What Providers Need to Know about COVID-19 

The Section of Epidemiology (SOE) within DHSS’s Division of Public Health continues to provide guidance in accordance with the CDC to health care providers across Alaska regarding the monitoring, detection and treatment of any possible cases of COVID-19 (the 2019 novel coronavirus disease). Alaska currently has no cases of COVID-19.

Below is a Q and A for health care providers and links to the most important resources. Most of this information is from the CDC website.  If you have any further questions, call SOE (907) 269-8000 or after hours (800) 478-0084.  

Q: What are the best sources for information?

Q: Who is most at risk? Where might we expect to see COVID-19 cases?

A: Alaska currently has no confirmed cases of COVID-19. There are also no “persons under investigation” or PUIs who are defined by having certain respiratory symptoms and exposures criteria that warrant collection of specimens for testing.

Currently, those at greatest risk of infection are persons who have had prolonged, unprotected close contact with a patient with symptomatic, confirmed COVID-19 infection and those with recent travel to China, especially Hubei Province.

For any patient meeting criteria for evaluation for COVID-19, clinicians need to contact and collaborate with the DHSS Section of Epidemiology. This flowchart will help guide providers through this process. We suggest you print this out and provide copies to all staff, including those who schedule appointments.

The criteria below is intended to serve as guidance for evaluation. Patients should be evaluated and discussed with our Section of Epidemiology on a case-by-case basis.

Criteria to Guide Evaluation of Persons Under Investigation (PUI) for 2019-nCoV


(Click to view full size)

Q: Should we be concerned about people who have been traveling to China and are returning to the US?

A: The DHSS Section of Epidemiology, like other states, is receiving notifications of passengers with recent travel to China who have cleared customs upon entry into the US. In the process of clearing customs, passengers are screened for symptoms; those who have no symptoms continue on to their final destination. The states are notified of these passengers and SOE makes contact with them to establish self-monitoring with public health supervision. They are considered “persons under monitoring” for 14 days after they left China.

Q: What should clinic staff do if someone calls to make an appointment and says they think they may have COVID-19?

A: Please print out the flowchart (see below) for your front line staff. The current focus is on patients with recent travel to China, or those with known exposure to a patient with COVID-19. When scheduling appointments, instruct patients and persons who accompany them to call ahead or inform health care personnel upon arrival if they have symptoms of any respiratory infection (e.g., cough, runny nose, fever). Take appropriate actions if they do have symptoms (e.g., ask them to wear a facemask upon entry and follow triage procedures).

If respiratory symptoms are present, ask about recent travel. If the patient travelled in China in the past 14 days, please ensure you have proper infection control procedures in place for staff and other patients. During scheduling, if your intake staff detects a likely possible PUI, or “persons under investigation,” call the Section of Epidemiology immediately at (907) 269-8000 or after hours at (800) 478-0084. Our staff is here to help you problem solve and determine the best course of action.

Flowchart to Indentify and Assess 2019 Novel Cornoavirus

(Click image to view full size image)

Q: What should health care facilities do to protect patients if someone comes in exhibiting symptoms compatible with COVID-19?

A: Please refer to the CDC’s guidance on this webpage, “Upon Arrival and During the Visit.”  Here is the current guidance from that webpage.

  • Take steps to ensure all persons with symptoms of suspected COVID-19 or other respiratory infection (e.g., fever, cough) adhere to respiratory hygiene and cough etiquette, hand hygiene, and triage procedures throughout the duration of the visit. Consider posting visual alerts (e.g., signs, posters) at the entrance and in strategic places (e.g., waiting areas, elevators, cafeterias) to provide patients and health care staff with instructions (in appropriate languages) about hand hygiene, respiratory hygiene, and cough etiquette. Instructions should include how to use facemasks (See definition of facemask in Appendix) or tissues to cover nose and mouth when coughing or sneezing, to dispose of tissues and contaminated items in waste receptacles, and how and when to perform hand hygiene.
  • Ensure that patients with symptoms of suspected COVID-19 or other respiratory infection (e.g., fever, cough) are not allowed to wait among other patients seeking care.  Identify a separate, well-ventilated space that allows waiting patients to be separated by 6 or more feet, with easy access to respiratory hygiene supplies. In some settings, medically-stable patients might opt to wait in a personal vehicle or outside the healthcare facility where they can be contacted by mobile phone when it is their turn to be evaluated.
  • Ensure rapid triage and isolation of patients with symptoms of suspected 2019-nCoV or other respiratory infection (e.g., fever, cough):
    • Identify patients at risk for having COVID-19 infection before or immediately upon arrival to the healthcare facility.
      • Implement triage procedures to detect persons under investigation (PUI) for COVID-19  during or before patient triage or registration (e.g., at the time of patient check-in) and ensure that all patients are asked about the presence of symptoms of a respiratory infection and history of travel to areas experiencing transmission of COVID-19 or contact with possible COVID-19 patients.
    • Implement respiratory hygiene and cough etiquette (i.e., placing a facemask over the patient’s nose and mouth if that has not already been done) and isolate the PUI in an Airborne Infection Isolation Room (AIIR), if available. See recommendations for “Patient Placement” below. Additional guidance for evaluating patients in U.S. for 2019-nCoV infection can be found on the CDC COVID-19 website.
    • Inform infection prevention and control services, local and state public health authorities, and other healthcare facility staff as appropriate about the presence of a PUI for COVID-19.
  • Provide supplies for respiratory hygiene and cough etiquette, including 60%-95% alcohol-based hand sanitizer (ABHS), tissues, no touch receptacles for disposal, and facemasks at healthcare facility entrances, waiting rooms, patient check-ins, etc.

Q: What should health care facilities do to evaluate patients for COVID-19?

A: Again, follow the CDC flowchart and refer to this CDC webpage, Evaluating and Reporting Persons Under Investigation (PUI).

Alaska-specific guidance for health care providers is available here

Q: How should healthcare personnel protect themselves when evaluating a patient who may have COVID-19? Where can health care facilities find the most current information on infection control?

A: This CDC link covers infection control recommendations (including isolation precautions and PPE) for healthcare facilities.  Healthcare personnel evaluating PUI or providing care for patients with confirmed COVID-19 infection should follow universal precautions.

Q: What is the guidance on masks for the general public?

A: The CDC does not recommend that people who are well wear a facemask to protect themselves from COVID-19. A facemask should be used by people who have been exposed to COVID-19 and are showing symptoms of 2019 novel coronavirus. This is to protect others from the risk of getting infected.  

Q: What are the clinical features of COVID-19 infection?

A: The clinical spectrum of COVID-19 infection ranges from mild disease with non-specific signs and symptoms of acute respiratory illness, to severe pneumonia with respiratory failure and septic shock. There have also been limited reports of asymptomatic infection with COVID-19.

Q: Who is at risk for severe disease from COVID-19 infection?

A: The available data are currently insufficient to identify risk factors for severe clinical outcomes. From the limited data that are available for COVID-19 infected patients, and for data from related coronaviruses such as SARS-CoV and MERS-CoV, it is possible that older adults, and persons who have underlying chronic medical conditions, such as immunocompromising conditions, may be at risk for more severe outcomes.

Q: When is someone infectious?

A: The onset and duration of viral shedding and period of infectiousness for COVID-19 are not yet known. It is possible that COVID-19 RNA may be detectable in the upper or lower respiratory tract for weeks after illness onset, similar to infection with MERS-CoV and SARS-CoV. However, detection of viral RNA does not necessarily mean that infectious virus is present. Asymptomatic infection with COVID-19 has been reported, but it is not yet known what role asymptomatic infection plays in transmission. Similarly, the role of pre-symptomatic transmission (infection detection during the incubation period prior to illness onset) is unknown. Existing literature regarding other coronaviruses (e.g., MERS-CoV, SARS-CoV) suggest that the incubation period may range from 2–14 days.

Q: Which body fluids contain the virus?

A: Very limited data are available about detection of COVID-19 and infectious virus in clinical specimens. Detection of molecular material (i.e., RNA) doesn’t necessary mean that the virus is intact enough to be able to cause an infection. 2019-nCoV RNA has been detected from upper and lower respiratory tract specimens, and 2019-nCoV has been isolated from upper respiratory tract specimens and bronchoalveolar lavage fluid. 2019-nCoV RNA has been detected in blood and stool specimens, but whether infectious virus is present in extrapulmonary specimens is currently unknown. The duration of 2019-nCoV RNA detection in upper and lower respiratory tract specimens and in extrapulmonary specimens is not yet known but may be several weeks or longer, which has been observed in cases of MERS-CoV or SARS-CoV infection. While viable, infectious SARS-CoV has been isolated from respiratory, blood, urine, and stool specimens. In contrast, viable MERS-CoV has only been isolated from respiratory tract specimens. It is not yet known whether other non-respiratory body fluids from an infected person including vomit, urine, breast milk, or semen can contain the virus.

Q: Should any diagnostic or therapeutic interventions be withheld due to concerns about transmission of COVID-19?

A: Patients should receive any interventions they would normally receive as standard of care. Patients with suspected or confirmed 2019-nCoV should be asked to wear a surgical mask as soon as they are identified and be evaluated in a private room with the door closed, ideally an airborne infection isolation room, if available. Healthcare personnel entering the room should follow Standard Precautions, Contact Precautions, Airborne Precautions, and use eye protection (e.g., goggles or a face shield).

Q: How do you test a patient for 2019-nCoV?

A: See recommendations for reporting, testing, and specimen collection at Interim Guidance for Healthcare Professionals.

Q: Do patients with confirmed or suspected 2019-nCoV infection need to be admitted to the hospital?

A: Not all patients with 2019-nCoV infection require hospital admission. Patients whose clinical presentation warrants in-patient clinical management for supportive medical care should be admitted to the hospital under appropriate isolation precautions. Some patients with an initial mild clinical presentation may worsen in the second week of illness. The decision to monitor these patients in the inpatient or outpatient setting should be made on a case-by-case basis. This decision will depend not only on the clinical presentation, but also on the patient’s ability to engage in monitoring, the ability for safe isolation at home, and the risk of transmission in the patient’s home environment. For more information, see Interim Infection Prevention and Control Recommendations for Patients with Known or Patients Under Investigation for 2019 Novel Coronavirus (2019-nCoV) in a Healthcare Setting and Interim Guidance for Implementing Home Care of People Not Requiring Hospitalization for 2019 Novel Coronavirus (2019-nCoV).

Q: Will existing respiratory virus panels, such as those manufactured by Biofire or Genmark, detect 2019-nCoV?

A: No. These multi-pathogen molecular assays can detect a number of human respiratory viruses, including established human coronaviruses, but they do not detect the novel coronavirus that causes COVID-19.

Q: When can we expect testing for COVID-19 in Alaska

A: Our state public health laboratory is working with the CDC to bring testing for COVID-19 to Alaska but we don’t expect this testing to be available for at least a month. In the meantime, the CDC will perform all testing.

Q: What else can we do prepare?

A: Please see this CDC webpage for preparedness checklists for health care providers and for hospitals. Now, before we have cases of COVID-19 in Alaska, is also a good time to go over general preparedness planning in the event of an outbreak in Alaska.

For the full Provider FAQ from the CDC, visit their webpage. And visit the main CDC webpage on this outbreak for providers: Information for Healthcare Professionals

 

From Chief Medical Officer Dr. Anne Zink, MD, FACEP

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What Providers Need to Know about Novel Coronavirus (COVID-19)


 

State of Alaska
Department of Health and Social Services
Website: http://dhss.alaska.gov/
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