and at the very least can impact the quality of life dramatically.

COVID-19 IMMUNITY AND POTENTIAL RE-INFECTION

Re-infections are thought to be uncommon up to 90 days from the initial infection.

A positive test after recovery (“re-positive”) does not indicate whether a person is shedding virus that is infectious. The California Department of Public Health (CDPH) does not recommend re-testing (surveillance, pre/post-movement, or quarantine, etc.) within the 90-day window from the onset of initial symptoms or initial test, if asymptomatic, unless new symptoms appear after previous resolution. See details and CDPH criteria for re-testing for more information on how to identify and manage potential reinfections or false positive in “Re-testing Previously Positive Patients and Employees After Recovery from COVID-19“.

SARS-CoV-2 ASSOCIATED MULTISYSTEM INFLAMMATORY SYNDROME IN CHILDREN (MIS-C)

A new syndrome, MIS-C, appears to be a post-infectious complication of the SARS-CoV-2 infection, and the definition includes adults ages 18-21 years of age. Hence, it is important to keep the symptoms (below) in mind when seeing young adults since cough is often absent altogether. A high index of suspicion is needed because young, relatively healthy persons, may not show signs of COVID-19, and the precipitating event may not be recognized. Much is still unknown about MIS-C.

Patients will have a fever, systemic inflammation, and a variety of signs and symptoms of multi-organ system involvement. Up to Date on MIS-C lists the following presenting symptoms:

  • Persistent fevers (median duration 4-6 days) – 100% of patients
  • GI symptoms (abdominal pain, vomiting, diarrhea) – 60 to 100%
  • Rash – 45 to 76%
  • Conjunctivitis – 30 to 81%
  • Mucous membrane involvement – 27 to 76%
  • Neurocognitive symptoms (headache, lethargy, confusion) – 29 to 58%
  • Respiratory symptoms – 21 to 65%
  • Sore throat – 10 to 16%
  • Myalgia – 8 to 17%
  • Swollen hands/feet – 9 to 16%
  • Lymphadenopathy – 6 to 16%

If MIS-C is suspected, Up to Date recommends sending a respiratory specimen for NAAT and serology testing. Approximately 50 to 60% of patients have positive serology with negative PCR, and approximately 25 to 30% are positive on both tests. A minority of patients (approximately 10 to 15%) have negative results on both tests. In these cases, the diagnosis of MIS-C requires an epidemiologic link to SARS-CoV-2 (e.g., exposure to an individual with known COVID-19 within the four weeks prior to the onset of symptoms).

The CDC’s case definition for MIS-C is:

  • An individual aged <21 years presenting with: feveri, laboratory evidence of inflammationii, and evidence of clinically severe illness requiring hospitalization, with multisystem (>2) organ involvement (cardiac, renal, respiratory, hematologic, GI, dermatologic or neurological); AND
  • No plausible alternative diagnoses; AND
  • Positive for current or recent SARS-CoV-2 infection by RT-PCR, serology, or antigen test; or COVID-19 exposure within the 4 weeks prior to the onset of symptoms.

iFever >38.0°C for ≥24 hours, or report of subjective fever lasting ≥24 hours
iiIncluding, but not limited to, one or more of the following: An elevated CRP, erythrocyte sedimentation rate (ESR), fibrinogen, procalcitonin, d-dimer, ferritin, LDH or interleukin 6 (IL-6), elevated neutrophils, reduced lymphocytes, and low albumin

Certain symptoms of MIS-C often require ICU-level care, including blood pressure and inotropic support. These symptoms include severe abdominal pain, multisystem inflammation, shock, cardiac dysfunction, and, rarely, coronary artery aneurysm. A minority of children with MIS-C meet the criteria for typical or atypical Kawasaki disease below.

The CDC’s epidemiological case definition for Kawasaki’s Disease is:

Illness and fever for 5 days or more (or fever until the date of administration of intravenous immunoglobulin if given before the fifth day of fever), and the presence of at least 4 of the following 5 clinical signs:

  • Rash
  • Cervical lymphadenopathy (at least 1.5 cm in diameter)
  • Bilateral conjunctival injection
  • Oral mucosal changes
  • Peripheral extremity changes

Patients whose illness does not meet the above case definition but have a fever and coronary artery abnormalities are classified as having atypical or incomplete Kawasaki’s Disease.

RECOMMENDATIONS FOR SUSPECTED MIS-C

Patients with suspected MIS-C should be considered for a higher level of care (HLOC).

There is currently insufficient data for the NIH COVID-19 Treatment Guidelines Panel to recommend either for or against any therapeutic strategy for MIS-C management.

Healthcare providers who have cared or are caring for patients younger than 21 years of age meeting MIS-C criteria should report suspected cases to their local, state, or territorial health departments.

For additional information, please contact the CDC’s 24-hour Emergency Operations Center at 770-488-7100. After-hour phone numbers for health departments are available at the Council of State and Territorial Epidemiologists website (https://cdn.ymaws.com/www.cste.org/resource/resmgr/pdfs/pdfs2/epioncall3.pdf).

CLINICAL MANIFESTATIONS, INCUBATION, AND INFECTIVITY OF INFLUENZA

The common presenting symptoms of influenza are abrupt onset of fever, headache, myalgia, and malaise, often with a dry cough, sore throat, and nasal discharge. These symptoms are very similar to COVID-19. Please refer to Table 5.1 for a summary of the symptoms of influenza.

The typical incubation period for influenza is 1-4 days, with an average of 2 days. Viral shedding can predate symptoms by 24-48 hours but has lower titers than during the symptomatic phase. In immunocompetent persons, the mean viral shedding lasts 6 days. The incubation and infectious periods of influenza are much shorter than for COVID-19 and are detailed in Table 5.2 Comparison of Influenza, COVID-19 and RSV.

In asymptomatic and mild cases of influenza, viral shedding is shorter and declines more rapidly than in more symptomatic or severe disease. The elderly, immunocompromised, and those with chronic conditions also have longer viral shedding, up to two weeks in those not treated with anti-viral medication.

SPECTRUM OF INFLUENZA DISEASE

The spectrum of influenza disease varies with the subtype. In uncomplicated influenza, symptoms resolve over 2-5 days. Some patients have lingering fatigue for several weeks after the acute illness (“post-influenza asthenia”).

The most common complication of influenza is pneumonia. Primary influenza viral pneumonia can be deadly. It should be suspected when high fevers and dyspnea occur and when symptoms persist instead of resolving after 5-7 days.

Secondary bacterial pneumonia is an important complication of influenza and contributes substantially to morbidity and mortality, especially among individuals ≥65 years of age. The common presentation is either a gradual worsening or an initially improved patient who relapses with high fevers, cough, productive sputum, and an abnormal x-ray. Streptococcus pneumoniae and Staphylococcus aureus are the most common bacterial secondary pathogens in influenza lower respiratory disease. Staphylococcus aureus can also cause toxic shock syndrome in active influenza infection. When Methicillin-resistant Staphylococcus aureus (MRSA) is the co-pathogen involved, the mortality, even in young patients, is high.

Influenza has central nervous system complications: encephalopathy, encephalitis, transverse myelitis, aseptic meningitis, and Guillain-Barré syndrome.

Other important complications of influenza include myositis and rhabdomyolysis, although they are much more commonly reported in children than adults.

An association with acute myocardial infarction and influenza infection exists. Influenza vaccination lowers the risk of cardiac complications.

Myocarditis and pericarditis from influenza infection are rare but do occur.

Influenza infection can also cause a worsening of current medical conditions.

CLINICAL FACTORS OF INFLUENZA ASSOCIATED WITH PROGRESSION TO SEVERE DISEASE, RESPIRATORY FAILURE, AND OTHER COMPLICATIONS

See Table 5.5 for a list of patients that are at risk for complications from influenza. The list is quite similar to that for COVID-19, but note the addition of Native American and Alaskan Natives as well as persons aged 18-19 who are on long-term aspirin therapy.

Table 5.5: Adult Groups at High Risk for Serious Influenza Complications. Please click on the image to open PDF for full table details.

LABORATORY FINDINGS ASSOCIATED WITH INFLUENZA

Laboratory findings are generally not helpful in making the diagnosis of influenza. Leukocyte counts are normal or low early in the illness but may become elevated later in the illness. White blood cell counts >15,000 cells/microL suggest bacterial superinfection.

SEQUELAE AFTER SEVERE INFLUENZA ILLNESS

Some patients have lingering fatigue for several weeks after the acute illness (“post-influenza asthenia”). In severe disease, sequelae from severe lung pathology, especially requiring ventilator support, or from multi-organ system involvement, can persist and cause morbidity long after the acute infection. Vigilance and close follow-up are needed for all with severe influenza infections.

INFLUENZA IMMUNITY AND POTENTIAL RE-INFECTION

Immunity, natural or vaccine-induced, lasts approximately 6 months. The antigens of influenza are constantly mutating (“antigenic shift”) and circulating strains vary year to year. Re-infections during the 6-month timeframe are considered rare. However, reinfection with a different strain can and does occur.

For more information on influenza, please refer to the CDC on Influenza, Up To Date Clinical Manifestations of Seasonal Influenza in Adults, and the Influenza Treatment section of this guidance.

CLINICAL MANIFESTATIONS OF OTHER RESPIRATORY PATHOGENS

RSV

Adults who get infected with RSV usually have mild or no symptoms. Symptoms, if present, are usually consistent with an upper respiratory tract infection which can include rhinorrhea, pharyngitis, cough, headache, fatigue, and fever (see Table 5.1). The disease usually lasts less than five days. In vulnerable adult populations, RSV can have very high morbidity and mortality.

Those at high risk for severe illness from RSV include:

  • Older adults, especially those 65 years and older
  • Adults with chronic lung or heart disease
  • Adults with weakened immune systems

RSV can sometimes also lead to exacerbation of serious conditions such as:

  • Asthma
  • Chronic obstructive pulmonary disease (COPD)
  • Congestive heart failure

More information on RSV can be found at the CDC website on RSV and Up to Date on adult RSV. Prevalence and case tracking are available at the CDPH Respiratory Pathogen Report.

Treatment information is located in the RSV Treatment section of this guidance.

COCCI

More information on coccidioidomycosis can be found in the CCHCS PHB Coccidioidomycosis Guidance documents: Cocci Skin Test Education and Coccidioidomycosis Surveillance (CDCR networking is required for access), the CDPH Valley Fever webpage, the CDC Valley Fever webpage, the Infectious Disease Society of America (IDSA) 2016 Treatment Guidelines, and Up To Date on Coccidioidomycosis.

TUBERCULOSIS

More information on Tuberculosis can be found in the IDSA and American Thoracic Society of America Clinical Practice Guidelines: Diagnosis of TB in Adults and Children.

TESTING - Updated 2/19/2021

TABLE OF CONTENTS

  1. INTRODUCTION COVID-19, INFLUENZA, AND OTHER RESPIRATORY VIRUS TESTING
  2. COVID-19 AND INFLUENZA DUAL TESTING
    1. DIAGNOSTIC COVID-19 AND INFLUENZA TESTING FOR SYMPTOMATIC PATIENTS
    2. TABLE 6.1 RECOMMENDED RESPIRATORY VIRAL TESTING BY CLINICAL PRESENTATION, INCLUDING CONFIRMATORY PCR TESTING
    3. STRATEGIES TO MAXIMIZE SENSITIVITY OF COVID-19 AND INFLUENZA TESTING
    4. PATIENT EDUCATION FOR VIRAL TESTING FOR COVID-19 AND INFLUENZA
    5. TESTING CONSIDERATIONS FOR COVID-19 AND INFLUENZA SINGLE OR DUAL-PATHOGEN OUTBREAKS
  3. COVID-19 TEST TYPES
    1. TABLE 6.2 OVERVIEW OF TEST TYPES FOR COVID-19
    2. TABLE 6.3 COVID-19 TESTING DEFINITIONS AND STRATEGIES
    3. COVID-19 NUCLEIC ACID AMPLIFICATION (NAAT)/PCR TESTING
    4. COVID-19 RAPID ANTIGEN TESTING
    5. COVID-19 SEROLOGY (ANTIBODY) TESTING
  4. COVID-19 OUTBREAK RESPONSE TESTING
    1. PRIORITIZING CONTACTS
    2. COHORTS: COVID-19 MASS TESTING
    3. COVID-19 EMPLOYEE TESTING DURING OUTBREAKS
    4. COVID-19 TESTING OF EXPOSED QUARANTINED PATIENTS AND PRIOR TO RELEASE FROM QUARANTINE
  5. ROUTINE AND SURVEILLANCE COVID-19 TESTING AMONG ASYMPTOMATIC AND NON-EXPOSED PATIENTS
    1. ROUTINE TESTING OF NON-EXPOSED ASYMPTOMATIC PATIENTS AT HIGHER RISK OF COVID-19 MORBIDITY AND MORTALITY
    2. ROUTINE COVID-19 TESTING OF INMATE WORKERS
    3. COVID-19 TESTING OF TRANSFERS
    4. COVID-19 TESTING OF EXPEDITED RELEASES/PAROLEES
    5. COVID-19 PUBLIC HEALTH SURVEILLANCE TESTING
  6. CONCERN FOR COVID-19 FALSE-POSITIVES: WHAT TO DO
    1. IF YOUR PATIENT IS DEEMED A FALSE POSITIVE
  7. RE-TESTING PREVIOUSLY POSITIVE PATIENTS AFTER RECOVERY FROM COVID-19
    1. SUMMARY OF LITERATURE ON COVID-19 VIRAL SHEDDING AND RE-INFECTIONS
    2. POTENTIAL COVID-19 RE-INFECTIONS
  8. INFLUENZA VIRAL TESTING
    1. INFLUENZA TEST TYPES
    2. INFLUENZA OUTBREAK TESTING
  9. OTHER RESPIRATORY VIRUS TESTING CONSIDERATIONS
  10. APPENDIX 5: COVID-19 CASE AND CONTACT SHAREPOINT REPORTING TOOL
  11. APPENDIX 9: MEMO TEMPLATE FOR NOTIFICATION OF COVID-19 CASES AND CONTACTS RELEASED TO THE COMMUNITY
  12. APPENDIX 13: COVID SCREENING AND TESTING MATRIX FOR PATIENT MOVEMENT
  13. APPENDIX 19: COVID-19 AND INFLUENZA SPECIMEN COLLECTION AND TEST ORDERING INFORMATION

1. INTRODUCTION COVID-19, INFLUENZA, AND OTHER RESPIRATORY VIRUS TESTING

This section contains information on diagnostic tests and testing strategies for COVID-19, influenza, and other respiratory pathogens. Influenza specific and other respiratory pathogen guidance are located at the bottom of this section.

It is impossible to reliably distinguish between influenza and COVID-19 clinically (see the Reported Symptoms of COVID-19, Influenza, and Respiratory Syncytial Virus table – Table 5.1). For details on when to test for both influenza and COVID-19, see the subsection Diagnostic COVID-19 and Influenza Testing for Symptomatic Patients.

The onset of the annual influenza season and/or the prevalence of influenza is designated by the California Department of Public Health (CDPH) when prevalence is “Local” or higher (See CDPH Weekly Influenza Surveillance Reports).

Always keep a differential in mind and use clinical judgment on the need for other viral pathogen testing. See the subsections in the Clinical Manifestations section: Differential Diagnosis of Influenza-Like Illness and Clinical Manifestations of Other Respiratory Pathogens.

Until each annual influenza season ends, there will likely be COVID-influenza dual pathogen outbreaks (see the Public Health Definitions section). At each facility, please assess the stock of testing supplies, including collection swabs for COVID-19 and influenza PCR, the COVID-19/influenza combination PCR test, the COVID-19 rapid antigen test, the rapid influenza test (RIDT), and the point of care (POC) COVID-19/influenza combination test.

2. COVID-19 AND INFLUENZA DUAL TESTING

DIAGNOSTIC COVID-19 AND INFLUENZA TESTING FOR SYMPTOMATIC PATIENTS

The symptoms of different respiratory pathogens are very similar. See the Reported Symptoms of COVID-19, Influenza, and Respiratory Syncytial Virus (RSV) table (Table 5.1).

At all times, all patients with ILI symptoms (including those who develop symptoms in quarantine for an index influenza or COVID-19 case) need testing for both COVID-19 and influenza.

Once either the annual influenza season arrives, there are community influenza cases, or an outbreak has occurred (at least one lab-confirmed case of influenza in the setting of a cluster [2 or more cases] of ILI within 72 hours), test all patients with symptoms listed in the Reported Symptoms of COVID-19, Influenza, and RSV table (Table 5.1) for both COVID-19 and influenza. A combination influenza/SARS-CoV-2 POC and PCR test is now available. Please refer to Appendix 19 for more information on the test itself.

Influenza testing should occur regardless of whether the patient was vaccinated or not.

Always use clinical judgment on the need to test for viral pathogens other than COVID-19, including influenza

Please see Table 6.1 for helpful guidance on testing indications for COVID-19 and influenza in different clinical scenarios.

Table 6.1: Recommended Respiratory Viral Testing by Clinical Presentation, Including Confirmatory RT-PCR Testing. Please click on the image to open PDF for full table details.

Patients presenting with symptoms of pneumonia (subjective fever or temperature >100° F, cough, or shortness of breath) should be prioritized for testing. Patients with these symptoms who are over age 65 or with medical comorbidities are at risk for complications and are the highest priority for COVID-19 and influenza testing (see Differential Diagnosis subsection in the Clinical Manifestations section). Please refer to the high risk for severe disease tables for COVID-19 (Table 5.3) and influenza (Table 5.5). RSV should also be considered in this vulnerable population and ordered if clinically indicated. The next priority would be those at risk of being exposed or are a high risk of transmitting to others (e.g., an inmate worker with multiple contacts or resides in dorm housing).

Repeat testing is recommended for patients with a high clinical suspicion of COVID-19 or influenza, but an initial negative test.

Testing is not recommended for explained symptoms such as typical allergic symptoms in a patient with a known history or other chronic conditions.

Note: Patients with undiagnosed symptoms or requiring POC confirmation should be housed in single cells with closed solid doors and not with any other cohort.

Symptomatic patients who refuse testing will still need to be isolated in single cells with solid walls and doors and complete the COVID-19 release from isolation criteria when exposed to influenza or COVID-19 or both. Please refer to the Control Strategies for Suspect and Confirmed section for more details on isolation.

Symptomatic patients require testing regardless of whether they are < or >90 days out from their initial COVID-19 infection (from the onset of symptoms or first positive test if asymptomatic). See the discussion below regarding re-positives.

STRATEGIES TO MAXIMIZE SENSITIVITY OF COVID-19 AND INFLUENZA TESTING

  • Test early:
    • COVID-19: The Centers for Disease Control (CDC) recommend that specimens should be collected as soon as possible once a suspect case is identified, regardless of the time of symptom onset. Testing in the first 5 days of symptoms will give the best sensitivity for both antigen testing and PCR for COVID-19. Viral load is highest in respiratory specimens early on in the disease when symptoms tend to be mild (the first five days). The median time to a negative PCR is 9 days. Studies show a patient with COVID-19 may have a negative upper respiratory PCR sample, while the virus can still be found in the lower respiratory tract in a patient with pneumonia.
    • Influenza: Specimens should be collected as soon as possible, preferably within the first 24-72 hours of symptoms onset.
  • Use the appropriate collection technique:
    Use anterior nares (AN) and oropharyngeal (OP), or nasopharyngeal (NP) and OP collection together, if possible, for either influenza or COVID-19 (see Appendix 19 on this topic).
  • Test frequently (COVID-19):
    Using a lower sensitivity test like the antigen Sofia 2 test for COVID-19 or influenza more often is an excellent way to increase sensitivity. Repeat testing as much as every 2-3 days can push the sensitivity to approximately 99%. Since the duration of influenza is much shorter than COVID-19, the utility of repeat testing will best be suited for COVID-19.

PATIENT EDUCATION FOR VIRAL TESTING FOR COVID-19 AND INFLUENZA

Part of testing is education. Patients need information regarding why testing is important, symptoms of COVID-19 and influenza, availability of testing, risks of getting infected, and transmission prevention. Patients will need to know why they need testing for influenza even though they received an influenza vaccine. Patients will need to understand that COVID-19 precautions will outweigh influenza when in doubt. If patients receive COVID-19 or influenza testing and have not been vaccinated for influenza, this education is an opportune time to advocate for vaccine importance.

A plan for giving test results and education for COVID-19 and influenza should be in place. See patient education resources on COVID-19 testing, isolation, and recovery. Also, see the nursing scripts on discussing COVID-19 isolation with patients and the influenza patient education resources.

TESTING CONSIDERATIONS FOR COVID-19 AND INFLUENZA SINGLE OR DUAL-PATHOGEN OUTBREAKS

It is important to recognize that outbreaks of respiratory viruses may occur alone or together, making testing and control more complicated. The occurrence of a dual outbreak is likely during any influenza season where COVID-19 viral circulation remains. Early testing, isolation of symptomatic patients, quarantine of contacts, and COVID-19 quarantine testing of contacts is crucial to control an outbreak. Note: persons quarantined for influenza only do not require testing.

Symptom and temperature screening alone is inadequate to promptly identify and isolate infected persons in congregate settings such as correctional and detention facilities. During the influenza season, ILI symptoms could be influenza or a co-infection, or any number of self-limited winter upper respiratory viral pathogens. See the Reported Symptoms of COVID-19, Influenza, and RSV table (Table 5.1). Persons with COVID-19, in particular, can be asymptomatic, or symptoms can be subtle and non-specific. In addition, incarcerated persons may be reluctant to report symptoms, even with active screening. Asymptomatic or pre-symptomatic staff or residents may contribute to transmission. Recent data from COVID-19 outbreaks indicate that symptom-based testing can fail to identify more than 80% of COVID-19 cases in these congregate settings. Influenza has a pre-symptomatic phase of 1 day before symptoms. There are also a high number of asymptomatic influenza cases, but the role in transmission is unclear.

Testing does not replace or preclude other infection prevention and control interventions, including case investigation, isolation of infected individuals, quarantine of exposed individuals, surveillance of quarantined individuals, screening of employees at the start of a shift for signs and symptoms of COVID-19 or influenza, universal use of cloth face coverings by staff and inmates for source control, use of recommended personal protective equipment (PPE) by staff working with suspect and confirmed cases for either illness, and environmental cleaning and disinfection (see Environmental Infection Control).

Order supplies in preparation for dual outbreaks (see Appendix 19 for more information). Please refer to the update on Ordering Sofia-2 Compatible COVID19 Testing Kits (CDCR networking is required for access) and Appendix 19 for more information on laboratory specifications.

3. COVID-19 TEST TYPES

See Appendix 19 for collection and laboratory details, Table 6.2 for a summary of the different test types for COVID-19, Table 6.3 for an overview of the different testing strategies for COVID-19 and their definitions, and Appendix 8 for a summary of the Infectious Diseases Society of America (IDSA) SARS-CoV-2 testing recommendations.

Table 6.2: Overview of Test Types for COVID-19. Please click on the image to open PDF for full table details.
Table 6.3: COVID-19 Testing Definitions and Strategies. Please click on the image to open PDF for full table details.

COVID-19 NUCLEIC ACID AMPLIFICATION (NAAT)/PCR TESTING

Quest labs should be considered the first-line COVID-19 testing laboratory. Quest provides a high-quality PCR with a turn-around time of typically 2-3 days and should be used as much as is practical before using a third party, non-electronic health records system (EHRS) interfaced laboratory.

There are SARS-CoV-2 (COVID-19) only Quest PCR tests and now a COVID-19 and influenza combination test. The EHRS order for the combination test is being built and will be available soon.

In the event of prolonged turn-around times with Quest, testing may be available through the local health department (LHD). Each institution should have a local operating procedure (LOP) for accessing COVID-19 testing through the county. When testing outside of Quest is necessary, the LHD will serve as the liaison to access other laboratories, such as the University of California, San Francisco (UCSF) Biohub.

Requesting Quest COVID-19 Test Kits: For information on ordering test kits, see Appendix 19.

COVID-19 RAPID ANTIGEN TESTING

The Quidel Sofia 2 Clinical Laboratory Improvement Amendments (CLIA)-waived rapid antigen test uses an immunofluorescent assay for a COVID-19 antigen. This POC test accurately detects viral proteins in about 15 minutes. COVID-19-influenza combination POC test cassettes are now available. Refer to the COVID-19 Antigen Test Ordering Information and FAQs in Appendix 19 the Quidel Sofia2 SARS + Flu Antigen information website, and the Sofia 2 device information on Quidel’s website (User Manual, Quick Start Guide, and FAQs are under “Product Documentation” near the bottom of the page).


Confirmation of COVID-19 POC (Rapid Antigen) Testing
All positive POC tests need to be confirmed using RT-PCR. See Table 6.1. Patients who are within the first 90 days of being resolved should not be tested unless they develop symptoms. See the section on Re-Testing Previously Positive Patients after Recovery from COVID-19.

Patients who test positive by POC have a presumptive diagnosis of COVID-19 and should be considered infectious. These patients should be isolated in single-person isolation with solid walls and a solid door pending confirmation by PCR. Because of the risk that the POC is a false positive, these patients should not be housed in cohort-isolation with other COVID-19 patients until PCR confirms the diagnosis.

Negative POC tests need to be confirmed using RT-PCR if the patient is symptomatic or there is a clinical suspicion for infection. See Table 6.1.

COVID-19 SEROLOGY (ANTIBODY) TESTING

At this time, serology testing for COVID-19 is not recommended for determining COVID-19 immunity. Antibodies become detectable about 2 weeks after the start of the infection. In addition to concerns with possible cross-reactivity with other coronaviruses, which and what levels of antibodies might confer immunity is unknown, and patients vary widely in their antibody response. According to the CDC, antibody test results should not be used to group people in correctional facilities in actionable cohorts.

Please refer to the Overview of Testing for COVID-19 table (Table 6.2) for more details on indications for COVID-19 viral testing.

4. COVID-19 OUTBREAK RESPONSE TESTING

When a COVID-19 outbreak is suspected based on the identification of one or more PCR-confirmed cases among inmates, institutions should immediately notify and engage the local public health department and the Public Health Branch (PHB) to support integrated staff-inmate contact investigations and consult on creating testing strategies. The PHB is available for consultation: CDCRCCHCSPublicHealthBranch@cdcr.ca.gov.

See Table 6.3, which describes the testing definitions and strategies, including the goals, timing, and frequency of testing.

As soon as possible, after one or more COVID-19 positive individuals (patients or staff) are identified in a facility or housing unit, outbreak response testing should be directed to exposed individuals susceptible to infection. Broad-based testing strategies, including testing of asymptomatic patients in the entire facility or institution, should be used to determine the extent of COVID-19 spread within the facility. Early resolved patients less than 90 days from their primary infection should not be tested unless they develop symptoms.

Testing strategies should consider the stage of the ongoing outbreak and implement more frequent twice-weekly testing in the context of escalating outbreaks and less frequent once-weekly testing when the transmission has slowed.

Refer to the CDC’s Performing Broad-Based Testing for SARS-CoV-2 in Congregate Settings for more information.

PCR is generally used for outbreak response testing, including mass testing. Antigen POC testing can be used if the number of tests needed is manageable, turn-around times for PCR are too long for the situation, and/or to target test those with the highest risk to get a quick estimate of the extent of the outbreak.

When testing is performed, a negative test only indicates that an individual did not have a detectable infection at the time of testing; individuals might have a COVID-19 infection still in the incubation period.

See the Recommended Respiratory Viral Testing by Clinical Presentation, Including Confirmatory PCR Testing table (Table 6.1) and Confirmation of COVID-19 POC (Rapid Antigen) Testing for information on when confirmatory PCR testing is needed for POC testing.

Testing must be accompanied by operational plans for use and follow-up of test results, including:

  • How patients will be educated about why testing is being done (see the patient education materials located in the Patient Education tab on the COVID-19 webpage – CDCR networking is required for access).
  • How patients who choose not to be tested will be managed
  • How individual results will be explained
  • How results will be used to guide the implementation of infection control measures: isolation, quarantine, and cohorting
  • How results will be communicated to ensure appropriate management when inmates are released or transferred

PRIORITIZING CONTACTS

Test all contacts (people who may have been exposed), if possible. An exposed contact is an asymptomatic person who may have had contact with a person who is a highly suspect case or a PCR-confirmed positive SARS-CoV-2 case and thus has the potential to become infected themselves. The more promptly this testing is done, the more likely the outbreak can be controlled.

If needed, testing can be prioritized as follows, in descending order: Exposure to a highly suspect or confirmed case includes but are not limited to:

  • Cellmates
  • Close proximity to highly suspect or confirmed cases (<6 feet proximity for at least a cumulative time of 10 minutes or direct contact with secretions/being coughed or sneezed upon), regardless of whether the case and/or contacts were masked and outside of 90 days from a prior infection.
    • Close exposures to the case:
      • Cellmates or inmates in adjacent beds and cells in the same housing unit of a highly suspect or confirmed case or linkage to a high-risk group defined by public health during an outbreak (e.g., an affected dorm, housing unit, or yard).
      • Sharing common spaces such as the yard, shower, dining hall, or day room and being in the same space for activities (e.g., work environments, in classrooms, groups, social activities, church, clinic visits, medication line, and commissary line) with highly suspect or confirmed cases.

Serial re-testing of housing unit inmates and others who are at potential exposure risk is necessary. See the section below on quarantine testing.

Consideration can be given to testing individual inmates at the highest risk of complications of COVID-19 based on underlying conditions and/or age. Inmates who test negative can be separated from the general inmate population to prevent becoming infected. Those who test positive should be isolated and closely monitored for progression of the illness.

COHORTS: COVID-19 MASS TESTING

Mass testing involves testing a moderate or large group of individuals suspected of having been exposed to COVID-19. Mass testing may include the entire institution, one or more yards, or one or more housing units. Workers with a common worksite exposure may also be tested as a group. Because mass testing helps determine the extent of transmission, it should also be used in areas not known to currently be involved in the active outbreak.

Inmates should be placed into separate cohorts based on exposure and test results. See Control Strategies for Suspected and Confirmed Cases and Control Strategies for Contacts to Cases sections.

Inmates are allowed to refuse to test. Inmates exposed in the previous 14 days need to be quarantined. If it is necessary to cohort quarantined inmates, the cohort should share exposure history and test outcome (negative versus refused).

Given the potential for high numbers of asymptomatic infections, ensure that plans include isolation options to house large numbers of infected individuals and quarantine options to house large numbers of close contacts, ideally separating exposure cohorts. Consider how the facility’s housing operations could be modified for multiple test result scenarios (e.g., if testing reveals that 10%, 30%, 50%, or more of incarcerated or detained persons test positive for COVID-19).

COVID-19 EMPLOYEE TESTING DURING OUTBREAKS

Integrating contact investigations and coordinating testing strategies amongst staff and inmates is imperative if successful disruption of viral transmission is to occur. For all situations that involve staff exposure, please contact Human Resources and the Office of Employee Health for further information/guidance. The CDCR Office of Employee Health Testing website can provide information on testing resources. Also see the COVID-19 Contact Tracing and Testing for Employees and Establishment of a Statewide Employee Health Program memos.

COVID-19 TESTING OF EXPOSED QUARANTINED PATIENTS AND PRIOR TO RELEASE FROM QUARANTINE

Patients who develop symptoms while in quarantine should be immediately isolated in a single cell with a solid walls and a solid door while awaiting test results.

Asymptomatic patients who have been exposed to COVID-19 should be offered viral testing, minimally, at the beginning (within 24 hours if they have not been tested within the last 7 days, or at 3 days post exposure), middle, and end of quarantine. If they test positive, they need to be removed from quarantine and isolated.

Because test sensitivity is imperfect, clinical judgment is essential in interpreting negative test results and discerning if additional testing is indicated. This is especially the case in high-risk exposures or exposures to persons at high risk of transmission to others (e.g., aerosol-generating procedures [AGPs] or job type).

Exposed patients who initially test negative shall be re-tested every 3-7 days. The specific re-testing interval that a facility chooses should be based on the stage of the ongoing outbreak (i.e., more frequent testing in the context of escalating outbreaks, less frequent testing when the transmission has slowed) and the risk level of the exposure (more frequent for higher risk exposures). Please refer to the Control Strategies for Contacts to Cases for more information on quarantine for case contacts.

Quarantine testing of exposed persons with POC antigen tests may be useful in some situations if immediate results are necessary, and PCR turn-around times are too long. Please refer to the section above on when confirmatory testing for POC should occur. Use only PCR when testing for release from quarantine.

For asymptomatic contacts of cases, follow up of negative POC tests with PCR is not generally necessary. However, if there is a clinical suspicion that the patient is infected, using PCR to confirm a negative POC is indicated.

Testing is also required to be released from quarantine. No sooner than quarantine day 12 of 14, and within 2 days prior to release, all patients shall be tested with PCR and have a negative result. Patients may refuse, but their quarantine time will be extended. For more details, please see the Control Strategies for Contacts of Cases section, the Release from Quarantine subsection, the Release from Quarantine Algorithm (Figure 13.1), and the last page of the Movement Matrix (Appendix 13) for more information. You may also request access to the COVID Transfer Registry to view patients’ isolation/quarantine status (CDCR networking is required for access).

Exposed Individuals <90 days from Prior COVID-19 Infection

The only persons who do not require testing when exposed are individuals who are within 90 days of their prior infection.

5. ROUTINE AND SURVEILLANCE COVID-19 TESTING AMONG ASYMPTOMATIC AND NON-EXPOSED PATIENTS

There are many situations where testing of asymptomatic, non-exposed persons will occur such as for high-risk patients, transfers and jail intakes, and surveillance testing. These testing recommendations provide strategies for monitoring potential transmission in asymptomatic, non-exposed persons. The goal of this asymptomatic monitoring is to prevent population transmission and to prevent individual morbidity and mortality through early identification and isolation of unrecognized COVID-19 cases.

ROUTINE TESTING OF NON-EXPOSED ASYMPTOMATIC PATIENTS AT HIGHER RISK OF COVID-19 MORBIDITY AND MORTALITY

  • In general, PCR can be used for routine testing of high-risk patients. The rapid POC test may be useful when a result is needed urgently, and PCR turn-around times are too long.
  • Routine testing among asymptomatic patients is recommended for those using AGPs such as nebulizers or continuous positive airway pressure (CPAP); repeat or serial testing may be valuable for patients with ongoing risk. This is particularly important if the areas in which these devices are used cannot be adequately ventilated or cleaned. In addition to routine serial testing, antigen POC testing may be used immediately before procedures. The higher the risk, the more frequently the testing should occur.
  • Consider routine (e.g., at least monthly) testing for patients aged 65 or older or with medical comorbidities that put them at risk for complications of COVID-19 (see Table 5.3 and the COVID-19 Risk Registry – CDCR networking is required for access).
  • Similar to the community, patients should be able to request COVID-19 testing regardless of symptom status.

ROUTINE COVID-19 TESTING OF INMATE WORKERS

CDC recommends expanding COVID-19 surveillance testing for workers in high-density worksites, worksites with large numbers of close contacts, and in healthcare and correctional environments.

Inmate workers in job categories with higher than average COVID-19 case rates in CCHCS are recommended to have routine weekly testing.

Leadership in each institution should review local healthcare and institutional operations and Prison Industry Authority (PIA) industries and identify inmate workers and worksites that may be at higher risk of infection or transmission, including those who work in:

  • Enclosed spaces with employees or in areas where employees congregate
  • Enclosed spaces with inmates outside of their housing unit
  • Healthcare or other areas where patients are quarantined or isolated for COVID-19 or receive care
  • Jobs that provide health aid or peer support for inmates with disabilities or other assistance needs
  • Jobs that require movement about the facility or institution

The following inmate workers should be offered weekly viral testing unless previously recovered from COVID-19 (within 90 days of first the positive test):

  • Culinary workers, including in kitchens, food preparation areas, scullery, and dining rooms
  • PIA workers, including in manufacturing or fabrication, food processing or packaging, fabric products, and health facilities maintenance custodial assignments
  • Workers in Correctional Treatment Centers (CTC), Skilled Nursing Facilities (SNF), and other healthcare environments, including all workers in the three SNF institutions (CCWF, CHCF, CMF)
  • American with Disabilities Act (ADA) workers and others (including voluntary) who provide health aid or peer support (e.g., mental health, recreational), and Inmate Advisory Council members working outside of their housing units
  • Porters, janitors, and clerks working in locations where employees work or congregate outside of their housing units
  • Plant operations workers in enclosed spaces with others (e.g., warehouses, tool rooms, garages)
  • All inmate workers should be screened for symptoms consistent with COVID-19 before leaving their housing units to report to the worksite as described in the Screening of Critical Inmate Workers memorandum (CDCR networking access is required).

COVID-19 TESTING OF TRANSFERS

Transfers to and from the institution may increase the risk of introduction and spread of COVID-19 between facilities. The COVID Screening and Testing Matrix for Patient Movement (Appendix 13) provides additional specifications on the testing strategy, housing, and what to do if the patient refuses to test. You may also request access to the COVID Transfer Registry to view patients’ isolation/quarantine status (CDCR networking is required for access).

COVID-19 TESTING OF EXPEDITED RELEASES/PAROLEES

COVID-19 PUBLIC HEALTH SURVEILLANCE TESTING

Surveillance testing is used to determine the extent of active infection in a population and to detect outbreaks in an early phase, even before developing symptoms. Early detection and rapid outbreak response can limit the spread of infection and prevent morbidity and mortality. Additionally, with sufficient numbers of appropriately selected patients testing negative, an institution can demonstrate with some confidence, the absence of an outbreak. PCR is preferred for surveillance testing.

The public health surveillance sample described below is appropriate for institutions (or parts of institutions) that are not responding to outbreaks or known exposures.

How Many to Test for COVID-19 Surveillance
Public health surveillance testing using PCR should be conducted weekly. Each cohort of patients at the prison that regularly commingles or shares airspace should be identified and have a sample tested each week. Depending on custody factors and the built environment, a cohort could consist of a single housing unit, a group of housing units on the same yard, or an entire yard. Using the following principles to guide the selection of patients for surveillance testing:

  • For cohorts with 100 or more susceptible patients, test 25 patients each week. A sample of 25 patients will allow detection of a prevalence of 10% with 92% confidence.
  • For cohorts with fewer than 100 susceptible patients, test 25% of the susceptible population each week.
  • If there are multiple housing units with significant numbers of susceptible patients within a cohort, patients from each unit should be tested. In other words, do not select the entire sample from a single housing unit.
  • Except for patients who are within the first 90 days after their first confirmed COVID-19 infection (early resolved period), all patients are considered susceptible for the purposes of surveillance testing. However, in the surveillance program, patients who are immunologically naïve (no history of COVID-19 infection or vaccination) should be the first priority for sampling since they are the most likely to become infected if exposed. Patients who are more than 180 days from their first infection should be the second priority for testing after the immunologically naïve.
  • Testing of quarantined patients does not count toward the surveillance target in a cohort. Quarantined patients are not regularly comingling with the non-quarantined population, and therefore are not an appropriate sample.
  • Surveillance testing of workers in a cohort does count toward the surveillance target of 25 (or 25%).
  • Other testing of non-quarantined, asymptomatic, susceptible patients in the cohort may count toward the surveillance target of 25 (or 25%).

6. CONCERN FOR COVID-19 FALSE-POSITIVES: WHAT TO DO

All viral testing has the potential for false positives and false negatives. False positives can occur among patients with no history of COVID-19 as well as patients who have recently resolved infections (<90 days) and patients with more distant infections (>90 days prior). False positives have been documented for both the COVID-19 point of care antigen tests and the Quest RT-PCR test. Please note there is a difference between a false positive test result and a positive that reflects non-infectious shedding (true positives that are not clinically significant).

Being in a congregate setting, we must be conservative in our policy toward potential false positives. The CDPH (July 2020) supports the policy that at CDCR, every positive viral test should be treated as a true positive unless proven otherwise. Our setting and its extremely high risk of widespread transmission requires us to be more conservative regarding false positives.

The determination that a test was a false first positive or false re-positive, and the patient is NOT infected with COVID-19, should only be made after a thorough investigation. Hence, all patients with positive tests, even if suspected of being a false positive, must be isolated with full isolation PPE used, have twice-daily medical monitoring, and have a contact investigation conducted immediately. Close contacts should be quarantined and tested.

A positive result is more likely to be a false positive when there has not been an exposure and the patient is asymptomatic. Below details the information that should be considered when trying to determine if a positive test is actually a false positive:

  1. The patient is asymptomatic when tested and remains asymptomatic
  2. The patient has no known exposures and was not in quarantine for suspected exposure
  3. PCR testing of contacts reveals no other positive cases
  4. Subsequent PCR testing of the patient is negative
    1. Confirmatory samples should be sent as soon as possible from the first positive in question

Any patients with symptoms and a positive test is unlikely to be a false positive.

If an individual does not meet the criteria above, treat as a first-time infection in a COVID-19 naïve patient or follow the instructions for re-infections if the result is a re-positive after prior infection.

  • Whether the test result in question is for a first-time positive or a re-positive, the patient must remain in isolation with full isolation PPE, continue with twice-daily medical surveillance, and the contacts remain in quarantine and continue quarantine testing while the steps are taken to investigate.

IF YOUR PATIENT IS DEEMED A FALSE POSITIVE:

  • The evidence for the false-positive test result needs to be clearly documented in the chart.
  • The supporting evidence for the false positive must be documented in the medical record by the Chief Medical Executive (CME), Chief Physician and Surgeon (CP&S), or designee. If the designee is the Primary Care Provider (PCP), the note must be sent for co-signing by the CME or CP&S.
  • The correct result needs to be entered into SharePoint by the institution Public Health Nurse (PHN) – see Appendix 5).
  • The patient may be released from isolation to the general population.
  • The patient will not start a 90-day period of presumed immunity and should be considered susceptible to infection.
  • The patient should participate in all testing programs and be quarantined if exposed.

7. RE-TESTING PREVIOUSLY POSITIVE PATIENTS AFTER RECOVERY FROM COVID-19

SUMMARY OF LITERATURE ON COVID-19 VIRAL SHEDDING AND RE-INFECTIONS

Although there are scattered events reported, there are currently only 5 confirmed cases of COVID-19 re-infection worldwide. Below details a summary of the CDC analysis and literature review on this topic.

Many studies show viral shedding to be prolonged after the resolution of symptoms of COVID-19, in some cases, as long as 60 days from symptom onset (median 31 days). Recovered patients can have COVID-19 RNA detected in their respiratory secretions for up to 90 days.

However, detecting viral RNA via PCR does not necessarily mean that an infectious virus is present. Viral shedding studies show that prolonged shedding is not likely to be infectious.

CDC analysis and literature review shows that viral shedding beyond 9 days from the onset of symptoms has not been grown in viral culture, except in immunocompromised patients with severe COVID-19. But even in these patients, 88-95% of specimens were no longer replication-competent after 10 and 15 days respectfully.

After 2 weeks of symptoms, the viral load found is orders of magnitude less than that in the first 5 days.

The statistically estimated likelihood of recovering a replication-competent virus approaches zero by 10 days from the onset of symptoms, if immunocompetent.

Also, as the likelihood of isolating replication-competent virus decreases, anti-COVID-19 IgM and IgG can be detected in an increasing number of persons recovering from the infection.

Concentrations of COVID-19 RNA in respiratory secretions decline after the onset of symptoms. Among those who continue to have detectable RNA, concentrations of detectable RNA 3 days following recovery are generally in the range at which replication-competent virus has not been reliably isolated by the CDC in unpublished data.

Infectious virus has not been cultured from urine or reliably cultured from feces in multiple studies; these potential sources pose minimal, if any, risk of transmitting infection, and any risk can be sufficiently mitigated by good hand hygiene.

A large contact study demonstrated that high-risk household and hospital contacts did not develop the infection if their exposure was 6 days or more after the case-patient’s symptom onset.

A Korean investigation reported by the Korean CDC of 285 “persistently positive” persons, which included 126 persons who had developed recurrent symptoms, found no secondary infections among 790 contacts attributable to contact with these case-patients. Efforts to isolate replication-competent virus from 108 of these case-patients were unsuccessful.

Despite some studies showing antibodies quickly declining, the scientific consensus is that immunity lasts at least 3 months. Cellular immunity is shown to be involved. An unpublished report of 20,000 people finds that 90% of antibody responses lasted at least 3 months.

Hence, after a review of the available literature, CDPH has responded with the following policy:

Previously positive COVID-19 patients (inmates and employees) who have recovered require re-testing when (includes all prior-to-infection testing including pre/post movement or transfers and quarantine/targeted housing/serial/mass/and surveillance testing):

  • The time elapsed since the onset of the prior infection’s symptoms (or the time since the first positive test if asymptomatic) is >90 days.
  • The time since the onset of the prior infection’s symptoms (or the time since the first positive test if asymptomatic) is <90 days, and the patient develops new symptoms.

All cases of new positives (POC or PCR) with symptoms, regardless of how long ago the patient recovered from their initial infection, are considered re-infections until proven otherwise and must be isolated using full isolation PPE, undergo twice-daily medical monitoring, have contact investigations started, and contacts put into quarantine.

Asymptomatic patients beyond the 90-day timeframe and newly test positive (POC or PCR) are also considered potential re-infections. They must be isolated using full isolation PPE, undergo twice-daily medical monitoring, have a contact investigation, and have close contacts quarantined and tested.

POTENTIAL COVID-19 RE-INFECTIONS

Patients being worked up for re-infection should remain in isolation, use full isolation PPE, have twice-daily medical monitoring, complete the contact investigation, and contacts should remain in quarantine and tested as close contacts.

The following factors should increase the suspicion for re-infection:

  • The patient has new symptoms consistent with COVID-19.
  • The patient tests positive by RT-PCR more than 90 days from their first positive test
  • The patient had a known exposure in the past 14 days.

<90 Days Symptomatic Potential COVID-19 Re-Infections:
Symptomatic patients <90 days out with a positive POC or PCR is a situation more concerning for a false positive or it may be due to non-infectious shedding. These patients should:

  • Have confirmatory PCR if the first test is a POC.
  • Have other causes for the symptoms investigated.
  • Be evaluated for other respiratory pathogens, and a comprehensive viral panel ordered.

If there is concern that the positive test is a false positive, follow the guidance on false positives in Concern for COVID-19 False-Positives: What to Do.

>90 Days Symptomatic Potential COVID-19 Re-Infections:
Symptomatic patients >90 days out also need to:

  • Have confirmatory PCR (if not done/prior test is POC).
    • Patients with a positive POC and negative RT-PCR cause concern for a false negative PCR because POC detects virus at a much higher threshold than PCR, and the non-infectious shedding period is presumed to be over. Repeat another RT-PCR in this circumstance.
  • Have other causes for the symptoms investigated.
  • Be evaluated for other respiratory pathogens, and a comprehensive viral panel ordered.

Then follow the directions in Studying Re-infections.

<90 Days Asymptomatic Potential COVID-19 Re-Infections:
Patients without symptoms within 90 days of their prior onset of symptoms (or first positive if asymptomatic) should not be tested. During this time frame, re-infections are highly unlikely and are considered false positives, and the test result may be disregarded.

>90 Days Asymptomatic Potential COVID-19 Re-Infections:
Asymptomatic patients >90 days out with a new positive:

  • Should have two positive RT-PCRs for re-infection to be in the differential.
  • Do not require other pathogen testing.

Consider if the result could be a false positive. See considerations for when a result might be a false positive in Concern for COVID-19 False-Positives: What to Do.

CDPH Studying COVID-19 Re-Infections and Re-Positives:

Whether re-positives are actually re-infections is of scientific interest and has a bearing on public health policy. The emergence of variant strains of the SARS-CoV-2 virus is concerning and potentially could be a cause of an increase in true re-infections. The CDPH viral lab may be able to support viral culture testing and whole genomic sequencing of suspected re-infection cases, especially if symptomatic. The CDPH criteria for further investigations are in flux, and as such, the PHB and CDPH are in constant communication regarding cases of interest and cases meeting the most recent CDPH criteria. In evaluating certain re-positive cases, PHN or Infection Control Nurse (ICN) completion of the secondary transmission and exposure information is important for understanding the context of re-positive cases and may be requested on a case-by-case basis.

Patients for whom CDPH opts not to pursue further testing should continue to be considered presumed re-infections, be isolated, and have twice-daily medical monitoring.

If there is any concern the result is actually a false positive, see the Concern for COVID-19 False-Positives: What to Do section.

If you have a re-positive patient who is >90 days out, whether symptomatic or asymptomatic, or a re-positive patient <90 days out with COVID symptoms, please do the following:

  1. Continue isolation using full isolation PPE, undergo twice-daily medical monitoring, have a contact investigation, and have close contacts quarantined and tested, as for all infections.
  2. Confirm any positive POC with a PCR as soon as possible.
  3. Ensure other causes for the symptoms, if present, have been investigated. If indicated, order a comprehensive viral panel or diagnostics for other pathogens.
  4. If a re-positive patient is symptomatic with classic COVID-19 symptoms and hospitalized, a re-positive case appears to be an index case for secondary transmission, or patients otherwise highly suspected of re-infection, please email an alert to the PHB (CDCRCCHCSpublichealthbranch@cdcr.ca.gov).

The PHB will contact Quest to hold the sample, try to obtain a cycle threshold, and pursue viral culture and genomic sequencing for specimens meeting the most updated CDPH criteria.

8. INFLUENZA VIRAL TESTING

Please refer to the Recommendations for Influenza and Other Respiratory Virus Testing and Reporting – 2020-2021 for detailed information on testing and reporting from CDPH.

Diagnostic testing of symptomatic persons is the only necessary testing for influenza. Symptomatic cases of ILI also need to be tested for COVID-19. While awaiting test results for both pathogens, patients should be isolated in single cells with doors that close.

Symptomatic patients are allowed to refuse testing but will still need to be isolated and complete the criteria defined in Release from COVID-19 isolation (not influenza).

Testing of asymptomatic people (e.g., contacts of influenza cases or mass testing) for influenza is not needed. Test only when symptomatic.

INFLUENZA TEST TYPES

See Appendix 19 for details on test ordering, collection, and laboratory details.

Quest Influenza NAAT/PCR

  • Test symptomatic patients for influenza and COVID-19. Use PCR for influenza testing exclusively until the beginning of the annual influenza season. PCR can always be used for influenza.
  • Follow Quest ordering information in Appendix 19.

Rapid Influenza Diagnostic Testing (RIDT)
Antigen testing (rapid influenza diagnostic testing (RIDT) can also be used for influenza testing once flu season 2020-21 arrives and/or the prevalence of influenza is designated by CDPH as “Local” or higher (See CDPH Weekly Influenza Surveillance Reports). Please refer to the Quidel Sofia2 SARS + Flu Antigen information website and the Quidel Sofia 2 device information webpage for detailed information.

Confirmation of Influenza Rapid Antigen Testing
Positive RIDT (when prevalence is high) test results can be relied upon to be true positives and do not need PCR confirmation.

Due to unreliable sensitivity, if the RIDT result is negative, further testing is always indicated. Order the influenza A/B RNA Qualitative PCR with or without RSV or other pathogens depending on the clinical scenario.

Please refer to Appendix 19 for order information.

Influenza Serology (Antibody) Testing

At this time, serology testing for influenza is not clinically used. Its main role is in research and special situations during public health investigations.

INFLUENZA OUTBREAK TESTING

Typically, influenza testing increases when an outbreak has been identified. Sometimes in the past, once an outbreak is identified, or a certain threshold of cases per housing unit, influenza could be presumed for ILI cases and isolated and treated accordingly. This will not be possible in the setting of a COVID-19 pandemic.

Mass testing, quarantine testing, surveillance testing, and testing pre/post movement is not needed for influenza.

9. OTHER RESPIRATORY VIRUS TESTING CONSIDERATIONS

TREATMENT - Updated 5/21/2021

TABLE OF CONTENTS

  1. TREATMENT OF COVID-19 AT THE INSTITUTION
    1. ANTIVIRALS
  2. MONOCLONAL ANTIBODY TREATMENT
    1. DEXAMETHASONE
    2. VITAMINS
    3. OUTPATIENT TREATMENT FOR COVID-19 TABLE
    4. MEDICATION CONSIDERATIONS
  3. SPECTRUM OF COVID-19 ILLNESS
  4. USING SEPSIS SCORES TO MONITOR FOR POSSIBLE NEED FOR HLOC IN COVID-19
  5. OTHER COVID-19 PRE-HOSPITAL CONSIDERATIONS
  6. TREATMENT OF COVID-19 PATIENTS ADMITTED TO THE HOSPITAL
  7. TREATMENT OF COVID-19 AFTER HOSPITALIZATION
  8. SURVEILLANCE FOR INFLUENZA REQUIRING HOSPITALIZATION
  9. TREATMENT OF INFLUENZA
    1. ANTIVIRAL TREATMENT OF INFLUENZA
    2. INFLUENZA TREATMENT TABLE
    3. INFLUENZA CHEMOPROPHYLAXIS
    4. INFLUENZA CHEMOPROPHYLAXIS WITH OSELTAMIVIR TABLE

This section will cover the treatment of COVID-19 and influenza. For diagnosis and treatment of other respiratory pathogens such as respiratory syncytial virus, coccidioidomycosis, tuberculosis (TB), and bacterial pneumonia, see relevant CCHCS care guides and/or UpToDate and national guidelines.

The Centers for Disease Control (CDC) has partnered with the Infectious Diseases Society of America (IDSA) to offer a new service to clinicians treating COVID-19 patients. Clinicians who have questions about the clinical management of patients with COVID-19 can call the main CDC information line at 800-CDC-INFO (800-232-4636), for IDSA volunteer clinician peer-to-peer support.

TREATMENT OF COVID-19 AT THE INSTITUTION

Studies continue to seek effective treatments for COVID-19 infection. Key outpatient treatment considerations are listed in “Outpatient Treatment for COVID-19” table below. For Treatment of COVID-19, the CDC refers to the National Institutes of Health (NIH) COVID-19 Treatment Guidelines.

ANTIVIRALS

Currently, the NIH, the IDSA, the CDC, and the World Health Organization (WHO) DO NOT actively recommend antiviral medication for the treatment of mild or moderate COVID-19 outside of a clinical trial setting.

There are insufficient data for the NIH Panel to recommend for or against the use of remdesivir for the treatment of COVID-19 for non-hospitalized patients.

When used in hospitalized patients, the NIH recommends stopping remdesivir before discharge. If there is any question regarding whether remdesivir should be given after discharge, consult with the hospital attending and/or infectious disease.

MONOCLONAL ANTIBODY TREATMENT

In November 2020, the following monoclonal antibody infusions received emergency use authorizations (EUAs) from the Food and Drug Administration (FDA): (1) bamlanivimab alone, (2) the bamlanivimab and etesevimab combination, and (3) the casirivimab/imdevimab combination. The recommendations for usage of monoclonal antibodies have changed over time, and the EUA for bamlanivimab alone has been revoked.

In February 2021, the NIH COVID-19 Treatment Guidelines Panel recommended “bamlanivimab 700 mg plus etesevimab 1,400 mg for the treatment of outpatients with mild to moderate COVID-19 who are at high risk of clinical progression as defined by the EUA criteria.” In March 2021, the U.S. government stopped distribution of bamlanivimab alone because of an increase in resistant SARS-CoV-2 variants. Furthermore, in April 2021 the FDA revoked the EUA for bamlanivimab alone. Therefore, our patients should no longer receive bamlanivimab monotherapy. In April 2021, the NIH Panel also recommended “casirivimab 1,200 mg plus imdevimab 1,200 mg” to treat “outpatients with mild to moderate COVID-19 who are at high risk of clinical progression.”

Who has been shown to benefit from monoclonal antibody treatment:
Selected high-risk patients with outpatient mild to moderate symptomatic COVID-19 could benefit from monoclonal antibody treatment. As stated in the FDA EUA Fact Sheets revised May 14, 2021, for bamlanivimab and etesevimab and for casirivimab with imdevimab, conditions such as the following place individuals at higher risk of progression to severe COVID-19:

  • Older age (for example age ≥65 years)
  • Obesity or overweight
  • Pregnancy
  • Chronic kidney disease
  • Diabetes
  • Immunosuppressive disease or immunosuppressive treatment
  • Cardiovascular disease or hypertension
  • Chronic lung diseases
  • Sickle cell disease
  • Neurodevelopmental disorders or other conditions that confer medical complexity
  • Medical-related technological dependence (e.g., tracheostomy)

Monoclonal antibody treatment may be administered off-site to our patients at certain hospitals or may be administered on-site by physicians. Off-site infusions require an infusion referral form (see the Coronavirus Resource Webpage > Internal Resources
tab > Clinical Guidance – CDCR networking is required for access). Work with your facility Utilization Management Registered Nurse (UM RN) about off-site referrals.

To aid in identifying and tracking patients who may benefit from receiving the therapy, the QM COVID-19 Monitoring Registry has added a column for patients who should be considered for monoclonal antibody treatment (i.e., bamlanivimab + etesevimab or Regeneron-Cov™ [casirivinmab/imdevimab]) consistent with the EUAs and also the date of monoclonal antibody therapy administration, if given. Also, the COVID-19 Results MPage inside the EHRS shows an identifying green alert badge next to potentially qualifying positive patients.

SARS-CoV-2 Vaccines and monoclonal antibody treatment:
If a patient has had monoclonal antibody treatment, it is recommended that the patient wait 90 days before getting vaccinated (any dose in the series) to avoid the theoretical blunting of the immune response by the treatment. The patient is considered protected during these 90 days with natural immunity.

If the patient has been vaccinated but tests positive and develops symptomatic COVID-19, they can receive monoclonal antibody treatment. The CDC Clinical Considerations for SARS-CoV-2 mRNA vaccines states that “for vaccinated persons who subsequently develop COVID-19, prior receipt of an mRNA COVID-19 vaccine should not affect treatment decisions (including use of monoclonal antibodies, convalescent plasma, antiviral treatment, or corticosteroid administration) or timing of such treatments.”

Who should not use monoclonal antibody treatment:

Patients with severe COVID-19 disease should not receive monoclonal antibody treatment. This includes any patient requiring oxygen therapy due to COVID-19 or an increase in baseline oxygen for those on chronic therapy, or those who are being sent to a HLOC for COVID-19.

DEXAMETHASONE

In the 10/8/2020 Update, the NIH RECOMMENDS AGAINST the use of DEXAMETHASONE in NON-HOSPITALIZED patients. Patients with escalating or vacillating oxygen requirements, having oxygen saturations < 94% on room air, or suspected of needing dexamethasone, should be immediately transferred to a higher level of care (HLOC). Patients requiring oxygen need very close monitoring; providers should have a low threshold for HLOC.

When patients refuse to go to the hospital, several factors including their record of non-adherence and the risk-benefit of giving dexamethasone on-site should be considered.

When given to hospitalized patients, the NIH recommends stopping dexamethasone before discharge. If there is any question regarding whether dexamethasone should be given after discharge, consult with the hospital attending and/or infectious disease.

VITAMINS

The NIH states there is insufficient data to recommend for or against VITAMIN C, VITAMIN D, or ZINC in the treatment of COVID-19.

Vitamin C, D, and Zinc are available in the canteen. A discussion between provider and patient regarding the status of the research and shared decision making is encouraged.

Regarding prevention:

  • The NIH RECOMMENDS AGAINST using over the recommended dietary allowance of ZINC for COVID-19, outside of a clinical trial. Zinc can be overdosed and toxic. Toxicity can cause copper deficiency, headaches, and neurologic and gastrointestinal side effects. The NIH considers 40 mg of zinc a day to be the upper limit zinc dose for adults.
  • The NIH states there is insufficient data to recommend for or against Vitamin D to prevent COVID-19.
  • Prevention of COVID-19 and Vitamin C was not specifically addressed.
Outpatient Treatment for COVID-19 Table. Based on the CCHCS Public Health Branch Literature Review 03/25/2021. Please click on the image to open PDF for full table details.
Outpatient Treatment for COVID-19 Table. Based on the CCHCS Public Health Branch Literature Review 03/25/2021. Please click on the image to open PDF for full table details.
Outpatient Treatment for COVID-19 Table. Based on the CCHCS Public Health Branch Literature Review 03/25/2021. Please click on the image to open PDF for full table details.

MEDICATION CONSIDERATIONS

Patients on ACEI or ARB: Remaining on previously prescribed angiotensin-converting enzyme inhibitors (ACEI) or angiotensin II receptor blockers (ARB) during COVID-19 illness is endorsed by the American Heart Association (AHA), American College of Cardiology (ACC), European Society of Cardiology, and the American College of Physicians.

Patients with diabetes: Because patients with diabetes are at increased risk for severe illness, the American Diabetes Association recommends to consider stopping sulfonylureas, metformin, and SGLT-2 inhibitors, as with all seriously ill patients with diabetes. Also, GLP-1 medications can cause nausea, vomiting, diarrhea, and anorexia; assessment of its continued use during COVID-19 illness is advised.

Patients on steroids: Patients prescribed oral or inhaled corticosteroid therapy prior to COVID-19 for another underlying condition should not discontinue it. If on oral therapy, supplemental or stress-dose steroids may be considered on a case-by-case basis if the patient becomes moderately or severely ill.

SPECTRUM OF COVID-19 ILLNESS

The NIH defines patients with COVID-19 illness into the following categories:

  • Asymptomatic or Presymptomatic Infection: Individuals who test positive for SARS-CoV-2 but have no symptoms.
  • Mild Illness: Individuals who have various signs and symptoms (e.g., fever, cough, sore throat, malaise, headache, diarrhea, muscle pain) without shortness of breath, dyspnea, or abnormal imaging.
  • Moderate Illness: Individuals who have evidence of lower respiratory disease, by clinical assessment or imaging, and saturation of oxygen (SpO2) ≥94% on room air at sea level.
  • Severe Illness: Individuals who have respiratory frequency >30 breaths per minute, SpO2 <94% on room air at sea level, a ratio of the arterial partial pressure of oxygen to fraction of inspired oxygen (PaO2/FiO2) <300, or lung infiltrates >50%.
  • Critical Illness: Individuals who have respiratory failure, septic shock, and/or multiple organ dysfunction.

In general, patients who are healthy at baseline and asymptomatic, mild or moderate illness can be managed in the institutions. Older patients and those patients of any age with significant chronic medical conditions who are at higher risk for complications with COVID-19 should be watched more closely, and the provider should have a lower threshold to consider transfer to a higher level of care (HLOC).

Moderate COVID-19 illness is defined as evidence of lower respiratory disease by clinical assessment or imaging with SpO2 ≥94% on room air. Rapid progression of pulmonary disease is possible, so close monitoring of patients with moderate disease is recommended.

Emergent hospitalizations and deaths at CDCR have occurred due to missed signs of developing severe COVID-19. Not uncommonly, patients initially do very well, only to precipitously decline. COVID-19 is known to cause, and our patients have demonstrated, silent hypoxia. It can be extremely useful to check a patient’s post-walking O2 saturation in addition to at rest. Additionally, close attention should be paid to the respiratory rate and the heart rate (see SIRS criteria), as changes in these vital signs have been missed with dire consequences.

Providers rounding on symptomatic patients (in isolation) may order additional tests such as a chest X-ray and labs, especially if the patient has signs and symptoms suggestive of lower respiratory tract disease or worsening respiratory status (see Monitoring Patients with Suspected or Confirmed COVID-19 section).

  • Based on the NIH COVID-19 Treatment Guidelines, any of the following suggest severe COVID-19 disease and transfer to an HLOC is strongly recommended:
    • Patient with a saturation of oxygen (SaO2) <94% on room air (or significant drop from baseline if prior chronic hypoxia)
    • Patient with a respiratory rate >30 breaths per minute
    • Patients with lung infiltrates >50% of lung volume
    • Patients with evidence of lower respiratory disease by lung auscultation or chest X-ray, but saturation of oxygen (SaO2) >94% on room air

COVID-19 Hospitalization Need Risk Calculator
COVID-19 risk calculator for severe disease is available at https://riskcalc.org/COVID19Hospitalization/. This is the first tool for assessing the factors that lead to hospitalization (as opposed to once hospitalized, those that require ventilation/intensive care unit [ICU] or mortally succumb). In a recent large study by Jehi et al, the predictors identified were: Age >65 years, male sex, hypertension, diabetes, immunosuppressive disease, former smokers, and African American race.

USING SEPSIS SCORES TO MONITOR FOR POSSIBLE NEED FOR HLOC IN COVID-19

Using the Quick Sepsis-Related Organ Failure Assessment (qSOFA) score has been shown to correlate with the odds of in-hospital death with COVID-19. It is recommended by the International Consensus Sepsis-3 for outpatients to predict mortality (not sepsis itself).

It uses findings of an altered mental status (Glasgow Coma Score <15), a respiratory rate ≥22, and systolic blood pressure ≤100. The score calculator can be found at the MDCalc website on qSOFA. A score of 2 or higher suggests a high risk of poor outcome; these patients should be sent to an HLOC.

The literature is mixed regarding the use of the Systemic Inflammatory Response Syndrome Score (SIRS). A SIRS score is more sensitive, has more false-positive results, and can detect conditions other than sepsis. Reviewing the SIRS criteria may be useful in assessing patients who might be demonstrating very early sign of sepsis and may need heightened surveillance beyond twice a day.

SIRS Score: (1 point each indicator)

  • Temperate >38 °C (100.4 °F)
  • Heart rate >90
  • Respiratory rate >20
  • WBC >12,000/mm3, <4000/mm3, or >10% bands, suspected or present source of infection, lactic acidosis

A score of 2 or higher meets the SIRS definition. The SIRS Score calculator can be found at the MDCalc website on SIRS.

OTHER COVID-19 PRE-HOSPITAL CONSIDERATIONS

Thrombotic related complications: Other complications that have been described in COVID-19 patients include acute, life-threatening conditions such as acute pulmonary embolism, acute coronary syndrome, and acute stroke. Clinical suspicion for these complications should be heightened when caring for COVID-19 patients, and patients should be transferred to HLOC immediately. To date, there is NO recommendation for outpatient anticoagulation or thrombotic prophylaxis in these patients.

Advance Care Planning: Strongly consider discussing advance care plans, such as desires for intensive care support and desire for palliative care with patients who are frail or otherwise at high risk for complications and mortality due to COVID-19. Please refer to the CCHCS Palliative Care Guide and the many resources available in the Provider Resource Library (PRL) (CDCR networking is required for access) for End of Life Planning and Treatment, including COVID-19 Advanced Care Communication Tips for discussions with patients. It is extremely important to clarify who the patient would like to be their surrogate decision-maker and ensure this is documented, ideally in an Advance Directive for Health Care, but at the very least on the Next-of-Kin form and in your progress notes. There are often defunct phone numbers; try to obtain contact information for as many next-of-kin as possible.

Note: Up to Date June 2020 states that if a death should occur in one of our patients due to COVID-19, the cause of death should be listed as the new ICD-10 category “COVID-19”. Do not list the non-specific term “coronavirus.” (Currently, COVID-19 is NOT an available code within the electronic health record system (EHRS) ICD-10 code set, so for a Problem List, you will need to use a “coronavirus infection” code.)

TREATMENT OF COVID-19 PATIENTS ADMITTED TO THE HOSPITAL

Patients with COVID-19 who are admitted to the hospital may be treated with a variety of agents. Discussion of the treatment of hospitalized patients is beyond the scope of this document. Please refer to the NIH and IDSA for more information on inpatients.

TREATMENT OF COVID-19 AFTER HOSPITALIZATION

Post-hospital isolation, housing, and mask requirement: Patients may return from the hospital on oxygen and will need close medical attention. They should continue in isolation until release criteria have been met (see Release from Isolation). Patients may require more frequent surveillance than the scheduled twice-a-day monitoring depending on the patient’s clinical course and risk factors. If so, medical housing during isolation would be appropriate. Patients may still need significant care after return from hospitalization with isolation completed or for any illness severity after release from isolation. Patients may still be on oxygen or medical treatments. Any patients who are still completing treatment (including oxygen use) will need close attention after twice-daily isolation rounds have ended due to meeting isolation release criteria. Appropriate follow up for all patients needing close clinical monitoring, including the continuation of a higher level of care bed and daily or frequent clinic or nursing visits checks should be ordered as needed, based on overall patient assessment and level of concern. The patient should continue to wear a surgical mask for at least two weeks and until there is complete resolution of cough. Thereafter, a cloth mask will be required as it is for all staff and patients.

Clinical Trials: Hospitals have been contacting CDCR/CCHCS providers to ask permission for CDCR patients with moderate-severe COVID-19 disease to enter clinical trials. Note, this is NOT the decision of the CDCR/CCHCS provider. Although there is a general prohibition regarding “experimenting” on incarcerated patients, Penal Code 3502.5 states a prisoner may participate in a clinical trial of a drug if it has potential benefit. The decision would be up to the patient (or their surrogate decision-maker if the patient is too ill to consent) and his or her attending physician. Any medications used in the setting of a clinical trial would likely be completed prior to discharge. In rare cases, if the discharging physician indicates that the clinical trial medication is required to be continued upon discharge, CCHCS should be sure to include institution leadership and legal in the decision on whether this clinical trial medication can be continued in our setting. Information on registered clinical trials for COVID-19 in the United States is available at ClinicalTrials.gov.

Off-label medication use: Patients may be started on an off-label medication regimen (NOT in the context of a clinical trial) while hospitalized. Once the patient is returned to a CDCR facility, we are the medical decision-makers for our patients. In this capacity, we have no obligation to continue with the hospital’s treatment (experimental, trial, or otherwise); instead, we must make decisions based upon what we determine is medically indicated for each patient. This determination would likely involve our providers having discussions with the discharging physician and with the patient about continued care to determine the best course of action. If continuing a medication, be aware of significant drug-drug interactions (DDIs) that have been described, especially with cardiac, central nervous system medications, and antibiotics. Be sure to use a DDI checker for experimental COVID-19 drugs.

Rehabilitation: Research is showing that lingering symptoms can occur with all symptomatic patients, but a prolonged recovery in patients with severe illness may be expected, especially in those who required ICU care and/or ventilation. Patients may require prolonged oxygen, close follow up appointments, specialty visits, and attention to physical deconditioning, respiratory, swallow, cognitive, and mental health impairments after serious and especially post-intensive care for COVID-19. Referral to rehabilitation specialists may be needed, such as physical therapy, occupational therapy, mental health, cardiac and pulmonary rehabilitation, etc. If local facilities are impacted, it may be necessary to reach out to resources that might be farther away than desired or have the patient transferred to where care in the needed discipline can be obtained. A social worker consult may be helpful if finding appropriate care is problematic. Patients will require vigilance for persistent inflammation, thromboembolic events, and sequelae including, but not limited to pulmonary, cardiac, neurological, and renal complications, some of which may develop after the acute illness is resolved.

Follow-up for patients who had severe COVID-19 should be individualized and based on professional judgement of the patient’s specific case, risks, and needs. While no national guidelines exist at this time, clinical assessment with close attention to the major organ systems will be necessary. Additionally, it will be important to keep in mind simultaneously that organ dysfunction could have a non-COVID-19 cause. Some patients may never achieve their pre-COVID baseline status. Please refer to the “Clinical Manifestations” chapter for a discussion of late effects of SARS-CoV-2 infection (known by terms such as “Long COVID,” “Post-Acute Sequelae of COVID-19,” or “PASC”).

SURVEILLANCE FOR INFLUENZA REQUIRING HOSPITALIZATION

Monitor for signs and symptoms of declining status in an influenza infection, especially those at risk for severe disease. Some serious influenza complications are:

  • Hypoxia and pneumonia, difficulty breathing or shortness of breath
  • Myositis, rhabdomyolysis, and acute renal failure
  • Acute myocardial infarction, myocarditis and pericarditis
  • Central nervous system involvement including encephalopathy, encephalitis, transverse myelitis, aseptic meningitis, and Guillain-Barre syndrome
  • Toxic shock syndrome from staphylococcus aureus superinfections

The most common complication for patients with influenza is pneumonia and hypoxia. Secondary bacterial pneumonia also contributes substantially to morbidity and mortality; empiric antibiotic treatment for patients who are declining and preparing for HLOC should be started if clinically indicated.

Using Sepsis Scores to Monitor for Possible Need for HLOC and the information on advanced directives noted in the COVID-19 subsection above also applies to influenza.

Please refer to UpToDate on Influenza Management and the IDSA on Influenza 2018 Clinical Guidelines for more information.

TREATMENT OF INFLUENZA

During “flu season,” typically fall and winter, we may see patients presenting with influenza-like illness (ILI) who have influenza and not COVID-19. Co-infections are also possible. The following is a review of the antiviral treatment available for influenza.

ANTIVIRAL TREATMENT OF INFLUENZA

Influenza treatment guidelines do not change in the setting of COVID-19. Empiric treatment is recommended regardless of COVID-19 testing status while awaiting influenza testing results as detailed below. Oseltamivir is safe if a patient is co-infected with COVID-19. See the CDC on Co-circulation of Influenza and SARS-CoV-2 for more information.

Whom to Treat: Antiviral medication is generally indicated for those patients at higher risk for influenza complications based on their age or underlying medical conditions, as well as hospitalized or severe cases, if they have progressive disease, and if the testing results will influence clinical management. Those patients at higher risk for complications from influenza are the same as for COVID-19 with the addition of patients with Native American or Alaska Native background and patients 18 to 19-years-old on chronic salicylate medications.

The CDC states that antiviral medication can be considered for any previously healthy symptomatic outpatient with confirmed or suspected influenza, based on clinical judgment, if treatment can be initiated within 48 hours of illness onset. CDPH recommends the liberal use of anti-viral treatment and chemoprophylaxis in our congregate setting. Consider the housing unit situation, the location of vulnerable populations, and the risk of broader transmission in the decision making.

Timing of Antiviral therapy for influenza: While the maximum benefit likely occurs when antiviral treatment is started within 48 hours of symptom onset, there is some evidence to suggest that starting treatment later may provide benefit, especially in patients with worsening symptoms and hospitalized or critically ill patients. During the influenza season, do not wait for laboratory confirmation of influenza; the rapid influenza diagnostic point of care tests can be of use in this regard.

Available Medications: The summary of the treatment for influenza is described in the “Influenza Treatment” table below. NOTE: CDC is currently NOT recommending adamantanes in the US due to marked resistance emergence unless local resistance is low.

Influenza Treatment Table. Adapted from the CDC Influenza Antiviral Medications: Summary for Clinicians. Please click on the image to open PDF for full table details.

For information on how influenza medications can be used as chemoprophylaxis, please see the Influenza Chemoprophylaxis section below.

Resources
More information can be found at the recently updated sites:

INFLUENZA CHEMOPROPHYLAXIS

Oseltamivir may also be used for prophylaxis if less than 48 hours have elapsed since the first exposure. The CDC and CDPH state that antiviral medications can be considered for chemoprophylaxis to prevent influenza in certain situations and for high-risk individuals, as described in the “Influenza Chemoprophylaxis with Oseltamivir” table. Chemoprophylaxis should be used when indicated regardless of COVID-19 status. Oseltamivir is safe for use in patients with COVID-19 for the prevention of influenza.

Influenza Chemoprophylaxis with Oseltamivir®. Adapted from the CDC Influenza Antiviral Medications: Summary for Clinicians and The CDPH Recommendations for Prevention and Control of Influenza in California SNF During the COVID-19 Pandemic, October 2020. Please click on the image to open PDF for full table details.

PUBLIC HEALTH DEFINITIONS - Updated 11/20/2020

TABLE OF CONTENTS

  1. ACUTE ILLNESS COMPATIBLE WITH COVID-19
  2. INFLUENZA-LIKE ILLNESS (ILI)
  3. CONFIRMED CASE OF COVID-19
  4. SUSPECTED CASE OF COVID-19
  5. RE-POSITIVE FOR COVID-19
  6. CONFIRMED CASE OF INFLUENZA
  7. SUSPECTED CASE OF INFLUENZA
  8. SUSPECTED OUTBREAK OF COVID-19
  9. OUTBREAK OF INFLUENZA-LIKE ILLNESS OF UNKNOWN ETIOLOGY
  10. CONFIRMED OUTBREAK OF COVID-19
  11. CONFIRMED OUTBREAK OF INFLUENZA
  12. INFECTIOUS PERIOD FOR COVID-19
  13. INFECTIOUS EXPOSURE PERIOD FOR COVID-19
  14. INFECTIOUS PERIOD FOR INFLUENZA
  15. INFECTIOUS EXPOSURE PERIOD FOR INFLUENZA
  16. ASYMPTOMATIC CLOSE CONTACT TO COVID-19
  17. ASYMPTOMATIC CLOSE CONTACT TO INFLUENZA
  18. FALSE POSITIVE TEST
  19. ISOLATION
  20. ISOLATION COHORTING
  21. QUARANTINE
  22. QUARANTINE COHORTING
  23. MEDICAL HOLD

ACUTE ILLNESS COMPATIBLE WITH COVID-19

At least one of the following symptoms: cough, shortness of breath or difficulty breathing, fever (measured or subjective), chills, rigors, myalgia, headache, sore throat, new olfactory and taste disorder(s) (e.g., loss of sense of taste or smell).

For a full list of symptoms of COVID-19, see Table 5.1.

Note: The California Department of Public Health (CDPH) defines an acute illness compatible with COVID-19 in COVID-19 Outbreak Definition and Reporting Guidance as at least one of the following symptoms: cough, shortness of breath, or difficulty breathing; OR at least two of the following symptoms: fever (measured or subjective), chills, rigors, myalgia, headache, sore throat, new olfactory and taste disorder(s).

INFLUENZA-LIKE ILLNESS (ILI)

Fever (measured ≥100°F or 37.8°C) PLUS cough or sore throat, in the absence of a known cause other than influenza or COVID-19, as defined by the CDPH in Acute Respiratory Illness Outbreak Report Form for Community and Congregate Settings and by CCHCS in the Registered Nurse (RN) Protocol on Upper Respiratory and Respiratory Complaints (Non-Traumatic). In addition to fever, cough, and sore throat, ILI commonly presents with chills, headache, myalgia, or runny nose. Some persons, including the elderly, may be more likely to be afebrile when infected with influenza. For a full list of symptoms of influenza, see Table 5.1.

CONFIRMED CASE OF COVID-19

A positive laboratory test for the virus that causes COVID-19 in at least one respiratory specimen. A positive antigen test should be reflexively confirmed using a molecular test.

SUSPECTED CASE OF COVID-19

Acute illness compatible with COVID-19 of unknown etiology without a conclusive test result for the virus that causes COVID-19.

RE-POSITIVE FOR COVID-19

A positive test for the virus that causes COVID-19 in a patient who has previously tested positive.

CONFIRMED CASE OF INFLUENZA

A positive laboratory test for an influenza virus in at least one respiratory specimen.

SUSPECTED CASE OF INFLUENZA

An ILI of unknown etiology without a conclusive test result for the influenza viruses.

SUSPECTED OUTBREAK OF COVID-19

A cluster of acute illness compatible with COVID-19, as defined by CDPH in COVID-19 Outbreak Definition and Reporting Guidance, without laboratory testing or with pending laboratory testing.

OUTBREAK OF INFLUENZA-LIKE ILLNESS OF UNKNOWN ETIOLOGY

A cluster of ILI, with 2 or more onsets within a 72-hour period, without laboratory testing or with pending laboratory testing. This cluster may also be a suspected outbreak of COVID-19.

CONFIRMED OUTBREAK OF COVID-19

At least one case of laboratory-confirmed COVID-19 in the setting of 2 or more cases of acute illness compatible with COVID-19 in residents or staff members within a 14-day period, as defined by CDPH in COVID-19 Outbreak Definition and Reporting Guidance.

CONFIRMED OUTBREAK OF INFLUENZA

At least one case of laboratory-confirmed influenza in the setting of 2 or more cases of ILI in residents or staff members within a 72-hour period, as defined by CDPH in COVID-19 Outbreak Definition and Reporting Guidance.

INFECTIOUS PERIOD FOR COVID-19

48 hours prior to the onset of symptoms of a symptomatic case-patient, or 48 hours prior to specimen collection of an asymptomatic infected person until resolved (often 10 days after collection of the first positive specimen).

INFECTIOUS EXPOSURE PERIOD FOR COVID-19

48 hours prior to the onset of symptoms of a symptomatic case-patient, or 48 hours prior to specimen collection of an asymptomatic infected person until isolation (for patients) or last day in the workplace (for staff).

INFECTIOUS PERIOD FOR INFLUENZA

24 hours prior to the onset of symptoms until 7 days after the onset of symptoms.

INFECTIOUS EXPOSURE PERIOD FOR INFLUENZA

24 hours prior to the onset of symptoms until isolation (for patients) or last day in the workplace (for staff).

ASYMPTOMATIC CLOSE CONTACT TO COVID-19

A person without symptoms of COVID-19 who, in the past 14 days, has had close (within 6 feet and cumulative ≥10 minutes) contact with a confirmed case of COVID-19 OR direct contact with secretions of a confirmed case of COVID-19 during the infectious period AND who has had no positive tests for the virus that causes COVID-19 in the past 90 days.

ASYMPTOMATIC CLOSE CONTACT TO INFLUENZA

A person without ILI who, in the past 7 days, has had close (within 6 feet and cumulative ≥10 minutes) contact OR direct contact with secretions of a confirmed case of influenza during the infectious period AND who has had no positive tests for influenza in that timeframe.

FALSE POSITIVE TEST

A test which incorrectly indicated that a virus was present. A positive test for the virus that causes COVID-19 may be determined to be a false positive by Quest Diagnostics, the institution Chief Physician and Surgeon (CP&S), or the Chief Medical Executive (CME); see Concern for COVID-19 False-Positives: What to Do. Tests which accurately detect viral material, but at a low level where infectiousness is unlikely (e.g., a re-positive RT-PCR test for COVID-19 with a high Ct value), should NOT be considered a false positive.

ISOLATION

Separation of ill persons who have a communicable disease (confirmed or suspected) from those who are healthy. For diseases such as COVID-19 with airborne transmission, isolation requires separate airspaces (solid walls and solid doors).

ISOLATION COHORTING

The grouping of patients, in a shared airspace, who are infected with the same organism, to confine their care to one area and prevent contact with other patients. Cohorting can also conserve respirators in times of shortage. Cohorts are created based on clinical diagnosis, microbiologic confirmation when available, epidemiology, and mode of transmission of the infectious agent.

QUARANTINE

The separation and restriction of movement of well persons who are contacts of a confirmed communicable disease. Quarantine facilitates the prompt identification of new cases and helps limit the spread of disease by preventing new people from becoming exposed.

QUARANTINE COHORTING

The grouping of patients, in a shared airspace, who have been exposed to the same pathogen, have the same exposure risk, and have the same date of last exposure, when available facilities are insufficient to quarantine all exposed patients alone. The objective should be to cohort quarantined patients in the smallest groups possible.

MEDICAL HOLD

Prohibition of the transfer of a patient to another facility except for legal or medical necessity.

NOTIFICATIONS AND REPORTING - Updated 3/02/2021

TABLE OF CONTENTS

  1. INITIAL NOTIFICATIONS FOR COVID-19 AND INFLUENZA
  2. REPORTING COVID-19
  3. REPORTING CO-INFECTIONS OF COVID-19, INFLUENZA, AND OTHER RESPIRATORY ILLNESSES
  4. APPENDIX 5: COVID-19 CASE AND CONTACT SHAREPOINT REPORTING TOOL
  5. APPENDIX 11: LOCAL HEALTH DEPARTMENT CONTACT LIST

INITIAL NOTIFICATIONS FOR COVID-19 AND INFLUENZA

  • If health care or custody staff become aware of or observe symptoms consistent with COVID-19 or influenza (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 staff exposures, please refer to the Health Care Department Operations Manual (HCDOM) section on Employee Exposure Control.
  • When a patient with fever, cough, or shortness of breath is identified, institutional processes for notification to the PHN or PHN alternate must be established for ongoing surveillance and reporting.
  • Confirmed and suspected cases of COVID-19 or influenza 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 or influenza should be immediately referred to a provider for evaluation.
  • If a patient has a confirmed case of COVID-19 or influenza, 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 employee exposure to COVID-19.

REPORTING COVID-19

The PHN or PHN alternate is responsible for reporting respiratory illnesses and outbreaks to the Public Health Branch (PHB) and the local health department (LHD).

  • Per Title 17, confirmed COVID-19 cases should be immediately reported by telephone to the LHD. California Department of Public Health (CDPH) guidance also states that prisons should notify the LHD if they identify a suspected or confirmed outbreak of COVID-19 or a single case of confirmed COVID-19 among patients or staff. Follow usual guidelines for reporting influenza to the LHD. See Appendix 11 for the LHD contact list.
  • Notify CCHCS PHB immediately at CDCRCCHCSPublicHealthBranch@cdcr.ca.gov if there are significant developments at the institution (e.g., a new outbreak).
  • The following events require next business day reporting to the COVID-19 SharePoint: https://cdcr.sharepoint.com/sites/cchcs_ms_phos (CDCR networking is required for access).
    • All new suspected and confirmed COVID-19 cases, in a new SharePoint record.
      • Note that positive test results from Quest or a positive point -of -care (POC) test performed at the institution will auto-generate records in SharePoint.
      • Tests performed at outside labs (community hospitals, public health labs) require manual entry into SharePoint.
    • All new patients re-positive >90 days after the first positive test, in a new SharePoint record. Record whether there are any symptoms associated, including the onset date of the first symptom.
  • For previously reported suspected or confirmed cases, update the existing SharePoint record with first positive lab results, new symptoms, date of first symptom onset, and false-positive determinations.
  • Cases diagnosed while a patient is out-to-court should be reported to SharePoint by the institution where the patient was endorsed at the time of collection of the first positive specimen. The report should be made within one week of the institution being notified of the case.
  • Cases diagnosed while a patient is at a contract bed facility should be reported to SharePoint by the hub institution. The report should be made within one week of the positive test result returning.
  • Refer to Appendix 5 for step-by-step instructions on using the SharePoint Reporting Tool and definitions.
  • No report is needed if there are no new COVID-19 cases and no significant updates to existing cases.

REPORTING CO-INFECTIONS OF COVID-19, INFLUENZA, AND OTHER RESPIRATORY ILLNESSES

  • Co-infections of COVID-19 and other respiratory pathogens of public health concern (e.g., influenza) are reportable to SharePoint. Co-infections should be reported as updates to the case record where the COVID-19 case was reported; do not create a new record for the co-infection.
  • Outbreaks of other infectious respiratory diseases (e.g., influenza) should be reported to the Public Health Outbreak Response System (PhORS) (http://pors/; CDCR networking is required for access).
    • The PhORS preliminary report form is required for the report.
    • For respiratory outbreaks, PhORS line list and supplemental reports are optional, unless requested by a CCHCS epidemiologist.
    • Single cases of lab-confirmed influenza and single cases of influenza-like illness (pathogen unknown) do not need to be reported to PhORS.
    • COVID-19 cases, co-infections, and outbreaks do not need to be reported to the PhORS.

INFECTION CONTROL AND PERSONAL PROTECTIVE EQUIPMENT (PPE) - Updated 4/08/2021

TABLE OF CONTENTS

  1. BACKGROUND
    1. PPE TRAINING: EXPERIENCE FROM PAST OUTBREAKS
  2. TABLE 11.1: STANDARD, CONTACT, DROPLET, AIRBORNE PRECAUTIONS, AND PPE USE
  3. PPE SCENARIOS FOR INFLUENZA-LIKE ILLNESSES (ILI), INFLUENZA, and COVID-19
    1. STAFF, INMATE WORKER AND RESIDENT PPE FOR ILI/SYMPTOMATIC PATIENT
    2. STAFF, INMATE WORKER AND RESIDENT PPE WHEN NEAR SUSPECTED AND CONFIRMED COVID-19 CASE(S)
    3. PPE FOR QUARANTINE AREAS: STAFF, INMATE WORKER AND RESIDENT PPE WHEN NEAR AN ASYMPTOMATIC CONTACT OF A COVID-19 CASE (EXPOSED AND IN QUARANTINE) AND PRECAUTIONARY PRE/POST MOVEMENT QUARANTINED PATIENTS NOT KNOWN TO BE EXPOSED
    4. PPE FOR CONTACT OF A CONTACT
    5. STAFF, INMATE WORKER AND RESIDENT PPE FOR CONFIRMED INFLUENZA CASE
  4. COVID-19 FACE COVERINGS GUIDANCE
  5. COVID-19 N95 RESPIRATOR GUIDANCE
    1. LENGTH OF TIME ONE CAN SAFELY WEAR AN N95 RESPIRATOR
  6. COVID-19 FACE SHIELDS AND EYE PROTECTION GUIDANCE
  7. COVID-19 GOWN GUIDANCE
  8. COVID-19 TRANSMISSION FROM PAPER SURFACES
    1. MAIL DELIVERY FOR COVID-19 CONFIRMED/SUSPECTED CASES
    2. HANDLING OF FORM 7362s SUBMITTED BY COVID-19 CONFIRMED/SUSPECTED CASES
  9. HANDLING THE PROPERTY OF DECEASED INMATES/PATIENTS WHO DIED FROM COVID-19
    1. RECOMMENDATIONS TO THE FAMILIES: HOW TO HANDLE THE DECEASED’S BELONGINGS

BACKGROUND

Please refer to the Memo: Recommended COVID-19 PPE for Staff and Inmates-Patients Update (CDCR networking is required for access), which gives specific guidance for different locations.

It is a nationally accepted best practice standard for all healthcare workers to adhere to Transmission-Based Precautions to protect themselves and their patients from infectious diseases. Health care and public health workers, and CDCR custody and other staff should be trained to assess the risk of infection from identified pathogens, identify from the four classes of Transmission-Based Precautions, and familiarize themselves with COVID-19 personal protective equipment (PPE) guidelines to protect themselves.

During this SARS-CoV-2 (COVID-19) pandemic, our CDCR/CCHCS population is particularly vulnerable due to the congregated community living situation. In addition, many patient/inmates are suffering from underlying health issues, and incarceration alone is a known risk factor for health impacts. Inmate workers and residents in or near areas or persons where there is a high risk of exposure to themselves or risk of transmission to others also need to use PPE as described in this chapter. It is vital that the healthcare and custody staff model best practices regarding Transition-Based Precautions for the patients and inmate workers at all times. Further, staff should also model proper preventative infection control practices, including hand hygiene, six-foot social distancing, adherence to universal use of facemasks, and attention to maximizing ventilation when possible (see Primary Prevention on Ventilation).

PPE TRAINING: EXPERIENCE FROM PAST OUTBREAKS

Experience from CDCR outbreaks makes it clear that the need for training on appropriate PPE for the situation, donning and doffing PPE, and fit testing should not be underestimated. Proactive training before large outbreaks occur may be invaluable when the implementation of PPE programs is needed.

In the event of conflicting PPE direction between the Centers for Disease Control (CDC) and CCHCS/CDCR, the stricter form of protection shall be followed.

Other Resources
Personal Protective Equipment (PPE) for County Intake Processing memo and the Battelle N95 Respirator Decontamination memo (CDCR networking is required for access).

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 powered air-purifying respirator (PARP), and eye protection.

* During shortages, gowns will be reserved for specific procedures (e.g., aerosol-generating and transport of patients with respiratory symptoms) and close contact (e.g., bedside care with contact, bathing).
† Surgical masks or KN95 are required for all CDCR staff as source control for COVID-19. Surgical masks and KN95 masks provide enhanced protection over cloth.
‡ During shortages, N95 respirators will be reserved for aerosol-generating procedures (AGPs), procedures generating splashes and sprays, procedures that are very close and involve prolonged exposure to a COVID-19 case, and during the escort or vehicular transport of SARS-CoV-2 infected patients and patients with respiratory symptoms.

  • Don PPE upon room entry and discard before exiting the room.
  • Shoe or boot covers are not required.
  • Eye protection includes face shields or safety glasses that completely cover the sides of the upper face or goggles.
  • All face masks and respirators should be inspected and discarded if there is any question regarding structural integrity.
  • Do not touch the outside of the PPE when doffing.

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 Recommended COVID-19 PPE for Staff and Inmates-Patients Update (CDCR networking is required for access) for more information on scenario-based PPE guidance.

STAFF, INMATE WORKER AND RESIDENT PPE FOR ILI/SYMPTOMATIC PATIENT

Patients presenting with an ILI should be considered infectious for COVID-19 until proven otherwise. Standard, contact, droplet, and airborne precautions, plus eye protection, are recommended when in proximity of (during escort, entering a room with, or sharing air with) any patient with ILI symptoms. This includes patients in single-person isolation pending viral testing or awaiting results of viral testing. An N95 respirator, and a face shield or other eye protection, are necessary. The need for gloves and gown can be assessed by the anticipated level of contact with the symptomatic patient or their body fluids.

STAFF, INMATE WORKER AND RESIDENT PPE WHEN NEAR SUSPECTED AND CONFIRMED COVID-19 CASE(S)

Standard, contact, droplet, and airborne precautions, plus eye protection, are recommended when in proximity of (during escort, entering a room with, or sharing air with) patients with suspected or confirmed COVID-19 infection. An N95 respirator and a face shield or other eye protection are necessary. The need for gloves and gown can be assessed by the anticipated level of contact with the suspect or confirmed COVID-19 patient or their body fluids.

PPE FOR QUARANTINE AREAS: STAFF, INMATE WORKER AND RESIDENT PPE WHEN NEAR AN ASYMPTOMATIC CONTACT OF A COVID-19 CASE (EXPOSED AND IN QUARANTINE) AND PRECAUTIONARY PRE/POST MOVEMENT QUARANTINED PATIENTS NOT KNOWN TO BE EXPOSED

Standard, contact, droplet, and airborne precautions, plus eye protection, are recommended for all persons in quarantine areas. An N95 respirator, eye protection, gown, and gloves are the recommended PPE. Custody or other personnel that enter quarantined areas, do surveillance rounding, share air with or escort quarantined persons and/or are stationed with this quarantined cohort should wear an N95 respirator and a face shield or other eye protection. The need for gloves and gown can be assessed by the anticipated level of contact with the suspect or confirmed COVID-19 patient or their body fluids.

PPE FOR CONTACT OF A CONTACT

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

STAFF, INMATE WORKER AND RESIDENT PPE FOR CONFIRMED INFLUENZA CASE

Standard, contact, and droplet precautions are recommended for patients confirmed influenza. A surgical/procedure mask or KN95 mask, gloves, and a gown are the recommended PPE. The need for gloves and gown can be assessed by the anticipated level of contact with the symptomatic patient or their body fluids. An N95 respirator is not needed when in proximity of a confirmed influenza case (suspect or confirmed COVID-19 cases or COVID-19 quarantined should not share air space with confirmed influenza cases).

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.

COVID-19 FACE COVERINGS GUIDANCE

  • Please refer to the 11/19/2020 Authorized Facial Coverings for all Employees, Contractors and Visitors and CALPIA Cloth Face Barrier/Mask memo for the most up-to-date CDCR-CALPIA instructions (CDCR networking is required for access). CDC and the local health department guidance supersedes the above memo when dealing with quarantine and isolation. This guidance is not a substitute for healthcare and custody staff following the current CDC, local health department, or CCHCS recommendations in dealing with suspected, quarantine, or diagnosed patients (i.e., need for N95 respirators). See also: CDC on Facial Coverings. For inmates, see Use of KN95 Masks as Facial Barriers Only.
  • Staff and inmates/patients are required to wear a face barrier 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.
    • Surgical masks (also known as procedure or medical masks) or KN95 masks without exhalation valves are to be used by all staff.
    • Inmates can use cloth face coverings or KN95s without exhalation valves that cover both the nose, mouth, and chin.
      • A cloth mask is not a substitute for physical distancing and washing hands. Cloth masks are not PPE. Put a surgical face mask or KN95 on the patient if he/she has no cloth mask for source control (way to prevent exhalation into the air).
      • Cloth masks should be routinely washed, at least daily, laundered with detergent and hot water, and dried on a hot cycle. Advise inmates if their mask needs laundering.
      • Advise inmates to 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
      • Inmates must wear face coverings at all times, inside and outside, with the following exceptions:
        • ― When in their assigned cell or on their bunk
        • ― When eating and drinking, provided that at least 6-feet distancing is maintained from other people
        • ― While showering, bathing, shaving, or performing oral hygiene in common areas provided 6-feet distancing from others is maintained
  • Please be aware that eye-protective face shields do not constitute a facial covering. Eye protective face shields should always be worn with N95s, KN95s, or surgical masks.

COVID-19 N95 RESPIRATOR GUIDANCE

N95 respirators are to be worn as detailed above and described in the memo Recommended COVID-19 PPE for Staff and Inmate-Patients Update (CDCR networking is required for access). Detailed N95 information on CDCR endorsed N95 brands can be found in the COVID-19 N95 Respirators memo. See also the 8/31/20 memo on Fit Testing.

LENGTH OF TIME ONE CAN SAFELY WEAR AN N95 RESPIRATOR

The length of time an individual can safely wear an N95 respirator is different from person to person. The N95 respirator can be worn for a maximum of eight hours. However, if the respirator becomes damp, wet, or visually dirty, or if an individual has difficulty breathing through the respirator after a short time (e.g., half an hour), he/she should remove and discard the respirator. Care should be taken not to touch the outside of the respirator when removing it.

All reusable respirators must be cleaned and disinfected according to the manufacturer’s reprocessing instructions. See NIOSH’s general sanitizing guide and videos on maintenance and care at https://www.cdc.gov/niosh/npptl/cleaning.html.

In the event of respirator shortages, consult the Center for Disease Control (CDC) and National Institute for Occupational Safety and Health (NIOSH) guidelines which recommend a combination of approaches to conserve supplies while safeguarding staff and inmate 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.

COVID-19 FACE SHIELDS AND EYE PROTECTION GUIDANCE

  • Take care to ensure the selected eye protection and N95 respirator do not physically impede either PPE’s function or fit.
  • Wear face shields, goggles, or safety glasses that have coverage completely on both sides of the upper face/ lateral eye area. Eyewear (e.g., safety glasses, trauma glasses) with gaps between glasses and the face mask are likely to allow aerosols, noxious partials from splashes and sprays to contaminate the unprotected areas of the face.
  • Clean and disinfect reusable eye protection equipment in accordance with the manufacturer and CDC guidance.
  • Face shields and eye protection should be examined prior to use and discarded if the visual inspection reveals concerns or damage.

COVID-19 GOWN GUIDANCE

Risk assessment on the anticipated level of contact with aerosols, splashes and sprays, close contact with others, and direct contact with body fluids or contaminated items may be used in regards to the necessity of gowns. In the event of shortages, the following are contingency strategies for optimizing the supply of gowns:

  • During Shortages:
    • Reserve gowns for specific high-risk procedures such as aerosol-generating and transport of patients with respiratory symptoms and close contact (e.g., bedside care with contact, bathing) activities.
      • 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.

COVID-19 TRANSMISSION FROM PAPER SURFACES

SARS-CoV-2 (the virus that causes COVID-19) stays on plastic and steel for up to 3 days, on cardboard for up to 1 day, and on copper for up to 4 hours. There is no specific information regarding how long SARS-CoV-2 can live on an envelope/paper.

Note: The envelope/paper will not infect an individual directly. When an individual touches the envelope/paper, followed by touching his/her face, this will inoculate the virus into his/her nose, eyes, and mouth. This is how infection can occur.

MAIL DELIVERY FOR COVID-19 CONFIRMED/SUSPECTED CASES

  • Allow the mail/envelope to sit for 24 hours.
  • Handle the mail/envelope with gloves.
  • Perform hand washing after touching the envelope/mail and before touching the mouth or eyes.
  • Hand washing: Rub hands together for at least 20 seconds, and don’t forget to wash the thumbs, the skin under rings, and the area around fingernails.

HANDLING OF FORM 7362s SUBMITTED BY COVID-19 CONFIRMED/SUSPECTED CASES

  • Handle the Form 7362 with gloves.
  • Scan the Form 7362 into the medical record and wipe down the scanner with an EPA-registered disinfectant.
  • The scanned Form 7362s are transferred to Medical Records for storage.
  • Allow the Form 7362 to sit for some time (e.g., 5 days) before sorting with gloves.
  • Employees need to practice proper hand hygiene (rubbing hands together for at least 20 seconds, including washing the thumbs, the skin under rings, and the area around fingernails) after touching the Form 7362s and certainly before eating or touching the mouth or eyes.

HANDLING THE PROPERTY OF DECEASED INMATES/PATIENTS WHO DIED FROM COVID-19

  • When handling the property of deceased inmates/patients who died from COVID-19, custody staff should use appropriate PPE (same PPE when approaching the confirmed/suspected COVID-19 cases).
  • After packing and PPE removal, practice proper hand hygiene; wash hands (rubbing hands together for at least 20 seconds, including washing the thumbs, the skin under rings, and the area around fingernails) before eating or touching the mouth or eyes.

RECOMMENDATIONS TO THE FAMILIES: HOW TO HANDLE THE DECEASED’S BELONGINGS

  • Upon receiving the deceased inmate’s/patient’s property from the prison, the families should use gloves and practice proper hand hygiene when handling the deceased’s belongings. Avoid touching eyes and mouth with “contaminated” hands.
  • Depending on the type of belongings, families should follow the CDC’s guidance on Cleaning and Disinfecting Your Home.
  • For clothing and other textiles:
    • Do not shake out
    • Machine wash with warm or hot water using laundry detergent
    • Dry in a hot mechanical dryer
  • Personal items and hard surfaces should be cleaned and disinfected:
    • Clean surfaces using soap and water, then disinfect with an EPA-registered List N: Disinfectant for Use Against SARS-CoV-2 (COVID-19).
      • Follow the manufacturer’s instructions for use, which include contact time, etc.
      • Alternatively, a diluted household bleach solution (4 teaspoons bleach per quart of room-temperature water) with a contact time of at least 1 minute may be used.
      • Families should use appropriate PPE, including respiratory and eye protection, when preparing and using disinfecting solutions.
  • Personal items that cannot be cleaned and disinfected (e.g., paper photographs, greeting cards):
    • Keep in the bag provided by the prison for 10 days. The items should be safe to remove at that time.

CONTROL STRATEGIES FOR SUSPECTED AND CONFIRMED CASES - Updated 4/08/2021

TABLE OF CONTENTS

  1. INFLUENZA-LIKE ILLNESS (ILI) CASE AND OUTBREAK IDENTIFICATION
  2. CHECKLIST FOR IDENTIFYING COVID-19 SUSPECTS
  3. ISOLATION SPACE DEFINITIONS AND WHERE TO ISOLATE
    1. DEFINITION OF SINGLE-PERSON ISOLATION SPACE
    2. DEFINITION OF COHORT ISOLATION SPACE
  4. APPROPRIATE POPULATIONS FOR EACH ISOLATION TYPE
    1. ISOLATION: PRACTICAL CONSIDERATIONS FOR ALL CATEGORIES
  5. ILI, SUSPECTED COVID-19, AND SUSPECTED INFLUENZA STRATEGIC CONTROL STEPS
    1. TABLE 12.1 ISOLATION, PERSONAL PROTECTIVE EQUIPMENT, MONITORING, AND RELEASE FOR SYMPTOMATIC PATIENTS AND PATIENTS CONFIRMED TO HAVE INFLUENZA AND/OR COVID-19
  6. CONTACT INVESTIGATION
  7. MEDICAL HOLD
  8. COVID-19 SPECIFIC ISOLATION ISSUES
    1. MONITORING ILI OR SUSPECTED OR CONFIRMED COVID-19 CASES
    2. MEDICAL MONITORING SIGNS AND SYMPTOMS FOR SUSPECT AND CONFIRMED COVID-19
  9. RELEASE FROM ISOLATION FOR ILI PATIENTS WHO TEST NEGATIVE WITH PCR FOR INFLUENZA AND COVID-19
  10. CRITERIA FOR RELEASE FROM ISOLATION OF CONFIRMED COVID-19 CASES
    1. FIGURE 12.1: ALGORITHM FOR RELEASE FROM ISOLATION CRITERIA FOR PATIENTS WITH COVID-19
  11. INFLUENZA SPECIFIC ISOLATION ISSUES
    1. CONFIRMED SYMPTOMATIC OR ASYMPTOMATIC INFLUENZA ISOLATION
    2. MONITORING FOR SUSPECT AND CONFIRMED INFLUENZA CASES
  12. CRITERIA FOR RELEASE FROM ISOLATION FOR CONFIRMED INFLUENZA CASES
  13. CLEANING SPACES WHERE SUSPECT AND CONFIRMED COVID-19 or INFLUENZA CASES SPENT TIME
  14. APPENDIX 6: COVID-19 INDEX CASE – PATIENT CONTACT INVESTIGATION TOOL
  15. APPENDIX 7: COVID-19 INDEX CASE – PATIENT INTERVIEW CHECKLIST
  16. APPENDIX 13: COVID-19 SCREENING AND TESTING MATRIX FOR PATIENT MOVEMENT
  17. APPENDIX 20: RECOMMENDATIONS FOR SAFER MOVEMENT BETWEEN JAILS AND PRISONS TO PREVENT COVID-19 INTRODUCTION

1. INFLUENZA-LIKE ILLNESS (ILI) CASE AND OUTBREAK IDENTIFICATION

The Centers for Disease Control and Prevention (CDC) definition for ILI is a documented fever, cough, and/or sore throat in the absence of another cause. However, because the symptoms of ILI, COVID-19, influenza, respiratory syncytial virus (RSV), and other respiratory pathogen illnesses are similar and often overlap, caution is needed in managing symptomatic persons before testing and a diagnosis can be made. Another important situation is the development of symptoms within 3 days of receiving the COVID-19 vaccination. Please refer to the Reported Symptoms of COVID-19, Influenza, and Respiratory Syncytial Virus table (Table 5.1) when evaluating viral symptoms and to the Testing Algorithm.

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 (see Appendix 13), prior to allowing patients to be within 6 feet of other persons. Symptomatic screening in a separate clinic area with rooms and doors, or a physically removed area outdoor with a canopy, or indoor and separated, is critical for preventing viral transmission. Quarantine protocols on arrival should be followed. Refer to the Movement Matrix (Appendix 13).

Patients with viral symptoms may be discovered on arrival, present in the clinic, or be identified in quarantine. Patients with ILI or suspected influenza and COVID-19 will need to be isolated immediately. More details follow below.

If within 3 days of receiving a dose of the COVID-19 vaccine, patients develop symptoms that are consistent with the post-vaccination side effects (fatigue, headache, muscle and joint pains, and chills), they should be asked about recent exposure to anyone infected with COVID-19. If they have not been exposed, the symptoms are likely to be post-vaccination symptoms, and they do not need to be placed in isolation nor tested for COVID-19. If these symptoms persist beyond 3 days, the patient should be re-evaluated and tested for COVID-19.

If within 3 days of receiving a dose of the COVID-19 vaccine, patients develop a fever or symptoms of COVID-19 infection that are NOT typical of post-vaccination side effects (e.g., cough, shortness of breath, rhinorrhea, sore throat, diarrhea, or loss of taste/smell), they should be isolated, evaluated, and managed as a suspected case of COVID-19.

See the checklist below for active means to identify ILI already occurring within an institution.

2. CHECKLIST FOR IDENTIFYING COVID-19 AND INFLUENZA SUSPECTS

  • Examine laboratory testing results for positive COVID-19, influenza, and other communicable diseases requiring public health action.
  • Examine COVID-19 and influenza tests ordered in the last 24 hours to identify patients with ILI who may be infected.
  • Examine treatment and triage area (TTA) logs for patients with respiratory symptoms.
  • Do a retrospective review of patients with possible COVID-19/ILI symptoms utilizing the Medical Scheduling Registry (CDCR networking is required for access). This report registry helps locate patients with respiratory illness symptoms requesting a registered nurse (RN) medical encounter via the 7362 process.
  • Coordinate with the Utilization Management (UM) nurse on patients out to medical with ILI/pneumonia.
  • Review the daily movement sheet to identify patients who may have been sent out to a higher level of care (HLOC) due to ILI/respiratory symptoms.
  • Attend daily Patient Care (PC) clinic huddles, as time permits, to identify any patients being seen that day with ILI symptoms complaints.

Please refer to the COVID-19 Outbreak Testing subsection and the Outbreak Management and Preparedness Toolkit (CDCR networking is required for access) for more detailed information on COVID-19 outbreak management and the Influenza Outbreak Testing subsection and the CDC on Influenza Outbreak Management for more Influenza outbreak guidance.

Also, for outbreak response employee testing strategy and planning, refer to the Employee Testing page on Lifeline, the 10/30/2020 COVID-19 Staff Testing Guidance, and the 10/16/20 Establishment of a Statewide Employee Health memo.

3. ISOLATION SPACE DEFINITIONS AND WHERE TO ISOLATE

Isolation space needs to be able to accommodate medical beds, close medical monitoring, and supportive treatment for patients.

DEFINITION OF SINGLE-PERSON ISOLATION SPACE

Cells or rooms with floor to ceiling solid walls and a solid door that closes, such that separate air space for the one quarantined patient can be maintained and will not be shared with other persons or cohorts.

Single-person isolation:

  1. Isolate single persons in a negative pressure room if COVID-19 is suspected or confirmed (negative pressure is not necessary for influenza control).
  2. Isolate separately, in single cells with solid walls (i.e., not bars) and solid doors that fully close.

DEFINITION OF COHORT ISOLATION SPACE

Multi-celled or dorm buildings with floor to ceiling solid walls and a solid door that closes, such that air space within that building does not share air with other buildings or spaces for other cohorts.

Cohort isolation:

  • Cohort in a large, well-ventilated room with solid walls and a solid door that closes fully.
  • It is always prudent to continue social distancing while in cohorts.
  • If the ideal choice does not exist in a facility, use the next best alternative.

4. APPROPRIATE POPULATIONS FOR EACH ISOLATION TYPE

Isolation space will be needed for single-person isolation, isolation for cohorts of confirmed COVID-19, and isolation for cohorts of confirmed influenza cases. See which types of patients belong to these categories below.

The three types of populations to isolate:

  1. Single-person isolation:
    1. ILI patients – symptomatic and under evaluation/awaiting testing or results.
    2. Patients who have tested positive with a COVID-19 (SARS-CoV-2) POC test. These patients need a confirmatory PCR before being placed in a cohort where they could contract the disease if the POC is a false positive.
    3. Suspect COVID-19 (symptomatic awaiting test results).
    4. Suspect influenza (symptomatic awaiting test results).
    5. Patients with dual influenza and COVID-19 infections.
    6. Patients who are symptomatic and refuse to test.
    7. During the influenza season, patients who are symptomatic and still suspect for both influenza or COVID-19, awaiting influenza or COVID-19 test results on dual testing, and only one test has come back.
    8. Patients who test negative, but for whom there is still clinical suspicion of COVID-19 or influenza infection while awaiting re-testing and decision-making is underway.
    9. Symptomatic or asymptomatic patients >90 days out from a prior infection who have newly tested positive again (see the Testing Re-positives subsection). Because of the risk of false positives or non-infectious shedding in these occurrences, single cells are required and not cohorts where, if they do not actually have a new viral infection and are not immune, they are susceptible.
  2. Cohort isolation for confirmed COVID-19 cases:
    1. Asymptomatic or mild laboratory-confirmed COVID-19 cases
    2. Symptomatic patients with ILI who are COVID-19 positive and influenza negative.
  3. Cohort isolation for confirmed influenza cases:
    1. Symptomatic laboratory-confirmed influenza cases with a negative PCR for COVID-19.

Immediately (i.e., as soon as possible, and no later than 24 hours after recognition) isolate all confirmed cases (including COVID-19 POC/rapid influenza diagnostic testing [RIDT] scenarios that do and do not require PCR confirmation) and isolate all ILI patients who are undergoing dual testing for influenza and COVID-19 (see Testing Algorithm – Figure 6.1). Co-infected patients and those awaiting one or both (influenza and/or COVID-19) test results to come back should stay in single-person isolation. Do not place symptomatic, undiagnosed patients with any other patient or cohort, as it puts them at risk of becoming infected with a different disease or spreading their infection to others. Once a diagnosis is confirmed, patients can be isolated in cohorts of other infected patients, so long as they are all infected with the same pathogen. Asymptomatic but test-confirmed cases can also be cohorted with other patients who have been diagnosed with the same illness.

Patients with respiratory/ILI symptoms who refuse to test: People who refuse testing after showing symptoms in Table 5.1 should be treated as if they tested positive for COVID-19. They should be placed immediately in medical isolation in single-person isolation housing. They should NOT be placed in cohorts (doors with open bars, double-celled or in dorm housing) with other people who are symptomatic, pending a test result, or confirmed positive following testing. They should complete isolation and the release from isolation criteria for COVID-19, even if suspected of having influenza.

Medical isolation conditions should be as similar to regular housing as possible.

ISOLATION: PRACTICAL CONSIDERATIONS FOR ALL CATEGORIES

Patients may be quite ill or at risk of becoming ill. Many will require a comfortable medical bed with close monitoring and supportive treatment. Refer to the Treatment section for information on in-house treatment and supportive care and when to send to HLOC. Information on medical monitoring is discussed in Medical Monitoring Signs and Symptoms for Suspect and Confirmed COVID-19.

Provide individuals under medical isolation with extra soap, tissues, and if permissible, a lined, no-touch, trash receptacle. Instruct them to:

  • Cover their mouth and nose with a tissue when they cough or sneeze.
  • Dispose of used tissues immediately in the lined trash receptacle.
  • Wash hands immediately with soap and water for at least 20 seconds. If soap and water are not available, clean hands with an alcohol-based hand sanitizer that contains at least 60% alcohol (where security concerns permit). Ensure that hand washing supplies are continually restocked.
  • 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 the subsection in Primary Prevention on this topic). During outbreaks, this should be assessed daily (see the Outbreak Management and Preparedness Toolkit – CDCR networking is required for access, and outbreak testing considerations in the Testing section.
  • A sign should be placed on the door or wall of an isolation area to alert all persons entering to follow the required Transmission-Based Precautions.
  • Facilities should also ensure that plans are in place to communicate information about patients in isolation who are transferred to other departments (e.g., radiology, laboratory), another prison, or county jail or are being released to the community. Ensure communication and a plan before transfer. (Refer to the Inmates Releasing from Institutions and the Testing sections).
  • Patients with confirmed COVID-19 or influenza shall only be transported for emergent medically necessary procedures or transfers. If a patient with confirmed COVID-19 or influenza must be moved out of isolation, ensure he/she wears a surgical/procedure mask.
  • Patients in quarantine or isolation may develop medical, mental health, or dental symptoms and communicate this via a 7362, talking with a correctional officer (CO) or health care worker (HCW), or a staff member or other inmate may observe a problem. Depending on the type and severity of the problem and the prison’s physical layout, there are several possibilities for evaluation. General principles are limiting the exposure of other people to the patient as much as possible and the number of places they pass through. Each institution and group of health care staff should develop a plan for various contingencies, including the possibility of setting up temporary exam rooms, tents, or other areas within or just outside each housing area. This should include evaluating whether a 7362 or a reasonable accommodations request could be postponed or temporarily addressed without a visit.
    Thus, if possible, the inmate would be evaluated at the cell front. If the evaluation required more privacy or a physical exam, the next best place would be an exam room within or just outside the same housing. If more equipment were needed, the next best would be the yard clinic or the TTA. If the problem were severe enough that the patient needed to go to the emergency room (ER) or hospital, having the ambulance or state vehicle pick the patient up directly from the room or housing area would be ideal, as long as medical treatment and stabilization weren’t needed first, in which case moving to the TTA would be necessary. If it is a mild problem, then a visit to evaluate it should be postponed until the isolation or quarantine has ended. If it is a moderate or severe problem, and the patient needs to be brought to a yard clinic or TTA, they must wear a mask and be escorted directly to the exam/treatment room that has a closed door, with no interaction with other inmates and no time spent in a waiting room. The escorting staff member and the evaluating health care staff must wear appropriate PPE, and appropriate disinfection of the room to include high-touch surfaces must be done after the visit.

To the greatest extent possible, individuals under medical isolation should be provided access to the same necessities and privileges that would otherwise usually be available.

  • Patients under medical isolation for all isolation categories should have continued access to the following activities (see below). However, facilities must ensure there is adequate 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 dayroom 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 or influenza who are isolated as a cohort may participate as a group for yard time, dayroom time, while dining, and in medication and canteen lines, as long as they are masked and adhering to physical distancing rules from non-infected persons.
  • Providing access to the above necessities and time outside of isolation to a feasible and safe extent is important for reducing disincentives for symptomatic patients to seek medical attention.

5. ILI, SUSPECTED COVID-19, AND SUSPECTED INFLUENZA STRATEGIC CONTROL STEPS

Patients presenting with ILI, suspect COVID-19, or suspect influenza symptoms, need to wear a surgical facemask and be isolated immediately. Patients should be placed in an airborne infection isolation room (AIIR) if possible (this can be ordered in the electronic health records system – EHRS). If AIIR is not immediately available, the patient should be placed in a single-person isolation with solid walls and a solid door that closes until a health care provider can clinically assess and evaluate them.

Do not place these patients with cohorts of patients diagnosed with the same illness or any other cohort. Appropriate signage indicating precautions and required personal protective equipment (PPE) to enter should be visible outside the patient’s room.

Provide education to the patient about testing. Help allay fears, teach them about the symptoms of COVID-19/influenza, what isolation is like, how their housing might be affected, and what to expect with surveillance rounding. Providers may want to specifically order a nursing education session in the EHRS as well. See the patient education tri-folds for isolation, recovery, and the teaching script for isolation.

Isolated patients with ILI, suspect COVID-19, or influenza symptoms should be isolated until they have an alternate diagnosis and a provider tests and deems them to not have COVID-19 or influenza on medical evaluation or they are no longer infectious and have been cleared by the health care provider because they have met the criteria for Release from Isolation.

Patients who test negative, but there is still clinical suspicion of COVID-19 or influenza infection should remain in single-person isolation while re-testing and decision-making are underway.

For ILI, suspected COVID-19, and suspected influenza patients: standard, contact, and airborne (N95) precautions plus eye protection> should be implemented immediately for all staff and inmate workers (see Infection Control and Personal Protective Equipment section and the 3/18/21 Recommended PPE for Staff and Inmates Update for more information). Also, see the Isolation, Personal Protective Equipment, Monitoring, and Release for Symptomatic Patients and Patients Confirmed to have Influenza and/or COVID-19 table (Table 12.1) for helpful guidance regarding isolation rooms and PPE.

Table 12.1: Isolation, Personal Protective Equipment (PPE), Monitoring, and Release for Symptomatic Patients and Patients Confirmed with Influenza and/or COVID-19. Adapted from the CDC COVID-19 Guidance for Correctional and Detention Facilities. Please click on the image to open PDF for full table details.
  • For more information on communicating Transmission-Based Precautions, see HCDOM 3.8.8, Communicating Precautions from Health Care Staff to Custody Staff.
  • Assess the patient and treat as appropriate. For suspect influenza and COVID-19, medical rounding should begin.
  • Contact investigations should be started within 24 hours for suspected COVID-19 and suspected influenza cases, and the identified non-symptomatic contacts should be placed in quarantine. Contact investigations are needed to quickly identify and quarantine exposed close contacts and get them symptom and temperature screened and tested. This needs to happen quickly and not wait for confirmatory test results. Housing units, especially dorm settings, should be in quarantine immediately. POC COVID-19 and rapid influenza (RIDT) testing can be quite useful in such situations. Refer to Outbreak Response Testing and the Quarantine subsection in Control Strategies for Contacts of Cases for more details.
  • Assign dedicated health care staff and equipment to provide care to ILI suspected or confirmed cases. Take all possible precautions to keep the staff who care for patients in isolation separated from all other cohorts and the staff that care for other cohorts.
  • To the maximum extent possible, limit movement of designated staff between different parts of the institution to decrease the staff’s risk of spreading respiratory infections to other parts of the facility. To assist staff, traffic patterns may need to be changed or guided with demarcations. Refer to the Infection Control and Personal Protective Equipment and the 3/18/21 Recommended PPE for Staff and Inmates Update memo for more information on PPE needed during isolation, escort, and movement.
  • For guidance on notifications and reporting of ILI or suspected COVID-19, please see the Notifications and Reporting section.
  • For more transportation recommendations, see Safer Movement Between Jails and Prisons (Appendix 20).
  • Soon-to-be released patients with suspected COVID-19 or influenza need direct linkages to community resources to ensure proper isolation and access to medical care. Notify the local health department (LHD) of patients to be released who have suspect or confirmed cases and are still isolated.
    • IMPORTANT: Suspect influenza or COVID-19 cases, patients from facilities with large outbreaks, and influenza or COVID-19 case-patients should not be released without the coordination of CDCR discharge planning and LHD guidance. See the Inmates Releasing from Institutions section.
  • If COVID-19 has been ruled out clinically and by testing, airborne precautions can be stopped. Droplet precautions should continue until influenza has been ruled out. All persons should comply with global masking and social distancing policies. If a person is diagnosed with one or more viruses, continue isolation and medical rounding.

6. CONTACT INVESTIGATION

Contact investigation for suspected COVID-19 or influenza cases should be initiated within 24 hours, while COVID-19 and influenza test results are pending, especially when there is a highly suspicious suspect case or multiple suspect cases with known contact to a confirmed case. If unsure, consult with the PHB at CDCRCPHCSPublicHealthBranch@cdcr.ca.gov. Refer to the section Control Strategies for Contacts of Cases for detailed information regarding contact investigations. Some highlights from that section follow:

  • A contact investigation should be conducted for all confirmed (symptomatic or asymptomatic) COVID-19 and influenza cases.
    • INFECTIOUS PERIOD: Determine the dates of the case-patient’s infectious period during which other patients and staff may have been exposed. Refer to the Comparison Between Seasonal Influenza and SARS-CoV-2 table.
    • For symptomatic COVID-19 patients, this is from 2 days (48 hours) prior to the date of symptom onset to the date the case-patient was isolated. For asymptomatic case-patients, the infectious period should be considered 2 days prior to the date of the positive test.
    • For influenza patients, the infectious period starts 1 day prior to symptoms.
  • Interview the case-patient to identify all close contacts based on risk. An exposed contact is an asymptomatic person who may have had contact with the person who is a highly suspect case or a PCR-confirmed positive SARS-CoV-2 case (index case) and thus has the potential to become infected themselves (secondary viral transmission).
    • Identify patients with close contact/high risk exposures
    • 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.

      Potential exposures include but are not limited to:

      • Being in close proximity, within 6 feet for a cumulative total or ≥10 minutes (one ten minute or longer exposure or multiple shorter exposures that may add up to 10 minutes or more) contact with a confirmed case of COVID-19 or influenza during the infectious period.
      • Cellmate of a highly suspect or confirmed COVID-19 or influenza-positive patient (influenza case)
      • 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
      • Being directly coughed or sneezed upon (even though it may be a transient encounter) or in direct contact with secretions
      • Close contact during activities (e.g., in classrooms, groups, social activities, work, church, clinic visits, medication line, and commissary line) with the case
      • Linkage to a high-risk group defined by public health during an outbreak (e.g., an affected dorm, housing unit, or yard)
      • Sharing common spaces (e.g., yard, shower, dining hall, day room)
  • Use the Contact Investigation Tool (Appendix 6) and the Index Case-Patient Interview Checklist (Appendix 7) to guide and document the interview and identification of the case-patient’s close contacts.
  • All asymptomatic patients with known exposure to a confirmed case of either influenza or COVID-19 should be placed in quarantine. Exposed contacts should not be placed in cohorts with people who are symptomatic, pending a test result, or confirmed positive following testing. For influenza, there is no quarantine testing.
  • When new exposures occur while in quarantine, time is reset starting from the new exposure date, as detailed in Control Strategies for Contacts of Cases.
  • Identified contacts of COVID-19 or influenza cases should be reported as per the Quarantine section and the Notifications and Reporting section. Medical surveillance while in quarantine is discussed in Control Strategies for Contacts of Cases.
  • Any persons identified through the contact investigation to develop symptoms or test positive for COVID-19 should be immediately isolated, given a surgical mask, and undergo a medical evaluation. Refer to the Notifications and Reporting section.

Notify institutional leadership regarding any employees who may have been exposed. Leadership alerts to the Office of Employee Health and Wellness (OEHW) and the Return to Work Coordinator (RTWC) are strongly recommended. Resources are also available at the OEHW Employee Website.

7. MEDICAL HOLD

The following persons should have a medical hold:

  • A suspected or confirmed COVID-19 case
  • A suspected or confirmed influenza case

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. See Control Strategies for Contacts to Cases.

8. COVID-19 SPECIFIC ISOLATION ISSUES

For confirmed COVID-19 patients, standard, contact, and airborne (N95) precautions plus eye protection should be implemented immediately (see Infection Control and Personal Protective Equipment section). This applies to all persons working near and around, as well as escort and vehicular transport. Please refer to the 3/18/21 Recommended PPE for Staff and Inmates Update memo for more information.

MONITORING ILI OR SUSPECTED OR CONFIRMED COVID-19 CASES

Symptomatic patients with suspect COVID-19, and symptomatic or asymptomatic confirmed COVID-19, require a minimum of twice-daily nursing assessments. Symptomatic patients need care and attention. Please refer to the Treatment for COVID-19 table (Table 8.1) for supportive care options, and the Treatment section for details on gradations of severity of COVID-19, guidance on appropriate care, as well as when to send to HLOC.

For symptomatic COVID-19 patients, strong consideration should be given to an increased frequency of assessments beyond twice-daily because COVID-19 patients tend to decline precipitously (and after improvement), and silent hypoxemia (patient not experiencing undue dyspnea, but blood oxygenation is declining) may contribute to this. More than twice-daily surveillance may be prudent for patients at high risk of severe COVID-19 disease. Resting silent hypoxia <94% can be uncovered with a while-ambulating or post-walk oxygen saturation check. Ambulatory oxygen saturation is recommended for all patients with any abnormal vital signs or for those with oxygen saturations that are trending downward. Patients often may not reveal their symptoms, making vitals a critical part of monitoring the reportedly asymptomatic patients for decline.

MEDICAL MONITORING SIGNS AND SYMPTOMS FOR SUSPECT AND CONFIRMED COVID-19

All patients in isolation (symptomatic or asymptomatic) should have twice-daily medical monitoring.

  • COVID-19 Nursing assessments will include, but are not limited to:
    • Temperature monitoring
    • Pulse oximeter monitoring- at rest and with/after ambulation for any patients with abnormal vital signs or for patients with oxygen saturations that are trending downward.
    • Blood pressure checks
    • Respiratory rate and heart rate
  • Monitor patients for complications of lower respiratory 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, lethargy or inability to arouse

Patients with abnormal findings should be immediately referred to a provider for further evaluation.

  • Keep in mind the risk factors for severe illness: older age and those with medical conditions described in the High-Risk Conditions section.
    • Patients at high risk of progression, rapid deterioration, and death should be assessed by a nurse and monitored for complications described above, with consideration of increasing frequency beyond twice daily while in isolation.
    • Please refer to the Lifeline Quality Management (QM) COVID-19 Risk Registry (CDCR networking is required for access) to identify patients with medical conditions that place them at high risk for severe COVID-19 disease.
  • COVID-19 patients can 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 onset of symptoms.
    • Please refer to the QM COVID-19 Monitoring Registry (CDCR networking is required for access), which tracks patients with either confirmed or suspected of COVID-19. The COVID-19 Monitoring Registry helps health care staff stay apprised of COVID-19 testing results and ensures that rounding occurs as required across shifts, and flags certain symptoms, such as fever.

9. RELEASE FROM ISOLATION FOR ILI PATIENTS WHO TEST NEGATIVE WITH PCR FOR INFLUENZA AND COVID-19

If there is suspicion of a false negative COVID-19 or influenza test, continued single cell isolation and repeat testing as indicated. Regardless of test results, those who are suspected of having COVID-19 should complete the criteria for release from isolation for COVID-19 (see below). However, when the patient is released from isolation, conservatively, it cannot be assumed that this patient is now temporarily immune from COVID-19.

If the patient has an alternative diagnosis, there is no longer suspicion for COVID-19, and the PCR tests for COVID-19 and influenza are negative, release from isolation immediately, unless that diagnosis is contagious (e.g., tuberculosis – TB, in which case one would isolate as appropriate for the diagnosis). Contacts who had been quarantined because of the index ILI or suspect case would be released as well.

10. CRITERIA FOR RELEASE FROM ISOLATION OF CONFIRMED COVID-19 CASES

For individuals with asymptomatic or symptomatic, laboratory-confirmed COVID-19 under isolation, considerations to discontinue Transmission-Based Precautions include clinical and testing criteria. The CDC has moved away from test-based strategies based on evidence of the lack of culturable infectivity after 10 days of illness, and the best available research at this time. The use of a test-based release strategy is only considered for the severely compromised. There are two tiers of clinical criteria for release, one for higher-risk situations (those at risk to be potentially infectious longer than 14 days) and more liberal clinical criteria for releasing those highly likely not to be infectious after 14 days. Routine-risk patients are those who were asymptomatic, had normal vital signs throughout their illness, and had mild to moderate COVID-19 illness. The release should always be cleared by a medical provider who has seen and evaluated the patient.

Lower risk patients who have fevers beyond day 11 or who are not cleared for release should have isolation extended an additional 7 days. Any patient (high or low risk) who has a persistent fever beyond 14 days should receive an evaluation for alternative etiologies.

When patients are released from isolation, they may have concerns regarding infectiousness. Patients should be educated regarding the 90-day presumed immunity period and a have a discussion to understand that as long as they do not develop new symptoms, they are considered no longer infectious for this timeframe and it is safe to return to their regular housing. It is also helpful to review that during the immune period they will not need quarantine or surveillance testing but may still need to be tested if they have a need to be transported in a vehicle. See the Recovery Trifold patient education handout which is available in English and Spanish.

The guidance below is purposefully conservative due to our congregate setting. See Figure 12.1.

Figure 12.1: Algorithm for Release from Isolation Criteria for Patients with COVID-19. Please click on the image to open PDF for full table details.
  1. CLINICAL CRITERIA FOR HIGHER RISK SITUATIONS:

    Defining High-Risk Patients

    1. Patients who have returned from a hospitalization with COVID-19
    2. Patients who had severe^ COVID-19 requiring oxygen, without hospitalization
    3. Patients who are severely immunocompromised
    4. Patients who are still symptomatic after 14 days
      1. ^The National Institute of Health (NIH) Definitions for Severe and Critical COVID-19:
        1. Severe Illness: Individuals who have respiratory frequency >30 breaths per minute, SpO2 <94% on room air, ratio of arterial partial pressure of oxygen to fraction of inspired oxygen (PaO2/FiO2) <300 mmHg, or lung infiltrates >50%.
        2. Critical Illness: Individuals who have respiratory failure, septic shock, and/or multiple organ dysfunction.
  2. Criteria for Release from Isolation: See Figure 12.1

    1. At least 3 days after resolution of fever without the use of an antipyretic medication (if applicable) AND
    2. At least 21 days (minimum) from after the date of the onset of symptoms (or initial positive test in asymptomatic patients) AND
    3. Improvement in illness signs and symptoms AND
    4. Evaluated by a medical provider and cleared for release. The clinical evaluation should include an examination of temperature measurements in, at least, the last 72 hours. If unable to clear the patient after 21 days, a consultation with an infectious disease specialist is advised. Continue every 7 days as needed or as advised by the specialist, until the patient is cleared for release by a medical provider after a remote or live visit for medical evaluation.

      Patients in this category may need an extended period of convalescence. Refer to the subsection on Sequelae after COVID-19. They may still need to be on oxygen or need frequent provider visits for monitoring and/or significant rehabilitation due to physical deconditioning, respiratory, swallow, cognitive, and mental health impairments after serious illness and especially post-intensive care for COVID-19. A referral to a rehabilitation specialist may be needed, such as physical therapy, occupational therapy, mental health, cardiac and pulmonary rehabilitation, etc. Pay special attention to their lung and overall physical capacity if they will be re-engaging in physically demanding work (see Release to Fire Camp Work or Other Highly Physically Demanding Work below).

  3. CLINICAL CRITERIA FOR LOWER RISK SITUATIONS:

    Defining Lower Risk Situations:

    1. Asymptomatic throughout their illness
    2. Normal vital signs during their illness AND/OR
    3. Had mild to moderate^^ COVID-19 disease, or no fever beyond day 11 (documented afebrile days 12, 13 and 14)
      1. ^^NIH Definition for Mild to Moderate COVID-19:
        1. Mild Illness: Individuals who have any of the various signs and symptoms of COVID-19 (e.g., fever, cough, sore throat, malaise, headache, muscle pain) without shortness of breath, dyspnea, or abnormal chest imaging.
        2. Moderate Illness: Individuals who have evidence of lower respiratory disease by clinical assessment or imaging and a saturation of oxygen (SpO2) ≥94% on room air.

    Criteria for Release from Isolation: See Figure 12.1

    1. At least 3 days after resolution of fever without the use of antipyretic medication (if applicable) AND
    2. At least 14 days**(minimum) from after the onset of symptoms (or date of the initial positive test if asymptomatic) AND
    3. Improvement in illness signs and symptoms AND
    4. Evaluated by a medical provider as cleared for release
      1. Low-risk COVID-19 patients with mild or asymptomatic infection, who upon review of their medical records by a primary care provider (PCP), are found to have normal vital signs throughout the course of their illness, and complete vitals for at least the past 72 hours, can be released from isolation without being seen or physically evaluated by a medical provider.
        1. Do not release if the patient has a fever after day 11 from the initiation of symptoms (or initial positive test if asymptomatic). If not cleared by a medical provider, continue isolation another 7 days, and have a second medical evaluation. After 21 days, consultation with an infectious disease specialist is advised. Continue every 7 days as needed or as advised by the specialist until the patient is cleared for release by a medical provider after a remote or live visit for medical evaluation.
  4. WHEN TO USE A TEST BASED STRATEGY FOR RELEASE FROM ISOLATION
  5. The CDC recommends considering a test-based strategy only for patients who are severely immunocompromised. Further, the CDC recommends the test-based strategy (below) be in consultation with local infectious disease experts. Severely compromised patients are also covered by the preferred symptom-based strategy detailed above.

    Severely immunocompromised persons include but are not limited to, patients on chemotherapy for cancer or prednisone >20mg/day for more than 14 days, and patients with untreated human immunodeficiency virus (HIV) infection with CD4 T lymphocyte count <200 or combined primary immunodeficiency disorder.

    Test-based criteria: Resolution of fever without an antipyretic, symptoms have improved, and negative results of 2 consecutive respiratory specimens ≥24 hours apart using a Food and Drug Administration (FDA)-authorized molecular viral assay. For those without symptoms, solely the 2 tests ≥ 24 hours apart are adequate.

  6. RELEASE TO FIRE CAMP WORK OR OTHER HIGHLY PHYSICALLY DEMANDING WORK
    1. Patients releasing to the extreme demands of firefighting or other physically demanding work will benefit from extra time for recovery. These patients may feel that they are ready for fire work, but their physiology may not be. Give strong consideration to conservative extra time for physical recovery for those returning to highly physically strenuous work. Fire workers should have at least one week of recovery time after release from isolation.
  7. MAXIMUM TIME IN ISOLATION WHEN NO INDICATION TO CONTINUE ISOLATION EXISTS: 21 DAYS
    1. Detecting viral RNA via PCR does not necessarily mean that an infectious virus is present. Viral shedding studies show that prolonged shedding is not likely to be infectious.

      CDC analysis and literature review shows that viral shedding beyond 10 days from the onset of symptoms does not grow in viral culture. Refer to the Testing section on viral shedding and infectiousness.

  8. FACE COVERINGS AFTER RELEASE FROM ISOLATION
    1. 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.
    2. 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.
    3. Resolution of cough, is not necessary for release, however people with residual cough should wear a face covering once released, until completely without cough.
    4. Check for updates: https://www.cdc.gov/coronavirus/2019-ncov/hcp/disposition-hospitalized-patients.html.
  9. CONCERN FOR COVID-19 FALSE POSITIVES and RETESTING OF PREVIOUSLY POSITIVE PATIENTS:Please refer to the instructions detailed in the Testing section.

11. INFLUENZA SPECIFIC ISOLATION ISSUES

CONFIRMED SYMPTOMATIC OR ASYMPTOMATIC INFLUENZA ISOLATION

  • All the above practical considerations for isolation apply.
  • Limit the number of staff who have contact with confirmed influenza cases.
  • Confirmed influenza cases patients shall only be transported for emergent medically necessary procedures or transfers, and the patient must wear a surgical/procedure mask during transport.
  • For confirmed influenza patients: standard, droplet precautions plus eye protection should be implemented. Contact precautions should be used when appropriate (close contact/splashes or sprays expected). Staff and others working near and around, escorting, or involved in vehicular transport of confirmed influenza cases, should wear a surgical/procedure mask (as long as undiagnosed ILI or confirmed COVID-19 cases are not nearby, necessitating airborne precautions). See Infection Control and Personal Protective Equipment section and the 3/18/21 Recommended PPE for Staff and Inmates Update document.
  • Facilities should also ensure that plans are in place to communicate information about confirmed influenza cases who are transferred to other departments (e.g., radiology, laboratory) or another prison or county jail or LHDs before paroling. Ensure communication and a plan before transfer. (Refer to Inmates Releasing from Institutions and the Testing sections).

MONITORING FOR SUSPECT AND CONFIRMED INFLUENZA CASES

  • Patients with confirmed (symptomatic) influenza require daily medical monitoring rounds. Use the influenza surveillance tool in the EHRS. Patients with influenza require care and attention. Refer to the Influenza Treatment table (Table 8.3) for when to give antiviral medication and supportive care options.
  • Keep in mind the risk factors for severe illness: older age and those with medical conditions described in the High-Risk Conditions section. See the Adult Groups at High Risk for Serious Influenza Complications table (Table 5.5) for high-risk influenza factors.
  • Patients at high risk of progression, rapid deterioration, and death should be assessed by a nurse and monitored for complications described above, with consideration of increasing frequency beyond once daily while in isolation.
  • Nursing assessments are to monitor for signs of respiratory compromise or other complications of influenza. The following vitals are recommended:
    • Temperature monitoring
    • Pulse oximeter monitoring
    • Respiratory rate and heart rate
  • Monitor patients for complications of COVID-19 infection, including respiratory distress and sepsis:
    • Dyspnea (shortness of breath)
    • 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
    • Persistent dizziness, altered mental status or confusion, lethargy, inability to arouse, or seizures
    • Persistent abdominal pain or pressure
    • Not urinating
    • Severe muscle pain
    • Severe weakness or unsteadiness
    • Fever or cough that improves but then return or worsen
    • Worsening of chronic medical conditions

Patients with abnormal findings should be immediately referred to a provider for further evaluation.

12. CRITERIA FOR RELEASE FROM ISOLATION FOR CONFIRMED INFLUENZA CASES

  • Asymptomatic or symptomatic laboratory-confirmed influenza patients are to remain in isolation until 7 days from symptom onset and 24 hours after resolution of fever (without taking antipyretic medications) and improvement of respiratory symptoms.
  • After release from influenza isolation, all patients should comply with global face covering and social distancing policies for influenza and COVID-19.

13. CLEANING SPACES WHERE SUSPECT AND CONFIRMED COVID-19 or INFLUENZA CASES SPENT TIME

(See CDC page on this topic)

  • After a thorough cleaning of the area, any room/space is to be left unoccupied for 90 or more minutes prior to re-entry.
  • Refer to the Environmental Infection Control section.

CONTROL STRATEGIES FOR CONTACTS TO CASES - Updated 4/08/2021

TABLE OF CONTENTS

  1. WHAT QUARANTINE IS
    1. DEFINITION OF SINGLE-PERSON QUARANTINE SPACE
    2. DEFINITION OF COHORT QUARANTINE SPACE
  2. QUARANTINE ISSUES FOR COVID-19 AND INFLUENZA
    1. WHO SHOULD NOT BE IN QUARANTINE
    2. QUARANTINE HOUSING FOR COVID-19 OR INFLUENZA
    3. TABLE 13.1: RECOMMENDED HOUSING BASED ON PATIENT EXPOSURES FOR INFLUENZA AND COVID-19
    4. QUARANTINE PRECAUTIONS AND CONDITIONS FOR COVID-19 AND INFLUENZA
    5. HEALTH CARE ACCESS FOR QUARANTINED PATIENTS
  3. ISSUES UNIQUE FOR COVID-19
    1. COVID-19 – WHO SHOULD BE IN QUARANTINE
    2. QUARANTINE PRECAUTIONS AND CONDITIONS FOR COVID-19
    3. COVID-19 INFECTION CONTROL IN QUARANTINE
    4. COVID-19 SURVEILLANCE ROUNDING
    5. TESTING STRATEGIES FOR COVID-19-QUARANTINED PATIENTS
    6. RELEASE FROM QUARANTINE FOR COVID-19
    7. FIGURE 13.1 RELEASE FROM QUARANTINE
  4. ISSUES UNIQUE FOR INFLUENZA
    1. INFLUENZA – WHO SHOULD BE IN QUARANTINE
    2. QUARANTINE PRECAUTIONS AND CONDITIONS FOR INFLUENZA
    3. INFLUENZA INFECTION CONTROL IN QUARANTINE
    4. INFLUENZA SURVEILLANCE ROUNDING
    5. TESTING STRATEGIES FOR INFLUENZA QUARANTINE
    6. RELEASE FROM QUARANTINE FOR INFLUENZA
  5. APPENDIX 10: COVID-19 POWERFORM INSTRUCTIONS; SCREENING, ISOLATION, AND QUARANTINE SURVEILLANCE
  6. APPENDIX 13: COVID SCREENING AND TESTING MATRIX FOR PATIENT MOVEMENT
  7. APPENDIX 18: COVID-19 OPERATIONAL PREPAREDNESS FOR FACILITY LEADERSHIP AND INCIDENT COMMAND

1. WHAT QUARANTINE IS

Quarantine is defined as the separation and restriction of the movement of people who were exposed to a contagious disease to see if they become sick. Asymptomatic patients who may have been exposed to a confirmed or suspected COVID-19 or influenza case (the index case) shall be placed in quarantine. Hence, quarantine is for both close contacts (laboratory-confirmed index case) and contacts of undiagnosed influenza-like illness (ILI). These patients are at risk of already being infected or becoming infected as a result of their exposure. Thus, they need to be separated from the confirmed cases to avoid re-exposure and from the general population of unexposed individuals to prevent potential disease transmission.

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), California Correctional Health Care Services (CCHCS) Public Health Branch (PHB), and the Chief Medical Executive (CME).

Prior to initiating quarantine for either COVID-19 or influenza, patients should receive a full symptom screen and temperature check. If the patient screens positive, they should be given a surgical mask, immediately removed from the quarantine area, and moved to an isolation-designated location for further medical evaluation.

This section of the Guidance has three parts:

  • Issues that are universal for both COVID-19 and influenza,
  • Issues unique to COVID-19, and
  • Issues unique to influenza.

DEFINITION OF SINGLE-PERSON QUARANTINE SPACE

Cells or rooms with floor to ceiling solid walls and a solid door that closes, such that separate air space for the one quarantined patient can be maintained and will not be shared with other persons or cohorts.

DEFINITION OF COHORT QUARANTINE SPACE

Multi-celled or dorm buildings with floor to ceiling solid walls and a solid door that closes, such that air space within that building does not share air with other buildings or spaces for other cohorts.

2. QUARANTINE ISSUES FOR COVID-19 AND INFLUENZA

WHO SHOULD NOT BE IN QUARANTINE

  • Contacts to contacts of COVID-19 or influenza cases.
  • Patients with resolved COVID-19 infection who are within their presumed immunity period; within 90 days of the onset of symptoms or the initial positive test.
  • Patients out-to-court or hospital/medical appointments for <24 hours and not known to be exposed to any infection while away.
  • Contacts of resolved cases where the exposure occurred after the case has been released from isolation.

QUARANTINE HOUSING FOR COVID-19 OR INFLUENZA

When preferential housing space has been vacated or set aside for quarantine (or if quarantine space is full, but space set aside for isolation is not currently in use), be sure to always use these spaces when needed for separating persons who require quarantine.

  • Quarantined persons who have been exposed, have a high likelihood of being exposed, or are contacts of cases, should be assigned single person quarantine space as defined above.
  • Quarantine cohorts should be housed in cohort quarantine space as defined above, and the size should be as small as possible (no more than 10 persons) to minimize spread.
  • Cohorts with different exposure dates should be separated into different cohort quarantine spaces.
  • Cohorts with different types of exposures should be separated, such as those coming in from jails, transferring between institutions, coming from a hospitalization, etc.

See the table below regarding recommended housing based on patient exposures.

Table 13.1: Recommended Housing Based on Patient Exposures. Please click on the image to open PDF for full table details.

QUARANTINE PRECAUTIONS AND CONDITIONS FOR COVID-19 AND INFLUENZA

Several aspects related to precautions/conditions are unique to COVID-19 or influenza. The following text is for BOTH. For more detail on those that are unique, see Quarantine Precautions and Conditions for COVID-19 or Quarantine Precautions and Conditions for Influenza later in this document.

Education
Educate the patient on quarantine (e.g., what it is, what to expect, testing, etc.). Patients should also be provided education about signs and symptoms of the disease they were exposed to and the importance of immediately reporting symptoms to staff, should symptoms develop while they are in quarantine. See the Patient Education tab on the CCHCS COVID-19 website for more education materials and nursing scripts (CDCR networking is required for access).

Surveillance
Correctional nursing leadership is responsible for assigning nursing teams to conduct surveillance to identify new suspected cases. Surveillance rounds and the evaluation of quarantined asymptomatic patients must be done in all housing units where one or more patients with suspected or confirmed COVID-19 or influenza have been identified.

  • Nursing staff is advised to conduct at least once-daily surveillance on quarantined patients for the duration of the quarantine period to identify any new cases.
  • If new case(s) are identified, the symptomatic patient(s) must be masked, removed from the quarantine area for isolation, and evaluated by a health care provider as soon as possible during the same day symptoms are identified.
  • Surveillance may uncover patients in housing units with upper respiratory symptoms, without fever, and who do not meet the case presentation for COVID-19 and influenza. 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 all patients with ILI, confirmed influenza, and/or any suspected or confirmed COVID-19 cases. PHNs should be notified by phone and via the electronic health record system (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.

Quarantined Patient Developing Viral Symptoms
If a patient in quarantine develops symptoms consistent with COVID-19 or influenza, follow recommendations for isolation of the ill patient(s). Separate the ill-quarantined patients from the well-quarantined patients immediately, place a surgical mask on the patient and take them to the isolation medical evaluation area. These patients should be tested as indicated for specific virus. Please refer to the “Diagnostic COVID-19 and Influenza Testing for Symptomatic Patients” subsection of the Testing section.

Yard/Exercise
Quarantine does not include restricting the patient to his/her cell for the duration of quarantine without opportunity for exercise or yard time. Quarantined patients can have yard time as a group but should not mix with non-quarantined patients or other quarantined cohorts.

Meals
Quarantined patients may be given meals in their designated culinary area as a group;

  • if they do not congregate with other non-quarantined patients or other quarantined cohorts;
  • are the last group to get meals; AND
  • the dining room can be cleaned and disinfected after the meal.

If these parameters cannot be met in the culinary area, quarantined patients shall be given meals in their cells.

HEALTH CARE ACCESS FOR QUARANTINED PATIENTS

  • The evaluating health care staff must wear appropriate personal protective equipment (PPE), and appropriate disinfection of the room to include high-touch surfaces must be done after the visit.
  • As much as possible, limit the number of health care staff who interact with quarantined patients in order to reduce opportunities for exposure.
  • Patients in quarantine or isolation may develop medical, mental health, or dental symptoms and should communicate this by submitting a 7362 Healthcare Services Request form. Additionally, custody staff, health care workers (HCW), staff members, or other patients may observe a problem in a quarantined patient that requires medical evaluation. Depending on the type and severity of the problem and the prison’s physical layout, there are several possibilities for evaluation. General principles are to limit as much as possible the exposure of other people to the patient and the number of areas the patient passes through. Each institution should develop a plan for various contingencies, including the possibility of setting up temporary exam rooms, tents, or other areas that keep the quarantined persons separated from all other populations. This should include evaluating whether a 7362 or a reasonable accommodation request could be postponed or temporarily addressed without a face-to-face visit. Patients in quarantine should be reminded not to wait on the 7362 process, but to alert staff immediately should they develop ILI symptoms.
  • If possible, evaluate the patient at cell front. If the evaluation requires more privacy or a physical exam, the next best place would be an exam room within or just outside the same housing. If more equipment were needed, the next best option would be the yard clinic or the treatment and triage area (TTA).
  • If the problem is severe enough that the patient needs to go to the emergency room or hospital, having the ambulance or state vehicle pick the patient up directly from the room or housing area would be ideal. If medical treatment and/or stabilization are needed prior to transport to a community emergency room or hospital, moving the patient to the TTA would be recommended. All patients leaving the quarantine area for medical evaluation should wear a surgical mask; escorting staff should wear an N95 respirator.
  • If it is a non-urgent issue, postponing the appointment until the isolation or quarantine has ended should be considered. If the patient has an urgent or emergent issue and needs to be brought to a yard clinic or TTA, they must wear a mask and be escorted directly to an exam/treatment room with a closed door. The patient should not interact with other inmates and should not spend time in a waiting area.

3. ISSUES UNIQUE FOR COVID-19

COVID-19 – WHO SHOULD BE IN QUARANTINE

Definition of an Asymptomatic Close Contact of COVID-19:
A person without symptoms of COVID-19 who, in the past 14 days, has had close (within 6 feet and cumulative ≥10 minutes) contact with a confirmed case of COVID-19 OR direct contact with secretions of a confirmed case of COVID-19 during the infectious period AND who has had no positive tests for the virus that causes COVID-19 in the past 90 days. This definition is irrespective of the wearing of a mask. Patients should be quarantined immediately (i.e., as soon as possible, and no later than 24 hours) after it is recognized that they meet the definition above. Note: the Centers for Disease Control (CDC) use a 15-minute cutoff, but the California Department of Public Health (CDPH) has concurred that a more conservative time threshold for congregate settings is prudent. Also, the minutes do not have to be all at one time; they can be 10 minutes cumulative.

Due to the congregate-living nature of CCHCS’ population, CCHCS continues to mandate that anyone (regardless of vaccination status) exposed to a COVID-19 case will be quarantined and managed based on various aspects of this chapter. On February 10, 2021, the CDC released a recommendation that (under certain conditions) those who have been fully-vaccinated do not need to be quarantined if exposed to COVID-19. While this recommendation may make sense for a non-incarcerated population, the density of housing and frequency of close contact within CDCR facilities provides significantly greater risk of exposure and spread of viruses. Therefore, for the CCHCS population, being fully-vaccinated does not exempt a contact of a COVID-19 case from being quarantined.

For extensive details on other categories (such as transfers and jail intakes) of who should be quarantined, please refer to the COVID-19 Screening and Testing Matrix for Patient Movement (Appendix 13).

When in doubt about the exposure, err on the side of caution; quarantine and test.

QUARANTINE PRECAUTIONS AND CONDITIONS FOR COVID-19

Movement
Movement in or out of the quarantined area should be restricted for the quarantine period. When transport and non-essential movement is allowed, limit patient transports outside of the facility, permitting transport only for medical, custody, or legal necessity (e.g., specialty clinics, outside medical appointments, custody-related housing changes, mental health crisis, or out-to-court).

  • If transport becomes necessary, assign dedicated staff to the extent possible.
  • Quarantined patients and those transporting quarantined patients must use an N95 respirator and appropriate PPE recommended for the situation and potential COVID-19 contact. Refer to the PPE section.
  • Out-to-court appearances and medical visits should be evaluated on a case-by-case basis. With the CME or CME designee’s approval, a quarantined patient may keep the necessary appointments or transfers, provided that the court, medical provider, and/or clinic have been notified that the patient is in quarantine due to COVID-19 exposure and have agreed to see the patient.

COVID-19 INFECTION CONTROL IN QUARANTINE

Please refer to the PPE section and 3/18/21 Recommended PPE for Staff and Inmates Update for detailed guidance on PPE.

  • Any persons entering and working in COVID-19 quarantine areas should wear an N95 respirator (airborne precautions).
  • If possible, patients in quarantine for COVID-19 should wear an N95 or a surgical mask. Consider N95s for patients at high risk of severe COVID-19, especially if a desirable distance cannot be kept between cohorts and/or there is an unavoidable mix of higher risk exposure (e.g., direct exposure, cellmate of a case) and lower risk exposure cohorts (e.g., arrival from a facility with few or no cases).
  • Transport staff should wear an N95 respirator or other approved respirator for vehicular or escort transport of contacts of COVID-19 cases.
  • Other important considerations for the transport of quarantined persons are detailed in the COVID-19 Operational Preparedness for Facility Leadership and Incident Command (Appendix 18).

COVID-19 SURVEILLANCE ROUNDING

  • Use the new COVID-19 electronic Surveillance Rounds form tool in 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 not on the EHRS tool checklist in the free text box:
    • The only vital sign for quarantine is the temperature.
    • Keep a very low threshold for symptoms (see Table 5.1). Any symptoms of COVID-19 necessitate isolation and a provider evaluation.
    • 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 COVID-19 symptoms, possible complications, and the need for prompt assessment and treatment. Instruct patients to report symptoms at the first sign of illness. See patient education handouts on the CCHCS COVID-19 Webpage (CDCR networking is required for access).

TESTING STRATEGIES FOR COVID-19-QUARANTINED PATIENTS

All patients in quarantine for COVID-19 will be tested. Contacts to either staff or patients with COVID-19 should be tested, at minimum, at the beginning of quarantine, in the middle of quarantine, and prior to release from quarantine. This is especially important if people are cohorted in quarantine. If someone is in quarantine alone, testing beyond the prior to release test may not provide a significant benefit since they are to remain in quarantine anyway (although it could free up space).

  • Serial re-testing of quarantined persons who initially test negative: To prevent continued transmission of the virus within a quarantined cohort, those who initially test negative shall be re-tested every 3 to 7 days until no new cases are identified for 14 days after the most recent positive result. The specific re-testing interval that a facility chooses could be based on the stage of the ongoing outbreak (i.e., more frequent testing in the context of escalating outbreaks, less frequent testing when transmission has slowed) and the risk level of the exposure (more frequent for higher risk exposures).
  • If any viral testing (RT-PCR or Point of Care – POC) is positive, the patient should be immediately given a surgical mask and moved to an isolation-designated location for medical evaluation. Symptomatic patients should be considered for whether influenza testing is indicated (the reason for quarantine – exposure or not, influenza outbreak status, or community transmission is occurring).
  • If results are negative, the patient must still complete the 14 days of quarantine and meet the release criteria below.
  • If testing during quarantine is refused, re-offer testing every 3 to 5 days.
  • For patients in quarantine who will be released to the community, see FAQs for Releases and Testing and Release Protocol.

RELEASE FROM QUARANTINE FOR COVID-19

Figure 13.1: Release From Quarantine for COVID-19. Please click on the image to open PDF for full table details.
  • For COVID-19, the quarantine period is 14 days from the date of the last exposure to a confirmed case.
  • Quarantine must be extended by 14 days for every new exposure.
  • No sooner than day 12 of 14 of quarantine, and within 2 days prior to release, all patients should be tested with RT-PCR and have a negative result.
  • If a patient tests positive, they must be isolated and given a surgical mask immediately.
  • If a patient refuses testing for release, quarantine shall be continued for another 7 days before release. Re-offer testing. If the patient ultimately agrees to the test, and the results are negative, they may be released before the 7 days are up.
  • Someone who has been released from COVID-19 quarantine is not considered a risk for spreading the virus to others because they have not developed illness during the incubation period.
  • If a suspected COVID-19 case tests negative for both influenza and COVID-19, and clinicians release the index case from COVID-19, quarantined patient contacts to the index case should also be released.

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

4. ISSUES UNIQUE FOR INFLUENZA

INFLUENZA – WHO SHOULD BE IN QUARANTINE

Definition of an Asymptomatic Close Contact for Influenza:

  • A person without ILI who, in the past 7 days, has had close (within 6 feet and cumulative ≥10 minutes) contact OR direct contact with secretions of a confirmed case of influenza during the infectious period AND who has had no positive tests for influenza in that timeframe.
  • A person without symptoms who was exposed to both influenza and COVID-19 and is awaiting test results (single-cell quarantine).
  • Cellmates, co-workers or work-related contacts, housing contacts, and yard contacts of confirmed influenza cases (for whom COVID-19 has been ruled out).

Patient quarantine should be implemented when there is an influenza outbreak; defined as at least one case of lab-confirmed influenza in the setting of a cluster (2 or more) cases of ILI within a 72-hour period.

QUARANTINE PRECAUTIONS AND CONDITIONS FOR INFLUENZA

Medical Hold
Quarantined patients for influenza shall be placed on a medical hold. Providers will have to manually update the Medical Classification Chrono (MCC) to place medical holds on patients quarantined due to influenza exposure.

Movement
Movement in or out of the quarantined area should be restricted for the quarantine period. When transport and non-essential movement is allowed, limit patient transports outside of the facility, permitting transport only for medical, custody, or legal necessity (e.g., specialty clinics, outside medical appointments, custody-related housing changes, mental health crisis, or out-to-court).

  • If transport becomes necessary, assign dedicated staff to the extent possible.
  • Patients under quarantine and those transporting quarantined patients must use the appropriate PPE recommended for the situation and virus for which there is a contact. Refer to the PPE section.
  • Out-to-court appearances and medical visits should be evaluated on a case-by-case basis. With the CME or CME designee’s approval, a quarantined patient may keep the necessary appointments or transfers, provided that the court, medical provider, and/or clinic have been notified that the patient is in quarantine due to influenza exposure, and they have agreed to see the patient.

INFLUENZA INFECTION CONTROL IN QUARANTINE

Please refer to the PPE section and 3/18/21 Recommended PPE for Staff and Inmates Update for detailed guidance on PPE.

  • Any persons entering influenza quarantine areas should wear a surgical mask (droplet precautions).
  • Influenza-quarantined patients should wear surgical masks when around others. N95 respirators are not necessary.
    • For escort and vehicular transport of influenza contacts, the transport staff does not need a surgical mask if the patient is masked but must have a face covering and follow universal masking policies.

INFLUENZA SURVEILLANCE ROUNDING

  • Influenza (and other microorganisms) surveillance still uses the “Surveillance Round” in EHRS (Adhoc > All Items > CareMobile Nursing Task > Surveillance Round).
  • The only vital sign for quarantine is the temperature.
  • Any symptoms of illness necessitate a provider evaluation (see Table 5.1).
  • 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 influenza symptoms, possible complications, and the need for prompt assessment and treatment. Instruct patients to report symptoms at the first sign of illness. See patient education handouts on the CCHCS Influenza Webpage (CDCR networking is required for access).

TESTING STRATEGIES FOR INFLUENZA QUARANTINE

Contacts of influenza cases will not need testing. Influenza testing for patients in quarantine due to influenza exposure is unnecessary unless they develop symptoms and are moved to isolation.

RELEASE FROM QUARANTINE FOR INFLUENZA

  • Quarantine for influenza is 5 days from the last exposure to a confirmed influenza case.
  • Each new exposure will extend quarantine another 5 days.
  • Release from quarantine is time-based only. No testing is required.
  • If a suspected influenza index case tests negative for both influenza and COVID-19, and clinicians release the index case from influenza isolation, quarantined patient contacts to the index case should also be released.

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 or influenza (e.g., contacts to contacts).

INMATES RELEASING FROM INSTITUTIONS – COVID-19 TESTING, NOTIFICATION, HEALTH EDUCATION, AND VACCINE INSTRUCTIONS - Updated 7/28/2021

TABLE OF CONTENTS

  1. COVID-19 TESTING AND NOTIFICATION INSTRUCTIONS FOR ALL PATIENTS RELEASING FROM INSTITUTIONS
  2. COVID-19 HEALTH EDUCATION FOR ALL PATIENTS RELEASING
  3. COVID-19 VACCINE EDUCATION FOR ALL PATIENTS RELEASING
  4. SPECIFIC INSTRUCTIONS FOR PATIENTS ON COVID-19 ISOLATION OR COVID-19 QUARANTINE WHEN RELEASED

1. COVID-19 TESTING AND NOTIFICATION INSTRUCTIONS FOR ALL PATIENTS RELEASING FROM INSTITUTIONS

  • In general, reference COVID-19 Screening and Testing Matrix for Patient Movement – “Parole, medical parole, PRCS release” section (Appendix 13).
  • Note: Local Health Departments (LHDs), Parole, and Post Release Community Service (PRCS) all have been given access to “The CDCR/CCHCS Release Tracking Tool” which provides real-time updates regarding the COVID-19 status of people releasing from custody, including quarantine and isolation status, and reentry plan.

2. COVID-19 HEALTH EDUCATION FOR ALL PATIENTS RELEASING

Provide COVID-19 educational information for all patients regardless of status and whether or not they have started or completed the vaccine series.

  • Everybody releasing to the community shall wear a cloth mask upon exiting the institution.
    Exception: Reference the movement matrix for proper PPE to be worn for both staff and patients, for those releasing who require institution transport, e.g., to another state facility (see COVID-19 Screening and Testing Matrix for Patient Movement – Appendix 13).
  • For patients with COVID-19 restrictions, review the “Specific Instructions for Patients on Isolation or Quarantine When Released” section below for further details.
  • Document all notifications made and education provided in the Electronic Healthcare Record System (EHRS) via the Public Health PowerForm and other PowerForms as needed.

3. COVID-19 VACCINE EDUCATION FOR ALL PATIENTS RELEASING

The Receiving and Release (R&R) nurse provides COVID-19 vaccine educational information for all patients regardless of if they have received the vaccine or not. This includes educating the patient on the importance of either getting vaccinated or completing the vaccine series if they have received their first dose and need a second dose.

  • NOTE: When printing out “custom” educational materials, do not accidentally delete the materials.
  • The vaccine educational materials to be handed out upon release can be found in CERNER. Click on the “Patient Education” tab and enter in the search engine “COVID-19”; choose “contains” from the drop-down menu, and click “ALL.” Everybody should receive the following:
    • “COVID-19 Vaccination Information” document.
    • “COVID-19 CA Local Public Health Department List.”
      • The list contains local public health departments’ addresses and phone numbers so the patient can contact their public health department for vaccine information after they are released.
  • Ensure everybody has their vaccine card.
    • If they do not have their original card, print out a blank card and fill in the information. The card is listed in CERNER as “COVID-19 Blank Vaccination Record Card.”
    • For those who have received their first dose of the vaccine, review the vaccine they received and if it requires a second dose. Review the information on their vaccine card with them.
      • Remind them how important it is for them to keep their vaccination card and explain they need to sign up for the vaccine clinic that is offering the type of vaccine they originally received.
  • Screenshot of Instructions tab with Patient Education dropdown. COVID-19 research results include COVID-19 Blank Vaccination Record Card (Custom). Please contact CDCRCCHCSpublichealthbranch@cdcr.ca.gov for more information.
  • Document all notifications made and education provided in EHRS via the Public Health PowerForm and other PowerForms as needed.
  • Since COVID-19 vaccination information changes frequently, for updated information about COVID-19 vaccine development and other COVID-19 vaccine-related issues, visit the Lifeline website COVID-19 Vaccine and/or Centers for Disease Control and Preventions website.

4. SPECIFIC INSTRUCTIONS FOR PATIENTS ON COVID-19 ISOLATION OR COVID-19 QUARANTINE WHEN RELEASED

If continued medical isolation or quarantine upon release is needed:

  • Fill out the patient’s COVID-19 discharge materials, including specific dates written on the documentation for when their specific COVID-19 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).
  • Educate the patient on signs and symptoms of clinical deterioration.
  • Provide the local health department’s contact number if the patient doesn’t have a personal health care provider and becomes symptomatic.
  • The patient shall wear an N95 mask upon exiting the institution. (See COVID-19 Screening and Testing Matrix for Patient Movement – Appendix 13).
  • 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 patient’s status has not changed (e.g., if an asymptomatic quarantined patient develops symptoms, that patient’s precautions will need to change from quarantine to isolation).
      • If the discharge notification for the patient changes right before release, the local health department, parole/probation, and transportation officers, if applicable, will need to know the updated status before the patient is released.

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
  16. Centers for Disease Control 8/10/20 Interim Considerations for SARS-CoV-2 Testing in Correctional and Detention Facilities: https://www.cdc.gov/coronavirus/2019-ncov/community/correction-detention/testing.html
  17. Centers for Disease Control 7/22/20 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
  18. Infectious Diseases Society of America: Clinical Practice Guidelines by the Infectious Diseases Society of America: 2018 Update on Diagnosis, Treatment, Chemoprophylaxis, and Institutional Outbreak Management of Seasonal Influenza: https://academic.oup.com/cid/article/68/6/895/5369363
  19. Centers for Disease Control: Performing Broad-Based Testing for SARS-CoV-2 in Congregate Settings
  20. Jehi L, Ji X, Milinovich A, Erzurum S, Merlino A, Gordon S, et al. (2020) Development and validation of a model for individualized prediction of hospitalization risk in 4,536 patients with COVID-19. PLoS ONE 15(8): e0237419. https://doi.org/10.1371/journal.pone.0237419

APPENDIX 2: DROPLET PRECAUTIONS CHECKLIST

APPENDIX 3: HOW TO DOFF AND DON PPE

Sequence for Donning Personal Protective Equipment (PPE)

APPENDIX 5: COVID-19 CASE AND CONTACT SHAREPOINT REPORTING TOOL - Updated 12/22/2020

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

APPENDIX 7: COVID-19 INDEX CASE - PATIENT INTERVIEW CHECKLIST - Updated 10/28/2020

TABLE OF CONTENTS

  1. INTERVIEW CHECKLIST

As part of a Contact Investigation, it is recommended that all patients who test positive for COVID-19 be interviewed in order to identify all potential close contacts (within 6 feet of a confirmed case of COVID-19 for a cumulative total of 10 minutes or more during the infectious period) who may have been exposed to the case-patient. The interviewer should attempt to identify all inmates and/or staff who meet the exposure criteria through the interview process.

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. The interview process must be prioritized whenever the patient is the first identified case in a cell, dormitory, housing unit, or facility.

Prior to the index case-patient interview, a review of the case presentation or physician conference should occur. The interviewer should be prepared to gather a detailed account of the case-patient’s movements and activities during their infectious period.

Definition of the Infectious Period
For the purposes of the contact investigation, the infectious period starts 2 days (48 hours) before the onset of symptoms and ends when the patient was isolated or hospitalized at an outside facility. For asymptomatic case-patients, the start of the infectious period should be considered 2 days prior to the date of the positive test and ends upon isolation or hospitalization at an outside facility.

Interview Objectives

  • Confirming the medical information (e.g., symptoms, onset date, etc.)
  • Determining the infectious period
  • Determining where the patient spent time during the infectious period
  • Identifying 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 the medical record and consult with a physician as necessary for case presentation
  • Establish a preliminary infectious period
  • Collect housing, movement history, and work or program assignments from the Strategic Offender Management System (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

Conducting the Interview
Use the COVID-19 Index Case-Patient Contact Investigation Tool and the Interview Checklist included below to guide and document the interview. This tool is to be used for data gathering and is not to be inserted into the patient’s medical record.

Initiate a contact line list based on the findings from the interview. The interviewer has 3 options for tracking the contact line list.

  1. Enter the contacts under the Contacts section of the COVID-19 Public Health Outbreak Surveillance (PHOS) SharePoint webpage. The entry of contacts into this section is not required by the Public Health Branch (PHB) for reporting purposes but can be used by the institution for tracking purposes.
  2. Enter the contacts under the Line Listing tab after the case report is initiated in the Public Health Outbreak Response System (PhORS).
  3. Create a line listing of their own design for use at the institutional level.

Reporting and Follow-up:

  • Inmate-Contacts: All identified inmate contacts should be reported to the Public Health Nurse (PHN) for follow-up, signs/symptom screening, and referral to the Primary Care Provider (PCP) for evaluation, testing, and quarantine.
  • Employee-Contacts: All employee contacts should be reported to the institutional hiring-authority for referral to the Office of Employee Health and Wellness (OEHW) for follow-up.

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

Obtain Contact Information
Identify and list all contacts (inmates, employees, visitors) exposed for each group and activity listed below. 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: SUMMARY OF THE INFECTIOUS DISEASES SOCIETY OFAMERICA (IDSA) TESTING RECOMMENDATIONS

APPENDIX 10: COVID-19 AND INFLUENZA POWERFORM INSTRUCTIONS; SCREENING, ISOLATION, AND QUARANTINE SURVEILLANCE - Updated 2/04/2021

APPENDIX 11: LOCAL HEALTH DEPARTMENT CONTACT LIST

APPENDIX 13: COVID SCREENING AND TESTING MATRIX FOR PATIENT MOVEMENT - Updated 6/23/2021

APPENDIX 16: RECOMMENDED COVID-19 PERSONAL PROTECTIVE EQUIPMENT - Updated 8/27/2021

APPENDIX 19: COVID-19 AND INFLUENZA SPECIMEN COLLECTION AND TEST ORDERING INFORMATION - Updated 11/16/2020

APPENDIX 20: RECOMMENDATIONS FOR SAFER MOVEMENT TO PREVENT COVID-19 INTRODUCTION - Updated 8/27/2021

TABLE OF CONTENTS

  1. GENERAL PRECAUTIONS
  2. RECOMMENDATIONS FOR TRANSPORT
  3. ON ARRIVAL TO A CDCR INSTITUTION
  4. APPENDIX 13: COVID SCREENING AND TESTING MATRIX FOR PATIENT MOVEMENT

This document provides recommendations for vehicular transport (e.g., buses, vans, and cars). This guidance does not apply to escorting a patient on foot or transferring within a prison (e.g., between yards).

GENERAL PRECAUTIONS

Movement and transportation are risks of spreading COVID-19. AVOID Transport:

  • For court appearances, the use of telecommunication alternatives should be employed whenever possible to avoid movement.
  • Limit unnecessary transportation of inmates between prison institutions.
  • Avoid or minimize travel to multiple institutions during one trip.
  • Inmates who are quarantined, in medical isolation after testing positive for COVID-19, or who have symptoms of COVID-19, should only be transported for essential reasons (e.g., medical care that cannot be accomplished through telemedicine, regular releases to the community).

RECOMMENDATIONS FOR TRANSPORT

  • Staffing and equipment
    • Designate staff who are responsible for ensuring that policies are implemented.
    • If possible, assign transportation officers to one type of work assignment (e.g., transporting inmates between prisons or between prisons and hospitals).
    • If resources allow, dedicate one vehicle to transporting inmates who are positive for COVID-19. This vehicle and all other vehicles transporting inmates should be decontaminated after each trip.
  • Planning and preparation
    • Limit bus/van capacity to 50% or less to ensure that all passengers are seated 6 feet apart.
    • Ensure hand sanitizer is available.
    • Post signage regarding distancing and masking requirements.
    • Ensure appropriate personal protective equipment (PPE) is available for staff and inmates, including N95 respirators.
    • Sanitize each transport vehicle thoroughly first thing in the morning and after each trip.
    • Staff who share equipment should sanitize the equipment after each use.
    • If feasible and safe, consider installing solid paneling (e.g., plexiglass) between sections or seats on the bus.
  • COVID-19 testing prior to transport
    • Inmates should have a negative viral test prior to transport. Please refer to the COVID-19 Screening and Testing Matrix for Patient Movement (Appendix 13) for detailed guidance regarding transport and testing timeframes needed.
    • Testing correctional officers who transport inmates should follow the current Office of Employee Health and CCHCS testing policy.
    • Point of care (POC) testing for inmates and staff may be used immediately before transport.
  • Personal protective equipment
    • Wearing a fit-tested N95 respirator is required for correctional officers and staff in transport vehicles.
    • Inmates should be provided with N95 masks. Staff should monitor inmates to ensure they comply with masking requirements.
  • Screening for symptoms and temperature prior to transport:
    • All inmates and transport and custody staff should be checked for all symptoms of COVID-19, including a temperature check, prior to boarding the vehicle, within 24 hours of transport.
    • Please refer to the COVID-19 Screening and Testing Matrix for Patient Movement (Appendix 13) for screening and movement details.
  • Precautions during transit:
    • Provide hand sanitizer and require inmates and staff to use it when entering and exiting the vehicle.
    • Maximize ventilation, including opening windows, if feasible and safe.
      • Open all the vehicle windows and doors during stops to air it out.
      • Drive with the windows partially open on both sides of the bus/van.
      • Do not set the vehicle ventilation system to recirculate the air.
    • Minimize the time spent on the bus. Because N95 respirators increase the work of breathing, allow for breaks during long bus/van rides so that N95 users can remove their respirator during the breaks while maintaining a physical distance of 6 feet.
    • Because it may not be possible to use air conditioning and because passengers will be wearing masks, for travel of two or more hours, ensure stops for inmates and staff to exit the bus/van. Provide water for the inmates and staff during these breaks and ensure that passengers maintain 6 feet of social distance.
    • Discourage inmates and transport and custody staff from eating in the vehicle.
    • Clean and disinfect high-touch hard surfaces prior to re-boarding after breaks/stops.

ON ARRIVAL TO A CDCR INSTITUTION

  • Screen for symptoms and temperature per Reception/Triage and Treatment Area (TTA) policy.
  • Quarantine and testing after arrival:
  • Employee exposure-response:
    • Correctional transportation officers identified as having driven a vehicle with inmates or other staff who subsequently test positive should follow the current Office of Employee Health and CCHCS testing policy for quarantine and testing.

Additional Resources:

APPENDIX 22: mRNA VACCINE ADMINISTRATION ERRORS AND DEVIATIONS

APPENDIX 23: PLANNING CHECKLIST FOR SAFE GATHERINGS