Update: For the latest information regarding CDCR’s preparedness efforts for the novel coronavirus (COVID-19) please visit the CDCR COVID-19 Preparedness page.
CCHCS is currently experiencing technical difficulties with our online examinations. For more information, please contact CCHCS’ Examination and Certification Services via email at CPHCSSelectionServices@cdcr.ca.gov or via telephone at (916) 691-5894.
COVID-19 and Seasonal Influenza: Interim Guidance for Health Care and Public Health Providers
The purpose of this guidance 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), Influenza A and B, and other respiratory pathogens of public health significance. This guidance, which 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), 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 the CDC’s Interim Guidance on Management of Coronavirus Disease 2019 (COVID-19) in Correctional and Detention Facilities and Information for Health Care Professionals 2020-2021 Flu Season. This guidance is continuously updated; the latest revisions are summarized in the “Record of Changes.”
RECORD OF CHANGES
4/26/21 – Appendix 13: Replaced with updated (4/26/2021) Screening and Testing Matrix for Patient Movement.
4/16/21 – Vaccination: 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.”
3/09/21 – Vaccination: 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).
All patients being released from the institutions, regardless of the patients’ COVID status, shall be offered COVID-19 testing one week before release with notification of the results sent to LHDs and DAPO and/or PRCS
All “Appendix 9” notification forms are required to be “cc’ed” to a newly established public health notification email box.
Diagnostic Testing includes updated lab test names, ordering instructions for Coronavirus Disease 2019 (COVID-19) and rapid influenza point of care testing, new stability data, Saturday pick-ups, and a new testing algorithm.
This document serves to provide INTERIM guidance for the clinical management of SARS-CoV-2 virus pandemic at CDCR facilities. Due to the quickly changing guidelines from the Centers for Disease Control (CDC), the World Health Organization (WHO), and other scientific bodies, information may change rapidly and will be updated in subsequent versions. Revision dates are located at the bottom left of the document. Substantive changes will be posted to the website if occurring before release of updated versions.
This guidance supersedes the COVID-19 Interim Guidance for Health Care and Public Health Providers, Document 1.0.
This guidance supersedes the 2019 Seasonal Influenza Guidance except where noted.
Agency for Healthcare Research and Quality
Acquired Immune Deficiency Syndrome
Administrative Officer of the Day
Airborne infection isolation room
Body Mass Index
California Correctional Health Care Services
Centers for Disease Control and Prevention
California Department of Corrections and Rehabilitation
California Department of Public Health
Clinical Laboratory Improvement Amendments
Chief Medical Executive
Chief Nurse Executive
Coronavirus Disease 2019
Director of Nurses
Electronic Health Record System
Environmental Protection Agency
Health Care Personnel
Health Care Worker
Human Immunodeficiency Virus
Higher Level of Care
Infection Control Nurse
Local Health Department
Nurse Consultant Program Review
National Institute for Occupational Safety and Health
Occupational Safety and Health Administration
Office of Employee Health and Wellness OEHW
Personal protective equipment
Powered air purifying respirator
Preliminary Report of Infectious Disease or Outbreak form
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, 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.
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.
This section covers the core principles of primary prevention, pandemic preparedness, and operationalizing prevention practice. As discussed in the Transmission section, both SARS-CoV-2 and influenza viruses can be transmitted person-to-person through infectious respiratory particles in the air and on surfaces. Thus, prevention strategies for COVID-19 are also effective against influenza.
Primary prevention involves all people within the institution: staff, visitors, and inmates. 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, intensive staff and inmate education, leadership engagement and coordination, supportive policies, and teamwork. See Appendix 18.
1. CORE PRINCIPLES OF PRIMARY PREVENTION
More than 40% of people infected with COVID-19 do not have any symptoms. Asymptomatic people are thought to be a major source of transmission. It is important to assume everyone might be contagious, including yourself. Strategies for prevention of COVID-19 generally work for all respiratory infections. Immunization against COVID-19 is a key strategy for mitigating the spread of disease. For preventing influenza, treatment, vaccination, and chemoprophylaxis are available prevention tools.
A. COVID-19 IMMUNIZATION
Immunization/vaccination against COVID-19 is a crucial prevention strategy; all patients and staff without contraindications should get the vaccine when available.
Information about COVID-19 vaccination continues to develop and is more thoroughly addressed in the Vaccination section of this Guidance.
B. FACE COVERING
When universal face-covering mandates or directives from CCHCS leadership are in place, wear surgical/procedure masks or other cloth coverings of the nose and mouth (see the 6/24/2020 CALPIA Cloth Face Barrier/Mask memo – CDCR networking is required for access).
Face barriers can be cloth face coverings and include the California Prison Industry Authority (CALPIA) facial coverings, surgical masks, and masks as allowed by CDCR policy.
In situations when personal protective equipment (PPE) is required (see PPE section), PPE respiratory recommendations supersede cloth facial coverings (this also includes PPE for inmate workers). Surgical masks are part of PPE; cloth face coverings are not PPE.
C. AVOID AEROSOL GENERATION
Special measures must be planned whenever there is a high risk of the virus being spread through the air (aerosolized), which can happen with sneezing, coughing, nebulizer use, continuous positive airway pressure (CPAP)/bi-level positive airway pressure (BIPAP) use, and several medical procedures and treatments (see Aerosol-Generating Procedures memo and the Aerosol Transmissible Diseases Exposure Control document – CDCR networking is required for access).
Other activities that generate aerosols such as yelling, singing, laughing, and talking loudly around other people, should be avoided if possible.
D. RESPIRATORY PROTECTION
Face coverings provide some protection; however, N95s or higher provide more protection from exposure.
The fewer people one comes into contact with, the less chance of becoming infected by respiratory pathogens.
Social interactions such as handshaking, or the new idea of touching elbows, must stop. Bows or nods or waves from a distance of at least six feet away are okay.
Decreasing the number of inmates in each prison, cell, or dormitory may help give room for proper distancing. Consider early parole, home detention programs, and expediting medical parole and compassionate release (see Expedited Releases FAQs – CDCR networking is required for access).
F. MINIMIZE DURATION OF CONTACT
The longer the exposure, the more likely transmission will take place. Keeping encounters brief may reduce the risk of transmission (see the Transmission section).
If possible, these individuals should be dispersed throughout the general population, not concentrated in one place. In CDCR, however, people with particular needs for help are often grouped in an outpatient housing unit (OHU), correctional treatment center (CTC), skilled nursing facility (SNF), or in American’s with Disabilities Act (ADA) housing. For this to be successful, careful thought needs to go into the movements and mixing of vulnerable and non-vulnerable populations.
To decrease exposure to these inmate/patients: if there are special units, attempt to have dedicated personnel working in them so there aren’t as many different staff members entering the unit.
Consider having vulnerable patients only leave their housing for urgent/emergent need, and for designated yard time with their housing cohort.
Consider providing cell feeding with disposable trays if possible.
Consider providing pill line at housing, ideally cell to cell, but at minimum at a separate time from other inmates or within housing cohorts so that social distancing is possible and wait times are decreased. People in line should be spaced out six feet apart. Consider floor markings to delineate.
Consider having canteen items delivered to the highly vulnerable inmate/patients – same with laundry, clothing, shoes, library resources, etc.
If “stay in place” for these individuals is enacted, educate the patient on what can be expected and its challenges and temporary nature.
Consider the use of N95s for vulnerable populations, if supplies allow. This might be especially useful in dorm settings during outbreaks, in crowded/high-usage areas, or in quarantine when physically near or sharing air with persons with high-risk exposures to cases.
If physical therapy is needed, ideally provide it in the housing unit’s activity room if possible. If not possible, do not have the highly vulnerable patients mix with inmates from other housing areas.
Provide regular medical care within the unit, if possible. If not possible, call the patient for medical evaluation when the provider is ready to see them, so there is no wait time in a waiting area with other inmates.
Provide focused education and review the increased risk for the elderly, those with underlying diseases (especially of the lungs or heart), and those with immunosuppression. Provider or nursing education sessions may be needed.
If custody approves, discuss the possibility of moving to a more safe housing space. See the script for offering cell housing in Appendix 15.
Prioritize vulnerable patients for routine COVID-19 surveillance testing. If another part of the prison is having an outbreak, housing units with vulnerable populations should be protected from exposure; patients should be screened for symptoms and tested.
H. HAND HYGIENE
Provide plenty of soap, paper towels, tissues, or toilet paper for coughs/sneezes (above the normal allotment for bathroom needs), and a no-touch lined trash receptacle. Provide alcohol-based hand sanitizer, if possible.
Provide extra hand-washing and hand sanitation stations for staff and inmates, especially in high use areas.
For cells with automatic push buttons or handles regulating water flow, make sure the flow is set for 30 seconds to allow the full recommended 20 seconds of handwashing.
I. CLEAN SURFACES
High touch surfaces should be cleaned frequently using products effective against coronaviruses and influenza viruses.
Provide extra cleaning supplies for inmates to use in their cells and common areas.
Enclosed workspaces and dorm-style housing are associated with increased transmission and risk of outbreaks even when physical distancing measures are in place.
Separating people with solid walls and solid doors generally protect against transmission through breathing shared air.
ee the section below on Ventilation for additional details.
K. AVOID CROWDS AND MIXING
Keeping group sizes as small as possible limits the spread of the virus and reduces the size of outbreaks.
In general, groups should be kept to below 10 people.
Mixing groups (e.g., in worksites, common areas, and clinic spaces) increases the risk of widespread transmission affecting many housing units.
Staff should be cohorted whenever feasible.
Inmate workers (e.g., PIA workers or culinary workers) can be co-housed to reduce risk.
L. AVOID MOVEMENT
Non-essential movement in and out and within prison facilities should be avoided.
The risk of infectious disease introduction is increased when inmates arrive from jail or a different prison, an out-to-court legal appointment, a hospital, emergency room, and the community. The risk may be reduced by implementing prevention strategies such as testing and quarantine. See the COVID-19 Screening and Testing Matrix (Appendix 13).
Consider providing medical and legal visits through telemedicine and teleconferencing.
Consider having employees telework whenever possible, minimizing the number of people coming from the community into the prison.
Screen the health of all employees entering the institution by checking each person’s temperature and asking about acute respiratory illness symptoms. Anyone who is ill should not enter (see the Staff COVID-19 Testing memo and the Staff Testing FAQs – CDCR networking is required for access).
M. VIRAL TESTING
Viral testing is critical for diagnosing symptomatic people and identifying people who are asymptomatic, pre-symptomatic, or unwilling to disclose symptoms (see Testing section).
Testing is used for surveillance to detect outbreaks early, and in response to outbreaks to guide isolation and quarantine.
Testing is an essential component of movement between and within institutions.
Patients who are suspected of being infected with COVID-19 or influenza must be in medical isolation by themselves.
Once the diagnosis is confirmed, patients who test positive only for COVID-19 may be housed with others who have tested positive only for COVID-19. Isolation space must be separated by solid walls and solid doors from all other populations (see Isolation section).
Patients who test positive only for influenza may be housed with others who have tested positive only for influenza. Patients who test positive for both COVID-19 and influenza may only be housed with others who have tested positive for both.
People exposed to someone with COVID-19 must be quarantined for a minimum of 14 days to determine whether they have become infected and to be tested (see Quarantine subsection).
People exposed to someone with influenza must be quarantined for a minimum of 5 days (see Quarantine subsection).
Different cohorts within quarantine should be separated (i.e., exposed contacts, jail intakes, transfers, etc.). Single cells are preferred for exposed contacts of cases.
2. PANDEMIC PREPAREDNESS
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. It is recommended that a small working group of medical, nursing, and custody be formed to work through each guideline and situation and determine exactly how it will be carried out at that institution. The members of this group should be high-ranking enough to make decisions and know exactly how things are done throughout the institution.
For an operational checklist, please see Appendix 1. For detailed guidance for facility leadership on preparedness and pandemic operations, please see Appendix 18.
Provide all inmates with verbal instructions, written handouts, audiovisual or television programs where possible, and posted signs on hand hygiene, cough etiquette, and social distancing.
Provide education on the facility-wide changes that will be occurring and why they are important to stem transmission of the virus.
Educate staff and inmates on the symptoms of COVID-19 and influenza and what to do if symptoms develop.
Consider facility-wide announcements on new prevention measures (such as entry screening) and encouragement for distancing and face coverings.
STAFF PRECAUTIONS AND RESTRICTIONS
Correctional facilities should have signage posted at entry points in English and Spanish alerting staff and visitors that they should not enter the facility if they have a fever and respiratory symptoms.
Instruct staff to report fever and/or respiratory symptoms at the first sign of illness.
Staff with respiratory symptoms should stay home (or be advised to go home if they develop symptoms while at work). Ill staff should remain at home until they are cleared by their provider to return to work.
Post signage and consider population management initiatives throughout the facility encouraging vaccination for influenza.
VISITORS PRECAUTIONS AND RESTRICTIONS
Visitor websites and telephone services will be updated to inform potential visitors of current restrictions and/or closures before they travel to the facility.
Consider screening the health of all visitors and volunteers entering the institution, checking for fever, and asking about acute respiratory illness symptoms. Anyone who is ill may not enter.
Advise visitors who have a fever and/or respiratory symptoms to delay their visit until they are well.
Consider having visits and programs by teleconferencing, using telephone or computer-based methods such as Skype or Zoom, that allow people to interact without coming into contact with each other.
Consider temporarily suspending volunteer programs and visitation or modifying visitation programs, when appropriate.
If necessary, initiate other social distancing procedures (e.g., halt volunteer and contractor entrance, discourage handshaking).
Visitor signage and screening tools are available from the CCHCS Public Health Branch (PHB) and can be distributed to visiting room staff.
IDENTIFICATION OF QUARANTINE SPACE FOR INCOMING ARRIVALS, JAIL, AND INTER-FACILITY TRANSFERS
Cohorts with different arrival types/dates need to be separated from each other.
To prevent transmission, it is crucial to have quarantine space and testing stations planned and ready for incoming arrivals and transfers.
Consider postponing all non-essential, non-urgent appointments.
Consider using telemedicine for appointments.
Consider using letters to inform patients of medical results and plans when possible.
Consider spacing appointments farther apart or calling patients when the provider is ready to see them, to avoid the need for patients to wait in the waiting room. Place waiting room seats 6 feet apart.
Consider adding waiting room space outside the clinic, such as with a canopy and portable chairs 6 feet apart.
Anyone with fever or cough should be given a surgical mask (by the correctional officer or other staff) and immediately sent for a medical evaluation. If escorting the patient, the correctional officer or other staff member should don appropriate PPE (see PPE section).
Keep all transportation to a minimum and reserve for only absolutely necessary movements and, if possible, use single-patient transport.
Pay close attention to PPE, respiratory hygiene, physical distancing, ventilation, and infection control. Please refer to the Centers for Disease Control (CDC) guidance for Emergency Medical Services (EMS) on safely transporting individuals with confirmed or suspected COVID-19. This guidance link includes considerations for vehicle type, air circulation, communication with the receiving facility, and cleaning the vehicle after transport.
See Appendix 20 for specific recommendations for safer movement between jails and prisons.
SEPARATE AREAS FOR SYMPTOM SCREENING AND TESTING
Strongly consider providing a set-apart or dedicated clinic area of rooms with doors or an outside tent with a canopy specifically for evaluating patients with acute respiratory infection symptoms, to keep those individuals separate from patients needing other types of medical care. It is especially important to keep the evaluation and testing stations away from vulnerable populations, hospitalized patients, or patients sick with non-COVID ailments.
Screen all patients for fever and respiratory symptoms prior to bringing them into the dialysis unit, clinic, or waiting room.
SEPARATE AREAS FOR AEROSOL-GENERATING PROCEDURES (AGPs)
AGPs may increase aerosolization of the viral droplets that persist in the air and can be inhaled.
AGPs should be minimized to only the most medically necessary – refer to the Aerosol-Generating Procedures memo for detailed guidance (CDCR networking is required for access).
Proactively find space for when these procedures will need to be performed. Negative pressure rooms or distant outside open-air with canopy first, or single rooms with doors and preferably a unique ventilation system. PPE and strict cleaning protocols during and after these procedures must be adhered to.
Point of care (POC) COVID-19 testing is ideal, if possible, before AGPs.
Facilities can evaluate whether any of the following guidelines recommended by the CDC and the American Society of Heating, Refrigerating, and Air-Conditioning Engineers (ASHRAE) are possible and make changes as appropriate:
Lower the occupancy level in the building, if possible. This increases the effective dilution ventilation per person.
Minimize traffic in enclosed spaces such as elevators and stairwells. Consider limiting the number of individuals in an enclosed space at one time and designate one-directional stairwells, if possible.
Ensure the ventilation systems operate properly and increase the circulation of outdoor air as much as possible (e.g., opening windows and doors). Do not open windows and doors if doing so poses a safety or health risk to staff or attendees (e.g., custody risk, risk of falling, or triggering asthma symptoms).
If portable ventilation equipment like fans are used, minimize air blowing from one person directly at another person to reduce the potential spread of any airborne or aerosolized viruses.
Consider improving the engineering controls using the building ventilation system. This may include some or all of the following activities depending on your facilities physical limitations:
Increase ventilation rates.
Provide acceptable indoor air quality for each space’s current occupancy level.
Increase outdoor air ventilation, using caution in highly polluted areas.
Disable demand-controlled ventilation (DCV).
Further open minimum outdoor air dampers (as high as 100%) to reduce or eliminate recirculation. In mild weather, this will not affect thermal comfort or humidity. However, this may be difficult to do in cold or hot weather.
Improve central air filtration to the MERV-13 or the highest compatible with the filter rack, and seal edges of the filter to limit bypass.
Check filters to ensure they are within service life and appropriately installed.
Keep systems running longer hours, 24/7 if possible, to enhance air exchanges in the building space.
Also, make sure that shared rooms in the facility have as good of airflow from an air conditioner or an opened window as is physically and safely possible. Consider working with building maintenance staff to determine if the building ventilation system can be modified to increase ventilation rates or the percentage of outdoor air circulating into the system.
Each of the 14 core principles of primary prevention need to be considered in all aspects of prison operations, including housing, eating, programming, recreation, and accessing healthcare services.
Early analysis and preparation for social distancing in buildings are essential. Wherever possible, rooms must be arranged to have as few inmates as possible and allow as much social distancing as possible. A possible way to do this would be to set up tent housing, if available, for low-security risk prisoners, leaving more room inside buildings. If cells have bars rather than walls or are porous rather than solid closed doors, one would ideally leave an empty cell on each side of an occupied cell to maintain distancing.
If there are multiple inmates in a cell area, beds should be arranged to allow distancing. If there are bunks, inmates on the bottom bunks should have their heads facing one direction, and on the top in the other direction, so there is at least approximately six feet of separation of their heads. Similarly, if the beds or bunks are close together, the head of one inmate should be closest to the inmate’s feet in the adjacent bunk.
Consider temporary housing in buildings meant for other purposes, such as gymnasiums or classrooms.
Consider alternative portable housing such as tent accommodations, along with portable toilets, sinks, and showers.
Consider creative ways to decrease transmission in areas with many beds, such as dorms. If space does not allow 6 feet between bunks, try making smaller cohorts, such as 6-8 people, with 6 feet between each group. Try draping one side of the bunks with plastic sheeting to prevent the movement of respiratory droplets.
If cells have bars rather than walls and solid closed doors, one would ideally leave an empty cell on each side of an occupied cell to maintain distancing.
Place plastic barriers along counters or other dividers of room spaces, where appropriate, to prevent respiratory droplet spread.
Consider moving smaller groups at a time into the chow hall, according to housing divisions, and demarcate seating 6 feet apart.
Consider taping off sections with 6-foot-distancing for cohorts if there is insufficient space to distance the entire cafeteria.
Consider bringing hot and cold food carts into the housing day rooms.
Consider cell feeding if resources allow.
Schedules should be staggered to allow for 6-feet distancing during showering.
Showerheads may need to be removed or disabled.
Physical work environments may need to be re-engineered to allow physical distancing between workers.
Screen inmate workers for these units prior to them leaving their yards with standard questions and temperature measurement (see the Screening of Critical Inmate Workers memo – CDCR networking access is required). Screen anyone entering a unit comprised of or containing vulnerable patients; or, if they are widely dispersed through the institution, consider universal screening at all housing units, if feasible. Do not allow staff or inmate ‘visitors’ in those units, only essential workers. Signs regarding this should also be posted to encourage self-referral for care and voluntary social distancing from vulnerable wards.
Consider classes via computer connection rather than in person.
Consider small groups that incorporate social distancing.
YARD AND DAY ROOM ACTIVITY
Consider moving smaller groups (cohorts) at a time to these areas, according to housing divisions or isolation/quarantine cohorts. Outside time, exercise, and activity are important to mental and physical health, so it should be encouraged with the recommendation to maintain social distancing.
Consider individualized rather than group work.
Consider classes via computer connection rather than in person.
Consider small groups that incorporate social distancing.
This section covers pharmaceutical prevention interventions for COVID-19 and influenza A and B. 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, 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 at the Regulatory Affairs Professionals Society (RAPS) website at RAPS COVID-19 Vaccine Tracker.
NOTE: ON APRIL 13, 2021, THE CDC AND FDA ISSUED A JOINT STATEMENT RECOMMENDING “A PAUSE” IN THE USE OF JOHNSON & JOHNSON (JANSSEN) VACCINE “OUT OF AN ABUNDANCE OF CAUTION.” The statement followed six cases of cerebral venous sinus thrombosis and thrombocytopenia after administration of the vaccine. As such, patients should not receive the Johnson & Johnson (Janssen) vaccine until further notice.
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 11 cases of anaphylaxis per a million recipients). 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 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).
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 the vaccine.
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. For patients who refuse vaccination, an education session about the vaccine with healthcare staff is important.
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.
Other vaccine compatibility: Due to the lack of data on the safety and efficacy of the vaccine administered simultaneously with other (non-COVID-19) vaccines, the COVID-19 vaccine should be administered alone with a minimum interval of 14 days before or after administration with any other vaccines. If another vaccine is inadvertently given within 14 days of the COVID-19 vaccine, doses do not need to be repeated for either vaccine.
Contraindication: Prior history of hypersensitivity to a previous dose of an mRNA COVID-19 vaccine or any of the vaccine components.
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.
Mixing vaccine doses: A vaccine recipient is not to mix doses between the Johnson & Johnson vaccine and the mRNA vaccines.
Other vaccine compatibility: There is no information on the co-administration of the Johnson & Johnson vaccine with other 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 mRNA vaccine is not a live virus vaccine, not enough is yet known of the potential impact of mRNA vaccines on immune responses to say conclusively whether the COVID-19 mRNA vaccine 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.
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, and Moderna documents and can be accessed here:
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.
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.
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.
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.
Routine cleaning and disinfection procedures should be used. Studies have confirmed the effectiveness of routine cleaning (extraordinary procedures not recommended at this time).
CellBlock 64 is effective in killing corona and influenza viruses.
After pre-cleaning surfaces to remove pathogens, rinse with water and follow with an Environmental Protection Agency (EPA) registered disinfectant to kill corona and influenza virus.
If an EPA-registered disinfectant is not available, use a fresh chlorine bleach solution by mixing 5 tablespoons (1/3 cup) bleach per gallon of water or 4 teaspoons bleach per quart of water. If bleach solutions are used, change solutions regularly, and clean containers to prevent contamination. Prepare cleaning solutions daily or as needed.
Focus on cleaning and disinfection of frequently touched surfaces in common areas (e.g., faucet handles, phones, countertops, bathroom surfaces, doorknobs, and light switches).
Staff should clean shared equipment (e.g., radios, service weapons, keys, and handcuffs) several times per day.
All non-dedicated, non-disposable medical equipment used for patient care should be cleaned and disinfected according to the manufacturer’s instructions.
After a thorough cleaning of the area, any room/space is to be left unoccupied for 90 or more minutes prior to re-entry.
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 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.
Clean and disinfect all areas (e.g., cells, bathrooms, and common areas) used by the infected individual, focusing especially on frequently touched surfaces.
Cleaning after aerosol-generating procedures (AGPs): Consult the CDC for updates. Influenza has also been shown to be capable of being aerosolized but the CDC states that standard cleaning and disinfection are sufficient for influenza, even after AGPs. However, in the setting of dual pandemics, caution involving all symptomatic patients using AGPs is prudent.
After discharge, terminal cleaning may be performed by Environmental Services (EVS) personnel. They should delay entry into the room until sufficient time has elapsed for enough air changes to remove potentially infectious particles. 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 SARS-CoV-2 (COVD-19) remains infectious in the air. Regardless, EVS personnel should refrain from entering the vacated room until sufficient time has elapsed for enough air changes to remove potentially infectious particles (more information on clearance rates under differing ventilation conditions is available). After this time has elapsed, EVS personnel may enter the room and wear a gown and gloves when performing terminal cleaning. A surgical mask (if not already wearing for source control) and eye protection should be added if splashes or sprays during cleaning and disinfection activities are anticipated or otherwise required based on the selected cleaning products. Shoe covers are not recommended at this time for personnel caring for patients with COVID-19.
Hard (non-porous) surface cleaning and disinfection
If surfaces are dirty, they should be cleaned using a detergent or soap and water prior to disinfection.
Follow the manufacturer’s instructions for all cleaning and disinfection products (e.g., concentration, application method, contact time, etc.).
Diluted household bleach solutions can be used if appropriate for the surface. Follow the manufacturer’s instructions for application and proper ventilation, and check to ensure the product is not past its expiration date. Never mix household bleach with ammonia or any other cleanser. Unexpired household bleach will be effective against coronaviruses when properly diluted. Prepare a bleach solution by mixing:
– 5 tablespoons (1/3 cup) bleach per gallon of water or
– 4 teaspoons bleach per quart of water
Soft (porous) surface cleaning and disinfection
For soft (porous) surfaces such as carpeted floors and rugs, remove visible contamination, if present, and clean with appropriate cleaners indicated for use on these surfaces. After cleaning:
If the items can be laundered, launder items according to the manufacturer’s instructions using the warmest appropriate water setting for the items and then dry items completely.
For electronics such as tablets, touch screens, keyboards, and remote controls, remove visible contamination, if present.
Follow the manufacturer’s instructions for all cleaning and disinfection products.
Consider the use of wipeable covers for electronics.
If no manufacturer guidance is available, consider the use of alcohol-based wipes or spray containing at least 70% alcohol to disinfect touch screens. Dry surfaces thoroughly to avoid the pooling of liquids.
Additional information on cleaning and disinfection of communal facilities such can be found on CDC’s website.
Foodservice items. Cases under medical isolation should throw disposable food service items in the trash in their medical isolation room. Non-disposable food service items should be handled with gloves and washed with hot water or in a dishwasher. Individuals handling used food service items should clean their hands after removing gloves.
Laundry from COVID-19 cases can be washed with other individuals’ laundry.
Individuals handling laundry (e.g., bed sheets, towels, and cloth facial coverings) from COVID-19 cases should wear disposable gloves, discard after each use, and clean their hands after. Laundry workers should wear appropriate PPE (e.g., gloves and protective garments) while handling the soiled linen.
Do not shake dirty laundry. This will minimize the possibility of dispersing the virus through the air.
Launder items as appropriate in accordance with the manufacturer’s instructions. Use laundry soap and if possible, launder items using the warmest appropriate water setting for the items and tumbled dry on a hot setting. Ensure items have dried completely.
The contaminated (soiled) laundry is placed into the leak-resistant bags and is securely tied to prevent leakage. The contaminated laundry must be clearly labeled as “contaminated/soiled.”
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.
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.
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.
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.
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.
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.
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.
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:
Chronic medical conditions as described in Table 5.3
Elevated LDH and inflammatory indicators in the blood as described in Table 5.4 below
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).
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.
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:
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.
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.
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.
CLINICAL MANIFESTATIONS OF OTHER RESPIRATORY PATHOGENS
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:
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.
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).
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
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.
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
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.
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).
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.
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).
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.
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.
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.
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
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:
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 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 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.
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).
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:
The patient is asymptomatic when tested and remains asymptomatic
The patient has no known exposures and was not in quarantine for suspected exposure
PCR testing of contacts reveals no other positive cases
Subsequent PCR testing of the patient is negative
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.
>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.
<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.
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 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:
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.
Confirm any positive POC with a PCR as soon as possible.
Ensure other causes for the symptoms, if present, have been investigated. If indicated, order a comprehensive viral panel or diagnostics for other pathogens.
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.
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.
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.
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
Clinicians should use their judgment in testing for other respiratory pathogens, including tuberculosis (TB), RSV, and coccidioidomycosis (Valley Fever).
The RSV season generally coincides with influenza season. RSV testing is indicated if it will affect clinical management. Consider testing for RSV in vulnerable populations, including those with heart or lung disease, bone marrow and lung transplant recipients, frail older adults, and those with multiple underlying conditions. More information can be found on the CDPH’s webpage on Influenza and Other Respiratory Pathogens.
Patients with coccidioidal infection develop symptoms and detectable antibodies within 7-21 days of exposure. Patients who demonstrate measurable anti-coccidioidal antibodies are likely to have a recent illness or one that continues to be active because antibody levels decrease over time and eventually become undetectable in most patients who resolve their infection. More information can be found in the Cocci Skin Test (CST) Education and Cocci Surveillance Training Slides (CDCR networking is required for access to both), the CCHCS Cocci Care Guide, and the CDPH’s webpage on Valley Fever.
This section will cover the treatment of COVID-19 and influenza. For diagnosis and treatment of other respiratory pathogens such as respiratory syncytial virus, coccidioidomycosis, tuberculosis (TB), and bacterial pneumonia, see relevant CCHCS care guides and/or Up to Date and national guidelines. Treatment for other respiratory pathogens is at the end of this section.
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.
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, bamlanivimab alone, bamlanivimab and etesevimab combination, and the casirivimab/imdevimab combination monoclonal antibody infusions received emergency used authorization (EUA) from the Food and Drug Administration (FDA). Both drugs are IgG1 human antibodies to the spike protein. The EUAs for all three therapies are based on one randomized controlled study each, and results were statistically significant but overall numbers were small. The bamlanivimab study showed hospitalizations were decreased in the treatment arm at 1.6% versus 6.3% for the placebo arm. A post hoc analysis showed that the cohort of patients that are ≥65 years old or with ≥35 BMI who had bamlanivimab had hospitalizations in 4.3% versus 14.9% in the placebo arm. Symptom scores were also decreased in days 1-6. The casirivimab/imdevimab study revealed that hospitalizations were decreased in the treatment arm at 3% versus 9% in the placebo cohort. All three drugs are given as one-time infusions and have nearly identical EUAs.
In February, an EUA was approved for the bamlanivimab and etesevimab combination monoclonal antibody cocktail after results of the phase 3 portion of the BLAZE-1 RCT showed a similar benefit as bamlanivimab alone, namely faster symptomatic recovery and decreased hospitalizations and death (70% reduction). The study did not compare bamlanivimab alone directly with the bamlanivimab/etesevimab combination; rather, it compared both with placebo. The FDA states the main theoretical benefit of using this combination over bamlanivimab alone is if new variants present resistance to the bamlanivimab alone. The medications are not packaged together, and etesevimab is not approved to be given alone. The combination has similar adverse event rates, including serious hypersensitivity reactions. The bamlanivimab/etesevimab combination has different infusion times than bamlanivimab alone.
The NIH does not recommend for or against bamlanivimab and casirivimab/imdevimab and states that the therapies should not be considered the standard of care. The IDSA recommends against routine use of bamlanivimab and casirivimab/imdevimab but says that it can be offered with a risk-benefit discussion with patients.
Who has been shown to benefit from monoclonal antibody treatment:
CDCR will only be using bamlanivimab on-site. This therapy is to be used only in outpatient mild to moderate COVID-19, and both monoclonal antibody EUAs specifically address only those risk factors for severe COVID-19 that were studied in the BLAZE-1 trial:
≥65 years of age
Have a body mass index (BMI) ≥35
Have chronic kidney disease (CKD)
Have an immunosuppressive disease or currently receiving immunosuppressive treatment
Are ≥55 years of age AND have cardiovascular disease, OR hypertension, OR chronic obstructive pulmonary disease/other chronic respiratory disease.
Nationally, bamlanivimab has a controlled allocation and distribution in California is being managed by the California Department of Public Health (CDPH).
At this time, there is no shortage of bamlanivimab and in fact, CDCR has a large surplus. The medicine is being allotted to all facilities with COVID-19 cases for direct on-site availability. On-site administration increases access to the therapy for our patients. For sites that do not have an on-site allotment yet, doses can be transferred from other institutions or the treatment can be administered off-site to our patients at certain hospitals. 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. A recent update to the bamlanivimab EUA was posted that allows for new rates of administration and expanded information on adverse events. The update is summarized in Appendix 4, along with ordering, administration, forms, and other useful information and guidance on the therapy.
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 have conditions specified in the EUA and also the date of bamlanivimab administration, if given. Also, the COVID-19 Results MPage inside the EHRS will show 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 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.” If a person becomes positive and receives monoclonal antibody therapy after the first vaccine dose but before the second dose, the second vaccine dose should also be deferred for at least 90 days.
Who should not use monoclonal antibody treatment:
Patients with severe COVID-19 and/or are hospitalized may have a worse outcome with monoclonal antibody therapy. The following patients should NOT receive monoclonal antibody treatment:
Those who are hospitalized due to COVID-19, OR
Require oxygen therapy due to COVID-19, OR
Require an increase in baseline oxygen flow rate due to COVID-19 in those on chronic oxygen therapy due to underlying non-COVID-19 related comorbidity.
Although unlikely, if rationing is needed, the CDPH recommends that symptomatic patients with age ≥65 or BMI ≥35 (especially if in skilled nursing or other long term care and at risk for severe COVID-19) be prioritized to receive this treatment (Tier 1), followed by those with CKD, diabetes, and immunosuppression (Tier 2), followed by those who are 55 years or older and also have cardiovascular disease, hypertension or chronic lung disease (Tier 3).
Studies on monoclonal antibody therapy for COVID-19 are ongoing.
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.
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.
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.
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.
Recent randomized controlled studies for hospitalized patients with COVID-19 have shown encouraging results with Remdesivir and potential for treatment with a regimen of interferon beta-1b, lopinavir/ritonavir, and ribavirin. However, so far, a mortality benefit was not shown in either study. Whether giving the antiviral medications earlier could lower mortality or disease progression to severe, is yet to be determined. Recent studies on dexamethasone have changed the current recommendations on steroids. The NIH recommends the following regarding use of medications for COVID-19:
Post-hospital isolation, housing, and mask requirement: Patients may return from the hospital on oxygen and will need close medical attention. They should continue in isolation until release criteria have been met (see Release from Isolation). Patients may require more frequent surveillance than the scheduled twice-a-day monitoring depending on the patient’s clinical course and risk factors. If so, medical housing 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 atClinicalTrials.gov.
Off-label medication use: Patients may be started on an off-label medication regimen (NOT in the context of a clinical trial) while hospitalized. Once the patient is returned to a CDCR facility, we are the medical decision-makers for our patients. In this capacity, we have no obligation to continue with the hospital’s treatment (experimental, trial, or otherwise); instead, we must make decisions based upon what we determine is medically indicated for each patient. This determination would likely involve our providers having discussions with the discharging physician and with the patient about continued care to determine the best course of action. If continuing a medication, be aware of significant drug-drug interactions (DDIs) that have been described, especially with cardiac, central nervous system medications, and antibiotics. Be sure to use a DDI checker for experimental COVID-19 drugs.
Rehabilitation: 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.
SURVEILLANCE FOR INFLUENZA REQUIRING HOSPITALIZATION
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.
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 Table 8.3 below. NOTE: CDC is currently NOT recommending adamantanes in the US due to marked resistance emergence unless local resistance is low.
For information on how influenza medications can be used as chemoprophylaxis, please see the Influenza Chemoprophylaxis section below.
More information can be found at the recently updated sites:
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 Table 8.4. 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.
TREATMENT OF OTHER COMMON RESPIRATORY INFECTIONS
RESPIRATORY SYNCYTIAL VIRUS (RSV)
Treatment of RSV is supportive: oxygen and intravenous fluids (IVFs). Most medical treatment has been studied in children, including bronchodilators and corticosteroids. However, their use in adults with asthma and chronic obstructive pulmonary disease (COPD), or elderly adults with wheezing is deemed reasonable. Many different entities are researching RSV vaccines.
More information on RSV treatment can be found at:
Antifungal therapy is NOT needed for healthy patients. Treatment should be administered to those with severe disease and those at high risk for developing more serious/complicated/disseminated disease. Please refer to the CCHCS Cocci Risk Registry (CDCR networking is required for access).
More details on Coccidioidmycosis treatment can be found at:
CCHCS PHB Cocci Guidance documents (CDCR networking is required for access):
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.
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.
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.
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).
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.
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.
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.
Prohibition of the transfer of a patient to another facility except for legal or medical necessity.
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.
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.
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
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.
TABLE 11.1: STANDARD, CONTACT, DROPLET, AIRBORNE PRECAUTIONS, AND PPE USE
* 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.
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 patientsconfirmed 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).
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.
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.
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:
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.
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.
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.
Isolate single persons in a negative pressure room if COVID-19 is suspected or confirmed (negative pressure is not necessary for influenza control).
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 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:
ILI patients – symptomatic and under evaluation/awaiting testing or results.
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.
Suspect COVID-19 (symptomatic awaiting test results).
Suspect influenza (symptomatic awaiting test results).
Patients with dual influenza and COVID-19 infections.
Patients who are symptomatic and refuse to test.
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.
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.
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.
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
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.
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.
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.
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)
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.
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.
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:
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
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.
CLINICAL CRITERIA FOR HIGHER RISK SITUATIONS:
Defining High-Risk Patients
Patients who have returned from a hospitalization with COVID-19
Patients who had severe^ COVID-19 requiring oxygen, without hospitalization
Patients who are severely immunocompromised
Patients who are still symptomatic after 14 days
^The National Institute of Health (NIH) Definitions for Severe and Critical COVID-19:
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%.
Critical Illness: Individuals who have respiratory failure, septic shock, and/or multiple organ dysfunction.
Criteria for Release from Isolation: See Figure 12.1
At least 3 days after resolution of fever without the use of an antipyretic medication (if applicable) AND
At least 21 days (minimum) from after the date of the onset of symptoms (or initial positive test in asymptomatic patients) AND
Improvement in illness signs and symptoms AND
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).
CLINICAL CRITERIA FOR LOWER RISK SITUATIONS:
Defining Lower Risk Situations:
Asymptomatic throughout their illness
Normal vital signs during their illness AND/OR
Had mild to moderate^^ COVID-19 disease, or no fever beyond day 11 (documented afebrile days 12, 13 and 14)
^^NIH Definition for Mild to Moderate COVID-19:
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.
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
At least 3 days after resolution of fever without the use of antipyretic medication (if applicable) AND
At least 14 days**(minimum) from after the onset of symptoms (or date of the initial positive test if asymptomatic) AND
Improvement in illness signs and symptoms AND
Evaluated by a medical provider as cleared for release
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.
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.
WHEN TO USE A TEST BASED STRATEGY FOR RELEASE FROM ISOLATION
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.
RELEASE TO FIRE CAMP WORK OR OTHER HIGHLY PHYSICALLY DEMANDING WORK
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.
MAXIMUM TIME IN ISOLATION WHEN NO INDICATION TO CONTINUE ISOLATION EXISTS: 21 DAYS
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.
Given studies showing highly variable prolonged viral shedding after resolution of symptoms, all patients should wear a face covering and continue social distancing after release from isolation. The timeframe for this has not been specified by the CDC. At this time, CCHCS is recommending a minimum of 2 weeks. If a facility-wide order for social distancing and universal face coverings are in place, continue for 2 weeks from release or as long as the universal order persists, whichever is longer.
IMPORTANT: Consider the potential for harassment of patients released from isolation into the general population, especially if wearing masks but the general population is not using them. Work with custody leadership to mitigate stigma-related risk as much as possible before release.
Resolution of cough, is not necessary for release, however people with residual cough should wear a face covering once released, until completely without cough.
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.
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:
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
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
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
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.
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).
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.
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.
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.
When in doubt about the exposure, err on the side of caution; quarantine and test.
QUARANTINE PRECAUTIONS AND CONDITIONS FOR COVID-19
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.
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.
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 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.
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
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 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.
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 2/22/2021
Review the transfer/release list in advance in order to schedule testing.
Schedule testing accordingly to have the test results before release.
Guidance for release based on test results:
Regular Release: All patients are released on their regular release date regardless of test results, which can be any of the following:
Negative, positive, or if the patient “refuses” testing OR the test results are “pending.”
Expedited release: Patients can only be released with a negative test result.
If the patient tests “positive,” results “pending,” or “refuses” testing, they cannot be released.
– They can be re-tested, and when they have a “negative” result, they can be released.
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).
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.
Review the information with the patient, especially the websites listed for finding vaccine locations, and remind them to check local drug stores and grocery stores for availability.
“COVID-19 CA Local Public Health Department List.”
The list of California’s local public health department’s addresses and phone numbers so the patient can contact their public health department for vaccine information after they are released.
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.
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.”
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.
Show the patient the section in the “COVID-19 Vaccination Information” that provides the statewide website for information on how they can find their vaccine information if they lose their card.
Document all notifications made and education provided in the Electronic Healthcare Record System (EHRS) via the Public Health PowerForm and other PowerForms as needed.
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 (LHD’s) contact number if the patient doesn’t have a personal health care provider and becomes symptomatic.
Only patients releasing who have COVID-19 restrictions, either on ISOLATION or QUARANTINED due to COVID-19, require notification to the following:
The LHD; AND (if applicable)
Division of Adult Parole Operations (DAPO – parole), and/or Post Release Community Supervision (PRCS – probation)
The public health nurse (PHN) is responsible for the case management for each of these patients, including discharge notification.
It should be noted that during this time, an unprecedented number of patients are being released. The PHN will require additional assistance to accommodate the increased workload, including patient education and coordination of the discharge notification process with the LHD and, if applicable, the parole or probation officer.
CASE MANAGEMENT/DISCHARGE NOTIFICATION FOR PATIENTS ON ISOLATION OR QUARANTINE
The following are case management and discharge notification responsibilities conducted by the PHN or designee in advance of patient release for patients with COVID-19 restrictions only (i.e., quarantine or isolation):
Obtain the following information prior to the patient’s release date so arrangements can be made:
The county to which the patient will be released (if paroling, it will be the county of the patient’s last legal residence).
The type of housing planned for the patient upon release (e.g., private home, congregate setting, or no housing destination).
The mode of transportation for leaving the institution (e.g., private car, public transportation, etc.) if that plans need to be made in advance to safely transport a patient on quarantine or isolation for COVID-19. (See COVID-19 Screening and Testing Matrix for Patient Movement – Appendix 13).
Other people identified in the home, residence, or facility who may be at risk for exposure since the patient being released is on COVID-19 restrictions (i.e., isolation or quarantine).
The LHD should be given advance notice of the patient’s plan at release, so planning can be done to implement effective isolation or quarantine
MANDATORY “NOTIFICATION FORM” FOR PATIENTS RELEASED ON COVID-19 ISOLATION OR COVID-19 QUARANTINE
The “notification form” (Appendix 9) shall be completed in its entirety, as it includes essential information including the patient’s COVID-19 status, COVID-19 test results, the patient’s destination (e.g., a congregate facility such as a drug treatment program), and if applicable, the parole or probation officer’s contact information.
Labeling and Sending “Notification Forms”:
All forms should be saved as a PDF and labeled as follows: Institution, Last Name, First Name, Current Date (e.g., San Quentin Smith John 2020-05-27).
All forms going to non-CCHCS email addresses (e.g., outside agencies) must be sent with NO personal identifying information (PII) in the subject line, and [Encrypt] must be written in the subject line (the forms contain confidential and sensitive information).
A copy of the notification form must always be sent to the “notification email” even if the form was faxed to outside agencies (e.g., LHD).
Initial notification should be made by telephone to the LHD’s communicable disease (CD) controller, followed up by sending a confidential fax or email (include [Encrypt] in the email subject line), with the “notification form” (Appendix 9).
The LHD’s CD controller contact information can be found on the CDCR Lifeline COVID-19 webpage; click on “CDC/External” tab and then select “County Health Departments.”
The notification to the LHD should be made during business hours and, if possible, with advance notice.
Due to the COVID-19 early releases, the PHN may not have a chance to obtain this information and share it with the LHD before the release. In cases of delayed-release information to the PHN, the PHN shall proceed with the necessary notifications upon discovery of the release.
Notify the parole or probation officer (if applicable):
Notification should be made by telephone and followed by sending an email (include [Encrypt] in the email subject line), with the “notification form” (Appendix 9) attached, to the appropriate officer.
ACTIONS UPON RELEASE FOR PATIENTS ON COVID-19 QUARANTINE OR COVID ISOLATION
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, the LHD, parole/probation, and transportation officers, if applicable, will need to know the updated status before the patient is released.
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
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 1: COVID-19 OUTBREAK RESPONSE CHECKLIST FOR INSTITUTIONAL LEADERS AND PUBLIC HEALTH PROVIDERS
1. RECOGNITION, REPORTING, AND DATA COLLECTION
a. Be on alert for patients presenting with fever or symptoms of respiratory illness.
b. Report suspect cases to institutional leadership, local health department, and the Public Health Branch.
2. INFECTION PREVENTION AND CONTROL MEASURES
a. Isolate symptomatic patients immediately in airborne infection isolation room (AIIR). Implement Standard, Contact, and Airborne Precautions, plus eye protection.
b. Educate staff & patients about outbreak. Emphasize importance of hand hygiene, respiratory etiquette,and avoiding touching eye, nose, or mouth. Post signage about the outbreak in high traffic areas.
c. Increase available of hand hygiene supplies in housing units and throughout the facility.
d. Separate patients identified as contacts from other patients and implement quarantine as appropriate.
e. Increase cleaning schedule for high-traffic areas and high-touch surfaces (faucets, door handles, keys,telephones, keyboards, etc.). Ensure available cleaning supplies.
3. CARING FOR THE SICK
a. Implement plan for assessing ill patients. Limit number of staff providing care to ill patients, if possible.
b. Ensure Personal Protective Equipment is available and accessible to staff caring for ill patients.
4. POSSIBLE ADMINISTRATIVE CONTROLS DURING OUTBREAKS
a. Institute screening for respiratory symptoms.
b. Encourage patients to report respiratory illness.
c. Halt patient movement between affected and unaffected units.
d. Screen for respiratory illness in patient workers in Food Service and Health Services; exclude from work if symptomatic.
e. Minimize self-serve foods in Food Service (e.g., eliminate salad bars).
f. Do controlled movement by unit to chow hall (cleaning between units), or feed on the units.
g. Temporarily discontinue group activities, e.g., recreation, chapel, activity therapy groups, education.
h. Schedule daily status meetings involving custody and medical leadership; other stakeholders shouldattend as appropriate.
i. Do controlled movement by unit to pill line, or administer medication on the units.
j. Encourage ill staff to stay home until symptoms resolve and/or they are cleared to return to work bytheir provider.
k. Post visitor notifications regarding outbreak. Advise visitors with respiratory symptoms to not enter thefacility (If large outbreak, consider suspending visits).
l. During large outbreaks, consider halting patient movement in and out (in consultation with local healthdepartment).
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.
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
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.
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.
Enter the contacts under the Line Listing tab after the case report is initiated in the Public Health Outbreak Response System (PhORS).
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.
Symptoms / Onset Date
Cough (new onset or worsening)
Shortness of breath (dyspnea)
Fever >100.4°F (38°C)
Subjective fever (felt feverish)
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
Routine Activities and Assignments
Regular appointments (medical, dental, legal)
Religious, worship or spiritual activities
TV room / day room
Sports team participation
Any other relevant information
APPENDIX 8: SUMMARY OF THE INFECTIOUS DISEASES SOCIETY OFAMERICA (IDSA) TESTING RECOMMENDATIONS
Administrators can plan and prepare for COVID-19 by ensuring that all persons in the facility know the symptoms (see our Table 5.1 and the CDC’s listed Symptoms of COVID-19), and the importance of reporting those symptoms, if they develop. Other essential actions include developing contingency plans for reduced workforces due to absences, coordinating with public health and correctional partners, training staff on the proper use of personal protective equipment (PPE) that may be needed in the course of their duties, and communicating clearly with staff and incarcerated/detained persons about these preparations and how they may temporarily alter daily life.
COMMUNICATION AND COORDINATION
Develop information-sharing systems with partners.
Create and test communication plans to disseminate critical information to incarcerated/detained persons, staff, contractors, vendors, and visitors as the pandemic progresses.
Communicate with other correctional facilities in the same geographic area to share information, including disease surveillance and absenteeism patterns among staff.
Where possible, put plans in place with other jurisdictions to prevent individuals with confirmed and suspected COVID-19 and their close contacts from being transferred between jurisdictions and facilities unless necessary for medical evaluation, medical isolation/quarantine, clinical care, extenuating security concerns, release, or to prevent overcrowding.
Review existing plans for influenza, all-hazards, and disasters, and revise for COVID-19.
Train staff on the facility’s COVID-19 plan. All personnel should have a basic understanding of COVID-19, how the disease is thought to spread, symptoms, and what measures are being implemented and can be taken by individuals to prevent or minimize the transmission of SARS-CoV-2.
Ensure that separate physical locations (dedicated housing areas and bathrooms) have been identified to 1) isolate individuals with confirmed COVID-19 (individually or cohorted), 2) isolate individuals with suspected COVID-19 (individually – do not cohort), and 3) quarantine close contacts of those with confirmed or suspected COVID-19 (ideally individually; cohorted if necessary). The plan should include contingencies for multiple locations if numerous infected individuals and/or close contacts are identified and require medical isolation or quarantine simultaneously (see Isolation and Quarantine subsections of the CCHCS Interim Guidance for more detailed cohorting considerations).
Facilities without onsite healthcare capacity should plan for how they will ensure that individuals with suspected COVID-19 will be isolated, evaluated, tested, and provided necessary medical care.
Make a list of possible social distancing strategies that could be implemented, as needed, at different stages of transmission intensity.
Designate officials who will be authorized to make decisions about escalating or de-escalating response efforts as the disease transmission patterns change.
Coordinate with local law enforcement and court officials.
Identify legally acceptable alternatives to in-person court appearances, such as virtual court, as a social distancing measure to reduce the risk of SARS-CoV-2 transmission.
Consider options to prevent overcrowding (e.g., diverting new intakes to other facilities with available capacity, and encouraging alternatives to incarceration and other decompression strategies where allowable).
Encourage all persons in the facility to take the actions below to protect themselves and others from COVID-19. Post signs throughout the facility and communicate this information verbally on a regular basis. Sample CDC signage and other communications materials are available on the CDC website. Ensure that materials can be understood by non-English speakers and those with low literacy, and make necessary accommodations for those with cognitive or intellectual disabilities and those who are deaf, blind, or have low vision. CCHCS signage and communications materials can be found on the Coronavirus webpage under the Internal Resources tab (CDCR networking is required for access).
Practice good cough and sneeze etiquette (CDC): Cover your mouth and nose with your elbow (or ideally with a tissue) rather than with your hand when you cough or sneeze, and throw all tissues in the trash immediately after use.
Practice good hand hygiene (CDC): Regularly wash your hands with soap and water for at least 20 seconds, especially after coughing, sneezing, or blowing your nose; after using the bathroom; before eating; before and after preparing food; before taking medication; and after touching garbage.
Wear face coverings, unless specific PPE is indicated.
Avoid touching your eyes, nose, or mouth without cleaning your hands first.
Avoid sharing eating utensils, dishes, and cups.
Avoid non-essential physical contact.
For incarcerated/detained persons: Educate on the importance of reporting symptoms to staff; social distancing and its importance for preventing COVID-19; and the purpose of quarantine and medical isolation.
Review the sick leave policies of each employer that operates within the facility.
Review policies to ensure that they are flexible, non-punitive, and actively encourage staff not to report to work when sick.
Determine which officials will have the authority to send symptomatic staff home.
Identify duties that can be performed remotely. Where possible, allowing staff to work from home can be an effective social distancing strategy to reduce the risk of SARS-CoV-2 transmission.
Plan for staff absences. Staff should stay home when they are sick. They may also need to stay home to care for a sick household member or care for children in the event of school and childcare dismissals.
Identify critical job functions and plan for alternative coverage.
Determine minimum levels of staff in all categories required for the facility to function safely. If possible, develop a plan to secure additional staff if absenteeism due to COVID-19 threatens to bring staffing to minimum levels.
Review CDC guidance on safety practices for critical infrastructure workers (including correctional officers, law enforcement officers, and healthcare workers) who continue to work after a potential exposure to SARS-CoV-2. Also, see the CCHCS Critical Inmate Workers memo (CDCR networking is required for access).
Consider increasing keep on person (KOP) medication orders to cover 30 days in case of healthcare staff shortages.
Consult with occupational health providers to determine whether it would be allowable to reassign duties for specific staff members to reduce their likelihood of exposure to SARS-CoV-2.
Make plans in advance for how to change staff duty assignments to prevent unnecessary movement between housing units during a COVID-19 outbreak.
If there are persons with COVID-19 inside the facility, it is essential for staff members to maintain a consistent duty assignment in the same area of the facility across shifts to prevent transmission across different facility areas.
Where feasible, consider the use of telemedicine to evaluate persons with COVID-19 symptoms and other health conditions to limit the movement of healthcare staff across housing units.
Offer the seasonal influenza vaccine to all incarcerated/detained persons (existing population and new intakes) and staff throughout the influenza season. CDC’s Symptoms of COVID-19 are similar to those of influenza. Preventing influenza in a facility can speed the detection of COVID-19 and reduce pressure on healthcare resources.
Ensure that sufficient stocks of hygiene supplies, cleaning supplies, PPE, and medical supplies (consistent with the healthcare capabilities of the facility) are on hand and available and have a plan in place to restock as needed. Supplies may include:
Standard medical supplies for daily clinic needs
Liquid or foam soap when possible. If bar soap must be used, ensure that it does not irritate the skin and thereby discourage frequent hand washing. Ensure there is a sufficient supply of soap for each individual
Hand drying supplies
Alcohol-based hand sanitizer containing at least 60% alcohol (where permissible based on security restrictions)
Recommended PPE (surgical masks, N95 respirators, eye protection, disposable medical gloves, and disposable gowns/one-piece coveralls). See the CCHCS Interim Guidance PPE section and Recommended PPE for Staff and Inmates at the Institution for more detailed information, including recommendations for extending the life of all PPE categories in the event of shortages, and when surgical masks are acceptable alternatives to N95s. Visit CDC’s website for a calculator to help determine the rate of PPE usage.
Consider relaxing restrictions on allowing alcohol-based hand sanitizer in the secure setting, where security concerns allow. If soap and water are not available, CDC recommends cleaning hands with an alcohol-based hand sanitizer that contains at least 60% alcohol. Consider allowing staff to carry individual-sized bottles for their hand hygiene while on duty, and placing dispensers at facility entrances/exits and in PPE donning/doffing stations.
Provide a no-cost supply of soap to incarcerated/detained persons, sufficient to allow frequent hand washing. (See CDC’s Hygiene section for additional detail regarding recommended frequency and protocol for handwashing.)
Provide liquid or foam soap where possible. If bar soap must be used, ensure that it does not irritate the skin, and thereby discourage frequent handwashing, and ensure that individuals do not share bars of soap.
If not already in place, employers operating within the facility should establish a respiratory protection program (CDC), as appropriate, to ensure that staff and incarcerated/detained persons are fit-tested for any respiratory protection they will need within the scope of their responsibilities.
Ensure that staff and incarcerated/detained persons are trained to correctly don, doff, and dispose of PPE that they will need to use within the scope of their responsibilities.
CCHCS GUIDANCE ON EARLY IDENTIFICATION AND LOCATION FOR ISOLATION AND QUARANTINE ROOMS AND FUTURE COHORTS
It is crucial to be ready for your first cases and contacts of cases.
Analyze your ventilation systems and staff/inmate traffic patterns.
If you anticipate the need for tent housing, consult the Department Operations Center (DOC) at DOCCOVID19@cdcr.ca.gov.
Work with the warden on evaluating and repurposing existing space in collaboration with the DOC.
Work with custody and supplies from the Office of Emergency Preparedness for physical space assistance. Ensure patients’ ability to access showers, bathrooms, and a path to the exercise yards that will not expose other inmates to the virus.
Consider what supplies you will need, inventory your current stock, and order accordingly (e.g., testing kits and swabs, PPE, cleansers, trash receptacles, extra tissues, extra soap, portable wash stations, housing tents or canopies, portable showers, duct tape, oxygen, incentive spirometry, nasal cannulas, O2, surgical masks, and tubing, etc.).
Mobilize your PPE: have it ready and available at the sites where it will be needed, including the Treatment and Triage Area (TTA), all medical and dental clinics, specialized medical housing, and for custody officers who may need to escort a symptomatic patient from the housing area to a site for medical evaluation.
CCHCS GUIDANCE ON ASSESSING AND OBTAINING RESOURCES FOR OUTBREAK PLANNING
For assessing needed supplies, the facility leadership, including the Chief Medical Executive (CME), Chief Nursing Executive (CNE), Warden, and Chief Executive Officer (CEO), should meet to discuss resources and allocation. After a leadership discussion at the institution, if there are needed items, lack of local resources, or concerns about being able to provide needed precautionary or treatment measures, contact the DOC (see below).
For requested items not available locally, a Form 213 Resource Request Message (CDCR networking is required for access) needs to be filled out and e-mailed to the DOC (e-mail address below). Form 213 can be sent by the Warden, CEO, or CME.
Note: A separate form should be submitted for each item (e.g., N95 respirators on one form, tents on another form). Needed items are obtained from another institution that currently has extra or from the state Office of Emergency Services (OES).
For questions, please contact the respective CDCR chain of command, or e-mail the DOC at DOCCOVID19@cdcr.ca.gov.
Detailed information on prevention can be found in the Primary Prevention section of the CCHCS guidance document.
Cases of COVID-19 have been documented in all 50 states. Correctional and detention facilities can prevent the introduction of SARS-CoV-2 and reduce transmission if it is already inside by reinforcing good hygiene practices among incarcerated/detained persons, staff, and visitors (including increasing access to soap and paper towels), intensifying cleaning/disinfection practices, and implementing social distancing strategies.
Because many individuals infected with SARS-CoV-2 do not display symptoms, the virus could be present in facilities before infections are identified. Good hygiene practices, vigilant symptom screening, wearing cloth face coverings (CDC) (if able), and social distancing are critical in preventing further transmission.
Set up an Incident Command Center with appropriate leadership representation (e.g., the CEO, medical, nursing, custody, the warden, pharmacy, dental, mental health, etc.). Make use of the Daily Institution Command Report (access permissions are required).
Stay in communication with partners about your facility’s current situation.
State, local, territorial, and/or tribal health departments
Other correctional facilities
Communicate with the public about any changes to facility operations, including visitation programs.
Limit transfers of incarcerated/detained persons to and from other jurisdictions and facilities unless necessary for medical evaluation, medical isolation/quarantine, clinical care, extenuating security concerns, release, or to prevent overcrowding.
Consider postponing non-urgent outside medical visits. Use telehealth to the extent possible as a social distancing measure within the facility and help minimize movement between the facility and the community.
If a transfer is absolutely necessary, perform verbal screening and a temperature check before the individual leaves the facility. If an individual does not clear the screening process, delay the transfer and follow the protocol for suspected COVID-19 infection – including giving the individual a surgical mask, if not already wearing one, immediately placing them under medical isolation, and evaluating them for SARS-CoV-2 testing.
Ensure that the receiving facility can properly quarantine or isolate the individual upon arrival.
See the Transportation subsection for information on precautions to use when transporting an individual with confirmed or suspected COVID-19.
Make every possible effort to modify staff assignments to minimize movement across housing units and other areas of the facility. For example, ensure that the same staff are assigned to the same housing unit across shifts to prevent cross-contamination from units where infected individuals have been identified to units with no infections.
Consider suspending work release and other programs that involve the movement of incarcerated/detained individuals in and out of the facility, especially if the work release assignment is in another congregate setting, such as a food processing plant.
Implement lawful alternatives to in-person court appearances where permissible.
Where relevant, consider suspending co-pays for incarcerated/detained persons seeking medical evaluation for possible COVID-19 symptoms.
Limit the number of operational entrances and exits to the facility.
Where feasible, consider establishing an onsite laundry option for staff to change out of their uniforms, launder them at the facility, and wear street clothes and shoes home. If onsite laundry for staff is not feasible, encourage them to change clothes before leaving the worksite, and provide a location for them to do so. This practice may help minimize the risk of transmitting SARS-CoV-2 between the facility and the community.
APPENDIX 19: COVID-19 AND INFLUENZA SPECIMEN COLLECTION AND TEST ORDERING INFORMATION - Updated 11/16/2020
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).
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.
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.
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.