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Follow‐upforPositiveCOVID‐19CasesandtheirCloseContacts
ToolsforLBOHs
HillaryJohnson,MHS,InfectiousDiseaseEpidemiologistScottTroppy,MPH,PMP,CIC,SurveillanceEpidemiologistBureauofInfectiousDiseaseandLaboratorySciences
MADepartmentofPublicHealth
June 26, 2020
TopicsToday• MAVENOverview• MAVENOnlineStatusMap– onetowntogo• SchoolImmunizationRequirementsfor2020‐2021
• ReminderaboutFlights– CallEpiProgramnotCDCQuarantineStationYourselves(wewilldoit)
• KeyConceptsWorthDiscussion• Serology(antibody)Testing• AntigenTesting• DefiningCloseContact
• YourQuestions2
ThisisOurLastFridayWebinar• IsolationofCasesandQuarantineofContactsisthegoaluntilthatstrategychanges/evolves.
• MAVENisthemainreportingsourceandwhereyoushoulddocumentyourwork.
• SendCasestoCTCforfollow‐upifnot:• Hospitalized,Deceased,orlinkedtoaClusterFacility
• FocusingonPriorityActivities
• ClustersinFacilitiesinyourcommunityneedyourhelp.
• CallEpiProgramtocreateclusterevents.
Tuesdays@11amwillcontinueinJuly
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
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Updatesfortoday,Tuesday,6/26• MAVEN Status Map – one town to go• Legionella and COVID co‐infection link• Reminder to review your COVID‐19 Immediate Notification Workflow – clear these events out on a daily basis
• Updated LBOH Final Review Workflow – we have removed COVID‐19 events
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ImmediateNotificationworkflow(COVID‐19Only)• UPDATE:We have updated the COVID‐19 Immediate Notification Workflow• This will allow proper notification of all new COVID‐19 events for your jurisdiction.
• Please review all events/cases in this workflow and complete your Step 1‐ LBOH Notification to “Yes” to clear out this workflow.
• If you are retaining ownership then complete Steps 2 (Investigation Started) & 3 (LBOH Investigator (name, lboh, phone number)
• When you are done then complete Steps 4 (CRF Complete) & 5(Final Review)
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LBOHFinalReviewWorkflow
• LBOH Final Review Workflow:We have updated the workflow to only show non‐COVID‐19 cases that are still pending. Please review this workflow and complete or close out any older events/cases.
• Once you complete Step 5 these non‐COVID cases will be removoed
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2020‐21SchoolImmunizationRequirements• Immunizationrequirementsmaintainedforupcomingschoolyear,whichincludethenewMenACWY vaccinerequirementforGrades7and11
• Rationale:• Schoolrequirementsareimportanttoolsformaintainingawell‐vaccinatedpopulation• Lowervaccinationratesincreasesusceptibilitytovaccine‐preventabledisease• WeneedtoreduceoverallburdenofdiseaseduringthisongoingCOVID‐19pandemic
• Compliancewithschoolrequirementsareenforcedatthelocallevel• Weencourageschoolstoworkwithfamiliesandhealthcareprovidersduringtheinitialmonthsoftheschoolyeartosatisfy therequirements for studentswhoare notcompliantonthefirstdayofschool
• Westronglyencourageevengreateremphasisonfluimmunizationthisfall• Flu‐visitsmaybeagoodtimetoadministercatch‐upvaccines 9
2020‐21SchoolImmunizationRequirements
• Schoolsurvey:• Childcare/Preschool,Kindergarten,andGrade7surveyswillbeconductedthisfallwithanextendeddeadline
• ThenewGrade11survey(assessingthenewMenACWY requirement)willbeimplementedinthe2021calendar year
• AssessmentUnitepidemiologistsareavailablebyemail([email protected])orphone(617‐983‐4330)toassistwithinterpretingcatch‐upvaccineschedules.
• Thankyouagainforeverythingyouaredoingtosupporttheseimportantpublichealthactivities!
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Flights&CruisesWhileInfectious
KeyDemographicDataNeeded:• CaseName• DateofBirth• Fulladdress• ClinicalInfo:
• SymptomOnsetDate&SpecificSymptoms
TravelInformation:• Airlineorcruisecompany,• Flightnumber,• Seatorcabinnumber,• Departureandarrivallocationsandtimes,
• Reasonfortravelandiftheytraveledaloneorwithothers.
Ifyourconfirmedorprobablecasetraveledwhileinfectiousandmayhaveexposedothersviaairplaneormaritimevessel(cruiseorcargo):
1.UpdateMAVENnotes2. CallEpiprogramsoMDPHcannotifytheQuarantineStation.3. LBOH– pleasedonotcalltheQuarantineStationYourself.
Do the best you can. Travel dates & flight numbers are key even if you don’t have seat
number.
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ThreeKeyConceptsWorthReview:
• SerologyTesting– Whatisourfollow‐upforpositiveserologiesandwhatisourmessagingaroundserologytesting?
• AntigenTesting– Whatistheappropriatefollow‐upforantigenpositivepatients?
• CloseContact– WhatisconsideredclosecontactandhowdoMasksinfluencethissituation?
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UseJune1ResultsInterpretationGuidance
• Describeswhattestresultslikelymean,(combinationsofPCRandantibodytesting),andthecorrespondingpublichealthresponse.
• BigJuneUpdate:Remember,nowwetriageserologyresultsbaseduponiftheyhaverecentsymptomsornot.
• AdditionalNote:AntigenTestsareonthischartand,whilestillasmall%oftestingconducted,worthnotingfortheirspecificfollow‐up. 13
KeyConcept:Serology(AntibodyTests)• SerologyTesting–Whatisourfollow‐upforpositiveserologiesandwhatisourmessagingaroundserologytesting?
• WestartedoutrequiringisolationforallserologypositiveindividualswithoutaconcurrentPCRtestoutofanabundanceofcaution.
• Serologytestsmeasureantibodies,butthoseantibodiesCANshowupfairlyquicklyafterinfection,soitisn’talwaysaguaranteethatapatientwasinfectedLONGAGO.
• Serologytestsdonotyettellusifapatientisimmune.• Wedon’tyetknowhowlongimmunitylasts,orwhatwouldbeagoodmeasurementofantibodiessowecoulddefinitivelysay,yes,thispersonisimmune.
• MDPHrecommendationstillstandstonotuseserologytestingforacutediagnosis,andtoobtainaPCRtestatthesametimeifyoudogetaserologytest.
• June1,MDPHupdatedourfollow‐upandserologyinterpretationtabletobegintofocusfollow‐uponlyonthoseserologypositivepeoplewhosaytheyhavehadrecentsymptomsinthelast14days.
• (Ifnosymptomsreported=thennoisolation&quarantine)14
PositiveSerology(withnocurrentPCRresult)Follow‐upprotocol:• Obtainsymptominformationandhospitalizationstatus
• IfneversymptomaticORasymptomaticforthelast14days:• noadditionaltestingorfollow‐upneeded
• Ifrecently(within14days)appropriately*symptomatic:• initiateisolationperiodbasedonsymptomonset(10dayswithatleast3daysfeverfreeandimprovementinrespiratorysymptoms)
o canconsiderpursuingPCRtesting,ifnegativecandiscontinueisolation
• Identifycontactswithexposuretocasethroughendofisolationperiodandinstitute14‐dayquarantineasappropriate
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PositiveSerology(withnocurrentPCRresult)
• Howisthisfollow‐upguidance(June)differentthaninitialfollow‐upguidance?• A.Initially,allpositiveserologybydefaultrequiredisolationofcasesandquarantineofcontacts(onlyaPCRresultcouldchangethat).Updatedguidancenowsaysifyouhaverecentsymptoms,youshouldisolateandcontactsquarantine,butifyoudonothaverecentsymptoms,LBOHcaninterviewcaseandbedone.
• PCRsstilltrumpserologytesting.ApositivePCRmeansaconfirmedcase.AnegativePCRmeansnotcurrentlyinfectiousandnoisolationneeded(butstillProbablebaseduponpositiveserology).
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YourQuestions:Serology(AntibodyTest)
• Q.Pleaseclarifyonceagainapositiveserologywithnosymptoms,pastsymptomsmonthsago,&noPCR.Dotheyhavetoisolate?• A.No.
• Thiswouldbeaprobablecasethatyouwouldcalltointerview(becauseyouhaveapositiveserologylab).
• Askthemiftheyhavehadsymptomsinthelast14days.• IfNO,thenyoucompletetheinterview.NoIsolation.NoContactTracing.(Oneanddone!)• IfYES,thenyoudetermineaninfectiousperiod&isolationbaseduponrecentsymptomonsetdate.
• Symptomsinlast14days=Yesisolation&YesContactNotification(baseduponsymptomonsets)
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TableReview• Ifyouhaveanewpositiveserology
(Andthecasehadaprevious+PCRtestawhileago)• Thiswasaconfirmedcasebefore.• Newpositiveresultsshouldjustattachtothepreviousevent.• Nonewisolationofcaseorquarantineofcontactsrequired.• NoNewAction.
Just a reminder that new serologies after a previous positive PCR (case was
followed up long ago) are potentially expected and require no action
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KeyConcepts:AntigenTesting• AntigenTesting– Whatistheappropriatefollow‐upforantigenpositivepatients?• A.Thefollow‐upissimilartoapositivePCR.
• Considerthisalikelynewcase.Interviewandfollow‐upaccordingtosymptomonsetdate.• Ifnosymptoms,usedateoftesttodetermineisolationperiodandcontactexposureforclosecontacts.
• Despiteconsideringthisalikelynewcase,thistypeoflabtestwillstillbeclassifiedasa“probable”forsurveillance.
• Antigentestingisstillrarer,butweanticipatemoretocomeintermsofbothguidanceanduse.
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Molecular(PCR)andAntigenTestingAntigenTest‐ Newer(stillrare)• Detectscertainproteinsthatarepartofthevirus.
• NasalorThroatswabtogetafluidsample
• RapidTest‐ resultsinminutesonsite.
• MaybeaccompaniedbyadditionalPCRTest
• Onlyseeingthemwithtwoproviderscurrently:• Carewell &SouthCoast
MolecularTest(PCR)• Detectsgeneticmaterialofthevirususingalabtechniquecalledpolymerasechainreaction(PCR).
• Nasal,Throat,orNasopharyngealSwaborfromsaliva
• TestcanbeaRapidTest(resultsinminutesonsite)
• Oronetotwodaysifsenttoanoutsidelab.
• SomehometestkitshavealsobeenFDAapproved.
https://www.mayoclinic.org/diseases‐conditions/coronavirus/expert‐answers/covid‐antibody‐tests/faq‐20484429
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Molecular(PCR)andAntigenTestingAntigenTest‐ Newer(stillrare)• ListedinLabTabasfollows:
• SARS‐CoV‐2Ag(AntigenTest)
MolecularTest(PCR)• ListedinLabTabasfollows:
• 2019‐nCoVReal‐timeRT‐PCR(PCR)
• SARScoronavirus2RdRp gene(PCRRAPID)
Case Classification Manual: http://www.maventrainingsite.com/maven‐help/pdf/case‐classification‐manual/COVID19__05282020_final.pdf
Positive Molecular Test: Case Classification = CONFIRMED
Positive Antigen Test: Case Classification = PROBABLE
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CaseClassificationManual
• Pages3&4• TableondifferentLabReports
• TestType• SpecimenSource• Resultpossibilities• Whatinformaticstermstouseforeachlab(whatyouseeintheLabTab&whatthetechnicalITjargonmeans)
Case Classification Manual: http://www.maventrainingsite.com/maven‐help/pdf/case‐classification‐manual/COVID19__05282020_final.pdf
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WhatisthePublicHealthFollow‐up?• PCR,Antigen,&SerologyNEGATIVE:(usuallyunclassifiedeventsinMAVEN).Nofollow‐upneeded.Butiftheywereacontacttheyshouldcompletetheirquarantine.
• NegativePCRorAntigendoesn’tendquarantineearly.
Testing Interpretation Guidance Document: http://www.maventrainingsite.com/maven‐help/pdf/Serology%20Interpretation%20for%20LBOH_ver3.0_June1.pdf
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InterpretingAntigenTesting• Thistablejustdescribeslikely“interpretation”andisnotofficialcaseclassification.
• PERCDC&CSTECasedefinition,AntigentestsarestillclassifiedasPROBABLE
• Antigentestingwasmostlikelypursuedforacutediagnosis,sowefollow‐uplikewewouldforPCRtestresults.
• PCRorAntigen POSITIVE(serologydoesn’tmatter):Treatlikeanewcase.Follow‐upAccordingly.
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YourQuestions:• Q.Ihaveheardbothantigentestingandantibodytestingreferredtoonourcalls.Arebothbeingdone?Dowerespondthesame?• A.Yes,botharebeingdone,butlikelyfordifferentreasons.Ourresponseisdifferent.
• Intheory,antigentestingisbeingusedforacutediagnosis.• Antibody(serology)testingislikelybeingdonefordeterminingpreviousillnessandimmunitystatus.• (ThisiswhatweWANTantibodytestingtotellus,butthedataisnotyettheretogiveusthisanswer.)
• Ifyougetanantigentest,treatitlikeanewcaseandproceedwithnormalinterview,isolation,andcontacttracing(usingsymptomonsetordateoftestifnosymptoms).
• Ifyougetanantibodytest,interviewthepatientanddetermineiftheyhadsymptomsinthelast14daysornot.
• Ifyestorecentsymptoms,treatlikeacase(isolatecase,quarantinecontacts,etc.)• Ifno,completeinterviewandyouarealldone(updatenotes,butnoisolationorcontacttracing). 25
YourQuestion:NewLabsforOldContacts• Q.Howdowedocumentcontactswhocompletequarantinethen2monthslaterhavepositivetestsandbecomeaprobableorconfirmedcase?
• A.GreatQuestion!Thisishappeningmoreandmore.TheanswermayevolveifwefigureoutadifferentstrategywithinMAVEN,butcurrentlytheprocessisasfollows:
• NewLabswillappendtoanoldmatchingpersonevent.• SoanewPCRwouldmergeontoanoldContactEvent(evenifyoualreadydidsteps1‐5longago).• MDPHisupdatingtheCaseClassificationStatusto“Confirmed”or“Probable”fromContact.• YourLBOHwillreceiveaMAVENTaskAssignment.
• Youshouldclearout/updateAdminQuestionPackageSteps1‐5accordinglyfornewfollow‐upandtracking.ThisincludesyourCTCassistancerequestedvariabletomakesureitaccuratelyreflectsthecurrentpreference.• AlsoupdateContactMonitoringStatus=InProgress(becauseyouwillwanttoupdatetoCOMPLETEwhenthecasenowexitsisolation).
• ClinicalInformationfromyourinterviewwillgointotheClinicalQuestionPackage#3.
• Ifyouhavequestions,giveMDPHacalloremailandwewilldoourbesttohelpyou. 26
KeyConcept:CloseContact&Risk• Q.Canyougooverclosecontact‐ isitclosecontactifyouarewearingamaskandmorethan15minutesand closerthan6ft,etc.?
• A.Wegiveaclearcutoffof>10‐15consecutiveminuteswithin6feetofaninfectiousindividualtogiveusastartingpointtoworkwith.
• Clothmasksareariskreductiontool.Theydonotcompletelypreventexposure.• Ifacaseandcontactworeclothmaskstogether,youwouldstillconsiderthecontactexposedandneedtoquarantine– buthopefullytheyhavereducedtheirchancesofdevelopingillnessbywearingthosemasks.
• Timingislinear.• Themoretimeyouspendwithacase,thegreateryourriskforexposureandinfection.Thepersonwhositsnexttoacasefor4hoursisatagreaterriskofinfectionthanthepersonwhosatnexttothecasefor20minutes,butwewouldconsiderthembothclosecontactsthatneedtoquarantine.
• Spaceislinearaswell.• Thepersonwhositsrightnexttoacaseisatgreaterriskthanthepersonwhosits6ftaway,andthatpersonisatgreaterriskofexposurethanthepersonwhois8feetaway.
Remember, all these elements are “and” components of risk reduction not “or.” Nothing replaces anything else. They all help, and together help more in reducing risk.
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KeyConcept:CloseContact&Risk• TherewillbescenariosthatdonotmeetthedefinitionofCloseContactperourcutoff,butthatdoesnotmeanthecontactwasn’texposed.Weneedacutoff,andweneedguidancetohelppeoplereducerisk,whichiswhywesay6feet.(Datasupportsusingthismetric.)• Otherthingsthataffectrisk:
• Enclosedvs.Openspaces.• Activitiesthatexpeldroplets(singing,exercising,playinganinstrument,yelling,etc.)
• Wefocusourfollow‐upeffortson“closecontacts”becausetheyareatthegreatestrisk.
• Peoplecanreducetheirriskbypracticingriskminimizingbehaviors,butwewouldstillconsiderthemexposed.• Ex:Ahairdresserandclientaremaskedandgloved,butthehairdresserthentestspositive.
• Theclientwasstillexposedandshouldquarantine(buthopefullyhasreducedtheirriskofdevelopingillnessbywearingmasksandotherthings)
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YourQuestions:Antigen&AntibodytestsQ.Ifanantibody/antigentestcomesbackpositiveareyousayingthatwehavetotreatitasacurrentprobablecaseandadviseisolationandcontactclosecontactstoquarantine?
• A.BothanantibodytestoranantigentestaretechnicallyPROBABLEfortheirsurveillancecasedefinition,buttheyarenotequalintheirfollow‐up.
• YouwouldtreattheantigentestlikeaPCRtest:theassumptionisanewcaseand(iftheyareasymptomatic,yougobydateoftestforisolationandfollow‐up).Theymaysaytheyhadsymptomsbefore,butwehavetogowiththeironlypositivetest,whichiscurrent.
• Theantibodytestiswhathasbeenupdatedintermsofourfollow‐up.Youwouldinterviewthemtodetermineiftheyhadsymptomsinthelast14daysandifnot,thereisnoneedforisolationandquarantineandtheirfollow‐upiscomplete.IftheyDIDhaverecentsymptoms,youwouldrespondbasedupondateofsymptoms.
• Consultthisdocumenthere,andnotethattheypositivePCRandantigentestsaregroupedtogether.Theserologyantibodytestsaregroupeddifferently.
http://www.maventrainingsite.com/maven‐help/pdf/Serology%20Interpretation%20for%20LBOH_ver3.0_June1.pdf29
YourQuestions:• Q.Istheirguidanceonwhocanorcannotdocontracttracinginasurge?
• A.ContactTracingisstillacorepublichealthfunction.Partnershipsareoftenrequiredtomakethathappen.
• StudentsinPublicHealthfromMASchoolsofPublicHealth• GovernmentdesignatedorganizationlikePIHandtheCTC• VNAsandregionalhealthgroups.
• Thequestionarises– dobusinessesandschoolsalsoparticipate?• Theylikelyhavearole.Butmoreonthistocome.
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