follow up for positive covid 19 cases and their close contacts · topics today • maven overview...

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:  isishelp@state.ma.usMDPH 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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MAVENStatusMapasof6/26/2020

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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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MAVEN Help

Section

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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(immassessmentunit@MassMail.State.MA.US)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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