COVID 19 Webinar for Case Investigation and Follow up...LBOH COVID‐19: Set Assistance to No Workflow • Newly confirmed cases within the past 24 hours • Cases are extracted to

COVID‐19WebinarforCaseInvestigationandFollow‐up

ToolsforLBOHs

HillaryJohnson,InfectiousDiseaseEpidemiologistScottTroppy,SurveillanceEpidemiologist

BureauofInfectiousDiseaseandLaboratorySciencesMADepartmentofPublicHealth

May 15, 2020

MAVENStatusMapasof5/15/2012

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MAVENReminders

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MAVEN Help

Section

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FirstResponderReport– ConfirmedCasesOnly

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• Probable• Contacts• Unclassified(negative)Donotshowonthisreport

ConfirmedandProbableLineListReport• UPDATE to your COVID‐19 Confirmed Case Line List Report:We have updated the existing report – the revised report is now named COVID‐19 Confirmed and Probable Case line list report. • You can run this on a daily basis to see events that had a negative lab then a positive lab.• Once you run the report look at the Create date and then Step 1 Notification Date – you may see an event with a create date of April then a Step 1 date of May 15th. This is a flag that you have had an update to the event. (Unclassified to a Confirmed Event).

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ImmediateNotificationworkflow(COVID‐19Only)• UPDATE:We have updated the COVID‐19 Immediate Notification Workflow ‐ it only retain events within the past 5 days.• This will allow proper notification of all new COVID‐19 events for your jurisdiction. The workflow will refresh every 24 hours and remove those cases that have you have not updated Step 1‐ LBOH Notification to “Yes”.

• You may see events with Step 1 populated to Yes. You need to review the Event Date associated labs with the event.

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LBOHCOVID‐19:SetAssistancetoNoWorkflow• Newly confirmed cases within the past 24 hours• Cases are extracted to CTC at 10 a.m. every day• This will allow you to retain your cases that you want to follow‐up on and leave blank those cases you want to forward to CTC. ***As a reminder CTC is only taking confirmed cases at this time not Probable or Contact cases.

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Congregate settingsClustersHealthcare workersContact eventsProbable events

Cases That Remain with LBOH

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Congregate settings Clusters Healthcare workers Any complex case Any case you request to manage Special requests to supervisors

High Priority Cases Remain with LBOH

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Including cases identified by CTC

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Employedat,admittedto,orvisitedahealthcaresetting?Thesedon’tgotoCTC

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• If a case comes in at (for example):• 9 am Tuesday, May 12: The LBOH can use the COVID Assistance Set to No

workflow or answer the question in the Administrative Question Package/Wizard.

• 5 pm Tuesday, May 12: The LBOH can use the COVID Assistance Set to No workflow or answer the question in the Administrative Question Package/Wizard.

• 11:30 pm Tuesday, May 12: The LBOH will have until 10am on Wednesday, May 13th to say “Yes” or “No” or leave blank.

• 12:01 am, 8 am, or any other time on Wednesday May 13: The case will remain in the LBOH queue until Thursday morning at 10 am for “Yes” or “No” or Blank decisions.

• If you leave the COVID Assistance Question as Blank for your Confirmed case – the case will be assigned to the CTC on the next data extract.

How would the CTC receive an event/case

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YoumayseetheseinMAVEN

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CTCsendingcasesbacktoMAVEN– lookinyourwizardforInvestigationstatus– datewillnotbepopulatedforthesecases

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QP#8– showsthatacasewassenttoMAVEN

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Steps 2, 3, & 4 are Updated with CTC Information once the CTC completes their case investigation

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ReportforCTCDataReport• COVID‐19 LBOH CTC Data Report

• This report pulls all cases that were sent to the Community Tracing Collaborative (CTC) and the data obtained at the CTC. The report will allow you to extract and see what fields were sent back to MAVEN for your events. When the CTC creates contacts on their side those events will be created in MAVEN with a flag that the CTC has the case and the CTC investigation status will show “In progress” until they have completed their investigation.

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MAVEN Help

Section

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CTCCaseQuestions

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Follow‐upforPositiveCOVID‐19CasesandtheirCloseContacts

ToolsforLBOHs

HillaryJohnson,InfectiousDiseaseEpidemiologistScottTroppy,SurveillanceEpidemiologist

BureauofInfectiousDiseaseandLaboratorySciencesMADepartmentofPublicHealth

May 15, 2020

TopicsToday

• FoodProtectionProgram• NewTestingGuidanceisHere!!!!

• May13Guidance.• DiscussesTestingContacts• DiscussesSerologyTesting

• YourQuestionsonSerology• YourQuestionsonTestingContacts• YourQuestions

Tuesday&FridayWebinarsforLBOHs• IsolationofCasesandQuarantineofContactsisthegoaluntilthatstrategychanges/evolves.

• MAVENisthemainreportingsourceandwhereyoushoulddocumentyourwork.

• SendCasestoCTCforfollow‐upifnot:• Hospitalized,Deceased,orlinkedtoaCluster

Facility

• FocusingonPriorityActivities

• ClustersinFacilitiesinyourcommunityneedyourhelp.

• CallEpiProgramtocreateclusterevents.

Tuesdays&Fridays@11am

MAVENHelphasGuidanceDocumentsandPreviousWebinars:http://www.maventrainingsite.com/maven‐help/toc.html

MDPH Epi Program: 617‐983‐6800MDPH MAVEN Help Desk: [email protected] Food Protection Program: 617‐983‐6712 CTC Help Desk: 857‐305‐2828

UpdatedTestingGuidance(PCR&Serology)forProvidersishere!• Date: May13,2020• RE: TestingofPersonswithSuspectCOVID‐19

• GuidanceaboutappropriateuseoflaboratorytestingforCOVID‐19andexpandstestingrecommendationsforCOVID‐19incommercialandclinicallaboratories.

• IndividualsshouldbetestedforpresenceofthevirususingamoleculardiagnostictestsuchasPCR:• SymptomaticIndividuals• CloseContacts• AsymptomaticIndividuals(asrecommended)

https://www.mass.gov/doc/covid‐19‐testing‐guidance/download

UpdatedTestingGuidance(PCR&Serology)forProvidersishere!

• CloseContactsofCOVIDCases:AllindividualsinMassachusettsidentifiedasaclosecontactbyaLocalBoardofHealth,theMassachusettsDepartmentofPublicHealth,theCommunityTracingCollaborative,orahealthcareprovidershouldbetested.

Yes!TheupdatedTestingGuidancerecommendsCloseContactsGetTested,regardlessofcurrentsymptoms.

https://www.mass.gov/doc/covid‐19‐testing‐guidance/download


• SerologyTesting:• ThemajorityoftestscurrentlyavailablehavenotreceivedFDAEmergencyUseAuthorization(EUA).

• AntibodytestsmaydemonstratewhetheranindividualwaspreviouslyinfectedwithSARS‐CoV‐2andantibodytestingisimportanttohelpunderstandhowmanypeopleinapopulationhavebeenexposedtothevirus.However,antibodytestsarenotindicatedfordiagnosticpurposes.

• Inordertobeappropriatelyinterpreted,moredataareneededontheperformancecharacteristicsofthesetests,theimmuneresponsetoCOVID‐19,thetiminganddurationofantibodyresponse,andhowantibodiescorrelatetoprotectiveimmunity.


• SerologyTesting:

• Ifanantibodytestisperformed,itisrecommendedthathealthcareprovidersorderamoleculardiagnostictestatthesametime.

• Atthistime,antibodytestingshouldnotbeusedtoguidereleasefromisolationorforreturntoworkpurposesandarenotindicatedfordiagnosticpurposes.


• May13UpdatedTestingGuidance:

• Posted to:• https://www.mass.gov/info‐details/covid‐19‐testing#should‐i‐be‐tested?‐

• https://www.mass.gov/info‐details/covid‐19‐guidance‐and‐directives#health‐care‐professionals‐&‐organizations‐

• Direct link to PDF:• https://www.mass.gov/doc/covid‐19‐testing‐guidance/download

WherecanIlearnaboutserologytests&publichealthfollow‐up?• ReviewtheWebinarsfromTuesdayMay12,2020&FridayMay8.Bigfocuswasonserologytesting,whattodo,andFAQsonhowtoappropriatelyfollow‐up.

SerologyTestingFAQs• Whywouldweisolateapatientwithapositiveserology?• A.Intheabsenceofothertestinginformationtohelpruleoutcurrentinfection,Massachusettspublichealthmusttakeaconservativeapproachtoprotectthepublic’shealth.

• Per“PublicHealthConsiderations:SerologicTestingforCOVID‐19Ver1,May7,2020.”(APHL&CSTE)• Apositiveresultindicatespastand/orpresentinfectionwithSARS‐CoV‐2.Apositiveresultalsomaybeduetodetectionofcross‐reactivity(i.e.,antibodiestonon‐SARS‐CoV‐2strainsmaycross‐reactwithSARS‐CoV‐2antibodies)whichwouldbeconsideredafalsepositivetestresult.

• ApositiveresultdoesnotmeanthattheindividualisimmunetoCOVID‐19infection.• Apositiveresultdoesnotmeanthatthepersonisnolongersheddingvirusorisnolongerinfectious.

• https://www.aphl.org/programs/preparedness/Crisis‐Management/Documents/Serologic‐Testing‐for‐COVID‐19.pdf

HelpfulReminders• LookintheLabTabtoseewhatlabsareavailabletoinformthesituation.

• Moreinformationisbetter.Intheabsenceofinformation,weneedtotakeaconservativepublichealthapproach.SeekPCRtestingtohelpruleinorruleoutcurrentinfectiousnessandtheneedforisolation.

• Thesecriteriamakesenseforwhereweareintheoutbreakandwhatweknownow.Theremaybechangesinthefutureandaswelearnmore.

• HelpfulDocuments:• CaseClassificationManual(CaseDefinitionsforCOVID‐19)• ReturntoWorkGuidance(HCW&NonHCW)• SerologyInterpretationsforLBOHs

AntibodyTesting(serology)• Wherecanwetellwhatkindoftestapatienthad?

• A.ChecktheLabTab.

Test Types You May See: PCR Test: 2019‐nCoV Real‐time RT‐PCRRapid PCR Test: SARS coronavirus 2 RdRp gene Serology IgM specific: SARS‐CoV‐2 IgM Serology IgG specific: SARS‐CoV‐2 IgG Serology IgA specific: SARS‐CoV‐2 IgA Serology Antibody Type Unspecified: SARS‐CoV‐2 IgG + IgM

Check out the Case Classification Manual for lists of Tests http://www.maventrainingsite.com/maven‐help/pdf/case‐classification‐manual/COVID19__04292020_final.pdf

RecommendationforRoutineMolecularTestingofPeopleIdentifiedasCloseContactstoCOVID‐19Cases• Asrestrictionsonactivitiesbegintoloosen,itbecomesincreasinglycriticalthatthehealthcareandpublichealthsystemsworktogethertoidentifyeverycase.• Rapididentificationofcasesandidentificationoftheirclosecontactsisapriority.

• Closecontactsofconfirmedcasesarethepeoplemostlikelytobecomeinfectedthemselves.Tofacilitateidentificationofinfections,moleculartestingisrecommendedforallclosecontactsregardlessofsymptomstatus.

• MDPHissuedguidanceonMay11,2020:AllpeopleidentifiedasclosecontactsshouldbetestedviaPCRtestingassoonaspossibleafterbeingnotifiedabouttheirexposures.

HOT OFF THE PRESSES

RecommendationforRoutineMolecularTestingofPeopleIdentifiedasCloseContactstoCOVID‐19Cases

• Closecontacts,regardlessofsymptomsassociatedwithCOVID‐19,shouldbetestedassoonaspossibleaftertheyarenotifiedoftheirexposuretoCOVID‐19.

• TestingshouldbedonebyPCRorothermoleculartestfromanasopharyngeal,nasal,ororalswaborasputumsample.Serologic(antibody)testingisnotappropriateforthisuse.

• Thecontactisrequiredtoquarantineforthefull14days,evenfollowinganegativetestresult.

• Havealowthresholdforsymptoms(evenafterthenegativetest)andretestifsomeonestartstoshowillnessduringtherestofquarantine.

RecommendationforRoutineMolecularTestingofPeopleIdentifiedasCloseContactstoCOVID‐19CasesHowtoImplement:• NotifyaCONTACTabouttheirexposure.1. OutlinetheirQuarantinePeriod.2. RecommendtheygetaPCRTestASAP.(Testevenifno

symptoms)• IFthetestisPCRPOSITIVE:

• Theyarenowaconfirmedcase.SwitchtoIsolationbasedupontheirownsymptoms&testingdates.

• IfthetestisPCRNEGATIVE:• Complete14dayquarantine.(Negtestdoesn’tgetthemout)• Ifsymptomsstart,testagainimmediately.

• IfCONTACTdoesn’tgetPCRtest:• Stillmustcomplete14dayquarantine.

• NOTE:Essentialworkersthatareknowncontactsmaycontinuetoworkaslongastheyareasymptomaticanddonothaveapositivetest.

WhereCanPeopleGetTesting?• Correct link for MA COVID‐19 Testing:

https://www.mass.gov/info‐details/covid‐19‐testing

• Testing Sites: https://www.mass.gov/info‐details/covid‐19‐testing#testing‐sites

• These are not walk‐in sites. An appointment is necessary. View the current list:MA COVID‐19 Testing Sites (PDF) | (DOC).

SummaryofNewGuidance&Tools• Date: May 13, 2020 ‐ Testing of Persons with Suspect COVID‐19

• Updated Testing Guidance saying who should be tested.• Includes language stating we should test CONTACTS to COVID‐19 right away.• Discourages serology testing.

• BUT, if you ARE going to get serology testing, get a PCR at the same time.

• Date: May 11, 2020 ‐ Recommendation for Routine Molecular Testing of People Identified as Close Contacts to COVID‐19 Cases• Recommendation to Test Contacts identified through contact tracing – regardless of symptoms.

• They still need to isolate a full quarantine period, even if their test comes back negative early in quarantine.

• Date: May 8, 2020 ‐ COVID‐19 PCR and Antibody Testing Public Health Response Recommendations• Table describes different Public Health Actions based upon different testing results.

• Big take home: Encourage PCR testing to help alleviate unanswered questions. But in the absence of PCR testing information, we take a conservative approach and require serology positive individuals to isolate.

• Date: May 7, 2020 – Occupational Exposure & Return to Work Guidance• HCW & Non‐HCW discontinuation of Isolation Guidance.

• Describes strategies for ending isolation for cases.• Also outlines requirements for quarantine for contacts• (While there are two documents (HCW & non‐HCW), the key table on the front page is identical and tells key information)

SerologyTestingFAQs• Ifmycasehasapositiveserology,butalsohadapreviousnegativePCRtest,dotheyneedanewPCRtest?• A.Weareaskinglocalsandepistosomejudgmentbasedontheparticularscenario.Thetermintheguidanceis"recent"andthereisroomforjudgment.Twoweeksagowouldbetoolong.Acoupledaysagoismorereasonable,butcomparethatwithadditionalinformationtoinformyourjudgement.

YourQuestions:• Shouldwecountprobablecasesasapositivecaseforthetownreporting?

• ThecurrentDataDashboard(officialStateDailyReport)onlyreportsCONFIRMEDcases.

• https://www.mass.gov/info‐details/covid‐19‐response‐reporting• Townscanchosetoreportadditionaldatahoweveryouseefit.

YourQuestions:• Howmanydaysafteraclosecontacthasexposureisrecommendedfortestingaspartofthenewrecommendations?• A.Theguidancefortestingcontactsstatesthatcontactsshouldbetestedrightawayuponcontactnotification.Theyshouldthenremaininquarantinefortherestoftheir14dayquarantineperiod.Retestingisrecommendedonlyiftheydevelopany(evenmild)symptomsafterthat.

• Itisimportanttoconveytothecontactthatanegativetestatanypointduringquarantineisjustasnapshotofthatmomentanddoesnotmeantheycandiscontinuequarantineorthattheywon’tdevelopillnessatalaterpoint.Theymustcompletetheirfullquarantinebeforereturningtonormalactivities.

YourQuestions:• Ifapersontestedpositiveoutofstate,hascompletedtheirisolationperiodandreturnstoMA,dotheyneedtoquarantine?• A.Iftheycompletedtheirisolationperiodandarenolongersymptomatic,theywouldnotneedtoquarantine.Makesuretoconfirmtheirpreviousdiagnosis.

ContactTestingGuidelines:YourQuestions• ForEssentialWorkers:doesthetestingofcontactsguidanceapplytothemforgettingaPCRtestafterexposure?• A.Yes.Therecommendationisforanycontacts(regardlessoftheiressentialworkerstatus)toobtainPCRtesting.

• Remember:TheonlythingthatmakesessentialworkersdifferentisthattheymaycontinuetoworkduringtheirQuarantinePeriodfollowingexposure– Providedtheyarenotsymptomaticand/ordonottestpositiveforCOVID‐19.

• IfanEssentialWorkertestspositiveforCOVID‐19,theyarerequiredtoisolatepernormalIsolation&ReturntoworkGuidelines.

Beinganessentialworkermeansyoucanstillworkduringquarantine,butitDOESNOTmeanyoucan

stillworkifyoubecomeacaseyourself.

EssentialWorkers–WhoandWhattoDo?• Cangrocerystoreandconstructionworkersreallyworkduringquarantine?• A.TheGovernorsetswhoisconsideredan“essentialworker”duringCOVID‐19.

• https://www.mass.gov/info‐details/covid‐19‐essential‐services

• DPHGuidanceforall non‐healthcareworkers,updatedMay7: OccupationalExposure&ReturntoWorkGuidance

• AllowsEssentialWorkerstokeepworkingduringQuarantinePeriod(followingexposure)IFtheyremainasymptomaticanddonottestpositive/becomeacasethemselves.

YourQuestions:• AcasechosetoPCRRetestbeforethe10dayisolationperiodconcludedandresultsagain+.Whatisnowisolationperiod?• A.Thisdoesn’tnecessarilyextendtheirisolationperiod.Youcanstilluseasymptombasedstrategyandlooktowhentheirsymptomsresolveandtheymeetthatcriteria.

• CanProbableCasesinMAVEN(antibodypositive)besenttotheCTC?• A.Notatthistime.ProbablecasesarenotsentfromMAVENtoCTC.

• IFtheyobtainaPCRtestanditisPOSITIVE,theybecomeCONFIRMED,whichCANbesenttoCTC.IftheyobtainaPCRtestanditisNEGATIVE,theycanceaseisolationandyoudon’thavetoquarantinetheircontacts.

• Iftheconfirmedcaseisaparent,dowerecommendhavingthechildrentestedasclosecontacts,perthenewtestingguidance?• A.Yes.Theupdatedguidancetotestallcontactswouldalsopertaintochildren.Thereisnodistinctionbaseduponage.

SerologyTestingQuestions• HowcanwegetthewordoutthatprovidersshouldberequestingaPCRatthesametimeasaserology?• A.TheupdatedtestingguidanceforMAwasjustpublishedMay13,2020.Helpusbysharingwithyourproviders.

• https://www.mass.gov/doc/covid‐19‐testing‐guidance/download

YourQuestions–HCWsContinuingtoWork.• Whencanasymptomatichealthcareworkersbeatwork?Weareconfused.

• A.HCWs(andotheressentialworkers)areallowedtocontinueworkingafteranexposure– soduringanormal2weekquarantineperiodIFtheyareasymptomaticand/ordonotgetdiagnosed(testpositive)forCOVID‐19.

• HCWs(andotheressentialworkers)CANNOTworkiftheyareCOVID‐19positiveCASES,eveniftheyhavenosymptoms.OnceaHCWtestspositiveforCOVID‐19,theyareacase.Theymustisolateandcompletetheirisolationperiodlikeeveryoneelse.

YourQuestions‐ EndingIsolation• CanyouclarifywhensomeonecancomebacktoworkviatheSymptomBasedStrategy?

• A.IfusingaSymptomBasedStrategytodetermineendingisolation,theymustmeetALLofthefollowingcriteria:

Atleast3days(72hours)havepassedsincerecoverydefinedasresolutionoffeverwithouttheuseoffever‐reducingmedicationsand

Improvementinrespiratorysymptoms(e.g.,cough,shortnessofbreath);and, Atleast10dayshavepassedsincesymptomsfirstappeared.

• SoataMINIMUM,apatientwouldbeisolatedfor10daysfromtheirsymptomonsetdate.Butitcouldbemore.

WhereistheOfficialDiscontinuationofIsolationGuidance? Revised May 7, 2020

WhereistheOfficialDiscontinuationofIsolationGuidance?

YourQuestions?