Follow up for Positive COVID 19 Cases and their Close Contacts 6... · 957 events in this workflow...

Follow‐upforPositiveCOVID‐19CasesandtheirCloseContacts

ToolsforLBOHs

HillaryJohnson,MHS,InfectiousDiseaseEpidemiologistBureauofInfectiousDiseaseandLaboratorySciences

MADepartmentofPublicHealth

October 6, 2020

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TopicsToday• MAVENStatusMap• KeyDocuments• LastWeek’sRecap

• QuickFridayOfficeHoursSummary• UpdatedLanguageonHowSARS‐ CoV2isspread.

• BestPracticesforK‐12caseinvestigations.• Resources&guidancedocuments• DefiningCloseContact• UpdatedDESEGuidancefromtheSummer• WorkingwithschoolsandLBOHs• SchoolNurseGuidance

• WorkingwithLBOHs• MaintainingConfidentiality

• TrackinginMAVEN• TemplateLetters

• YourQuestions

COVID‐19 Test Results FAQs: postpone until next week. 2

TuesdayWebinarsforCOVID‐19CaseInvestigationandFollow‐up

• DiscussingNewGuidelines,MAVENUpdates,ChangesinProtocols,NewTools,CaseInvestigationFAQs,Follow‐upProcedures.

Tuesdays@11am

MAVENHelphasGuidanceDocumentsandPreviousWebinars:

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

MDPH Epi Program: 617‐983‐6800MDPH MAVEN Help Desk: [email protected] ISIS Help Desk: 617‐983‐6801MDPH ISIS Fax: 617‐983‐6813MDPH Food Protection Program: 617‐983‐6712

CTC Help Desk: 857‐305‐2828 Email: [email protected]

CTC Supervisor Contact ListHigher Ed Contact List

*

NEW!MAVENOfficeHoursDPHStaffFridays11:00‐12:00

• OpenQ&A.Notaformalpresentation.• Sendusyourquestionsoraskuslive.• Norequirementtoattend.Popin,popout.• You’llneedtoregisterviaScott’semail.

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MAVENUpdates

ScottTroppy,MPH,PMP,CIC,SurveillanceEpidemiologistBureauofInfectiousDiseaseandLaboratorySciences

MADepartmentofPublicHealth

As of 10/6/2020

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Updatesfortoday,Tuesday,10/6MAVEN Status Map – three towns offlinePlympton, New Ashford and WarwickLBOH Immediate Workflow – COVID‐19 event only –please check your workflow and clear out the workflowMAVEN Help Section – check for the DPH Office Hours Recording

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ImmediateNotificationworkflow(COVID‐19Only)UPDATE: COVID‐19 Immediate Notification Workflow ‐957 events in this workflow today This will allow proper notification of all new COVID‐19 events for your jurisdiction. (Confirmed and Probable Cases) 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)6

Additionalvariablesforlabinformation• Created four new fields in Clinical QKPG #3 for EPI/IMM model. These are not editable by users, MAEDSS‐12737

1. Specimen Date of First Positive Test Result2. Test of First Positive Test Result3. Ordering Facility of First Positive Test Result

4. Lab Facility of First Positive Test Result

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SummaryofKeyGuidance&Tools• 9/2/2020UpdatedCOVID‐19CaseClassificationManual

• Serologypositivelabsarenowclassifiedas“suspect”cases.• http://www.maventrainingsite.com/maven‐help/pdf/case‐classification‐manual/COVID19__09022020_FINAL.pdf

• Date:8/22/2020:‐ COVID‐19PCRandAntibodyTestingPublicHealthResponseRecommendations• TabledescribesdifferentPublicHealthActionsbasedupondifferenttestingresults.

• Bigtakehome:PCR&Antigenpositivepatientsshouldbetreatedlikecases.• Serology+casesnolongerrequirepublichealthfollow‐up.• http://www.maventrainingsite.com/maven‐help/pdf/COVID‐

19%20PCR%20and%20Antibody%20Testing%20Public%20Health%20Response%20Recommendations%20for%20LBOH%20Ver4.0_Aug22.pdf

• Date8/10/2020:Follow‐upforPositiveAntigenTestResults• http://www.maventrainingsite.com/maven‐help/pdf/Antigen%20Results%20Follow‐up%20Guidance_ver1.0_August_10.pdf.

• Date:8/9/2020:UpdatedIsolation&QuarantineGuidelinesDocuments• http://www.maventrainingsite.com/maven‐help/pdf/COVID19‐Isolation‐information‐and‐guidance_ver2.0_August9.pdf• http://www.maventrainingsite.com/maven‐help/pdf/COVID‐19‐Quarantine‐information‐and‐guidance_ver2.0_August9.pdf• Translations Pending

• Date:8/7/2020:UpdatedMATestingGuidance• https://www.mass.gov/doc/covid‐19‐testing‐guidance/download• UpdatesaystogetaPCRwithANYAntigentest• Alsosaysnoneedtotestagainin90daysafterinitialdiagnosis.

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SummaryofKeyGuidance&Tools• Date:7/24/2020‐ Gov.BakerissuedCOVID‐19OrderNo.45 whichissuesamandatory14dayquarantineperiodfortravelerstoMA(includingMAresidentswhotraveledoutsideofMAandarereturning).• Iftravelers(includingreturningMAresidents)don’tfitintooneofthe3ExemptionCategories,mustquarantine.• Thereisaformtofilloutonline.https://www.mass.gov/forms/massachusetts‐travel‐form• AnegativePCRtestwithin72hoursoftravelcanexcuseyoufromquarantine.• https://www.mass.gov/guidance/guidance‐for‐travelers‐arriving‐in‐the‐commonwealth‐of‐massachusetts• UpdatedFAQs:https://www.mass.gov/info‐details/covid‐19‐travel‐order#potential‐other‐traveler‐scenarios‐

• Date:Aug16,2020– UpdatedCDCGuidanceonDurationofIsolation&PrecautionsforAdultswithCOVID‐19• 10DayIsolationPeriodnowhasmoredatasupportingit.• IgnoremostadditionalPCRtestsupto3monthsafterinitialillnessonset.• Noneedtoquarantineupto3monthsafterinitialillnessonset.• https://www.cdc.gov/coronavirus/2019‐ncov/hcp/duration‐isolation.html

• Date:May7,2020– OccupationalExposure&ReturntoWorkGuidance• https://www.mass.gov/doc/healthcare‐personnel‐occupational‐exposure‐return‐to‐work‐guidance/download• https://www.mass.gov/doc/non‐healthcare‐workers‐occupational‐exposure‐return‐to‐work‐guidance/download

A bit outdated after the new CDC

guidance.

We do not yet have an updated State Doc reflecting this. But you should use this CDC updated guidance

for follow‐up.

More Updated FAQs. Check them out!

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Updates– Aquickrecapfor10/6.• 9/29– lastweekwediscussedthefollowing:

• Isolation&Quarantine• Revieweddifferentstrategiesforendingisolation(Symptombased,timebased,andTestBased(notrecommended))

• PracticedcalculatingInfectiousPeriod• PracticedcalculatingQuarantinePeriod

• JurisdictionsReview• MAVENSkills– Share,Task,Call

• DaycaresReview• AllcontactsneedContactEvents• ClusterEventsshouldbecreatedonlyifexposureoccurredinchildcarefacility

Checkoutlastweek’sPresentationonIsolation&Quarantine,Jurisdictions,andDaycaresinMAVEN

Help

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FridayOfficeHours:QuestionsonVaccinationClinics

• https://www.mass.gov/doc/important‐resources‐for‐fall‐vaccination‐clinics/download

• Lotsofquestionsareaddressedinthisdocumentandthelinkedresources

• ProperPPE• Setup,etc.• SeveralLinkstoCDCBestPractices

Alsoavailablehere:• OntheAdvisoriesandAlertspage:https://www.mass.gov/lists/massachusetts‐department‐of‐public‐health‐immunization‐division‐advisories‐and‐alerts (scrolldowntobottom)

• OntheVaxAdminandClinicalGuidance:https://www.mass.gov/service‐details/vaccine‐administration‐and‐clinical‐guidance (linkontherighthandside)

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FridayOfficeHours:QuestionsonHigherEdModelsandContactsWorkingonHigherEdAssociatedCases:Thereis

• TrythislistofhigheredcontactsintheMAVENhelpfolderforHigherEd HigherEdModelChoicesSpreadsheet

• Universityhealthservicesisanotherplacetostartifyouneedassistancewithaninvestigationandthedesignatedcontact(spreadsheetabove)isnottherightperson.AsktospeakwiththeirpointpersonforCOVID– liketheclinicaldirectorornursemanager.

• Howwouldyouhaveinvestigatedacollegemumpscase,orsomethingsimilar?Healthservicesmaybetheplacetostart.

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

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Isolation&Quarantine– AReview

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Isolation vs.QuarantineISOLATION

• Forsymptomatic people.• ForConfirmedCOVID‐19Cases.• Preventspeoplefrominfectingothers

• LASTSUNTILTHEPERSONISNOLONGERCONTAGIOUS

• UseCDCDiscontinuationofIsolationGuidance

QUARANTINE• Forasymptomatic peoplewhohavehadanexposure(i.e.travelersfromhighriskareas,closecontactsofconfirmedcases,etc.)

• Preventspeoplefrominfectingothersintheeventtheydevelopsymptoms

• LASTSFOR14DAYSFROMLASTEXPOSURE.(Ifyoudon’tdevelopillness,youarethenreleased.)

CASES CONTACTS

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DiscontinuationofIsolationGuidance

Atleast24hourshavepassed sincerecovery definedas

resolutionoffeverwithouttheuseoffever‐reducingmedications,and

improvementinothersymptoms(e.g.,cough,shortnessofbreath);

and Atleast10dayshavepassed sincesymptomsfirstappeared.

resolutionoffeverwithouttheuseoffever‐reducingmedications,and improvementinothersymptoms(e.g.,cough,shortnessofbreath);

and NegativePCRresultsfromatleast2specimenscollected>24hoursapart

Symptom‐BasedStrategy Test‐BasedStrategy

IfPatientEverHad Symptoms:

OR

Symptoms need to have

resolved before starting testingUse Symptom

Onset Date = Day 0

Not Recommended for most scenarios

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DiscontinuationofIsolationGuidance

Atleast10dayshavepassedsincethedateoftheirfirstpositiveCOVID‐19diagnostictest.

Assumesnosymptomseverdeveloped.

NegativePCRresultsfromatleast2specimenscollected>24hoursapart

Assumesnosymptomseverdeveloped.

Time‐BasedStrategy Test‐BasedStrategy

IfPatientNEVERHad Symptoms:

Use Test Collection Date = Day 0

OR

Not Recommended for most scenarios

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Some definitions

Incubation period

The time interval from exposure to an infectious agent to the onset of symptoms of an

infectious disease.

Infectious period

The time interval during which a host (individual or patient) is capable of directly or indirectly

transmitting pathogens to another susceptible person.

Inoculum size

For all infections, there is a certain quantity of the infectious

agent that is likely to cause infection, for some infectious agents it is a small quantity for others it takes more on average.

3‐7 days on average, but could be as long as 14 days. This is why

quarantine is 14 days long.

Two days before symptom onset through 10 days after, with the day of symptom onset as day 0.

The inoculum size for COVID‐19 is currently unknown.

COVID‐19

ALL DISEA

SES

Isolation&Quarantine

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DeterminingInfectiousPeriod– forCase• Notes:

• SymptomOnsetDate=DayZero (fordeterminingwhenCasecanexitIsolation)

• Usefulldays,nottimesofday.• Ifacasehadamorningmeeting,thendevelopedasorethroatthatnight,considerthatDayZeroandpeopleinthatmorningmeetingexposed.

• Example,aconfirmedcasedevelopedacoughintheeveningonThursday,April2.

• SymptomOnsetDate=Thursday,April2.• (Donotworryabouttimeofday.Thisfulldayistheonset.)

• InfectiousPeriodStartdate=Tuesday,March31.• Wewouldbelookingforanyclosecontacts/exposuresfromTuesdayMarch31st on.

• InfectiousPeriodEnddate=whencaseisnolongerinfectious(usuallywhentheyaredischargedfromisolation)• Returntonormalactivities=Day11• ForContactTracing:Youcanlikelyjustgotowhentheyenteredisolation(nomorecontactwithothers).

Sun Mon Tues Wed Thurs Fri Sat

Mar 29 Mar 30 Mar 31 Apr 1 Apr 2 Apr 3 Apr 4

‐ DAY 2 ‐ DAY 1 DAY 0 DAY 1 DAY 2

Apr 5 Apr 6 Apr 7 Apr 8 Apr 9 Apr 10 Apr 11

DAY 3 DAY 4 DAY 5 DAY 6 Day 7 Day 8 Day 9


Day 10 Day 11

Symptom Onset

Infectious Period Start

Entered Isolation

(No More Exposures)

Last Infectious

Day

Return to Normal Activities

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DeterminingQuarantinePeriod–forContact

• Youmustidentifyanexposuredatetodetermineaquarantineperiod.• ExposureDate=DayZero.• QuarantinePeriodisDay1throughtheendofDay14,returningtoactivitiesonDay15.• Example:

• ExposedonMarch29th.(DAY0)• QuarantinePeriod(Day1‐ Day14):March30– April12.• QuarantineisOver(Day15):April13th.

• Notes:• Haveacalendarhandy.Countthedaysoutloud.• Usefulldays,nottimesofday.• ContactwillalreadybeinQuarantinePeriodwhenyoucontactthem.Makesuretheystartquarantineimmediately.



DAY 0 DAY 1 DAY 2 DAY 3 DAY 4 DAY 5 DAY 6




DAY 14 DAY 15

Exposure

Quarantine Starts

Last Day Quarantine

Remember, quarantine periods are determined by when the contact was exposed, not by the symptom

onset of the case.

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DeterminingQuarantinePeriod–forHouseholdContact

• FordeterminingANYquarantineperiod,youmustdeterminethecontact’slastexposuretotheinfectiousperson.ThatisDayZero.• ForHouseholdMemberswhocannotcompletelyseparate,(children,spouse,roommates,etc.),theyare“inquarantine”whilecontinuouslyexposedtothecase.

• However,theirFINAL14DayCountdownofQuarantinedoesnotbeginuntiltheyarenolongerbeingcontinuouslyexposed.

• Inotherwords,theirfinal14dayQuarantinebeginsaftertheirLAST/Finalexposuretosomeoneinfectious.• IftheCONTACTcannotseparatefromtheCASE,thentheCasemuststopbeinginfectious(bereleasedfromisolation).Thatwilldeterminethecontact’sfinalexposuredate.

• Indexcase’slastdayinIsolation(Day10)=Day0(FinalExposure)forcountingoutthequarantine.


Mar 15 Mar 16 Mar 17 Mar 18 Mar 19 Mar 20 Mar 21

infectious infectious Symptom onset

Day 1 Day 2

Mar 22 Mar 23 Mar 24 Mar 25 Mar 26 Mar 27 Mar 28

Day 3 Day 4 Day 5 Day 6 Day 7 Day 8 Day 9


DAY 10

Day 0

DAY 1 DAY 2 DAY 3 DAY 4 DAY 5 DAY 6




DAY 14 DAY 15

Isolation of Case

If Contact cannot separate from case, Contact should also be quarantining at this time.

Final 14 Day Quarantine of Contact

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ScientificBrief:SARS‐CoV‐2andPotentialAirborneTransmissionLinksofinterest– TwoupdatedCDCPages:• https://www.cdc.gov/coronavirus/2019‐ncov/more/scientific‐brief‐sars‐cov‐2.html

• https://www.cdc.gov/coronavirus/2019‐ncov/prevent‐getting‐sick/how‐covid‐spreads.html

• PageswereupdatedonCDC’swebsite10/5.

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ScientificBrief:SARS‐CoV‐2andPotentialAirborneTransmissionKeyTakeaways:

• Availabledataindicatethatitismuchmorecommon forthevirusthatcausesCOVID‐19tospreadthroughclosecontactwithapersonwhohasCOVID‐19thanthroughairbornetransmission.

• Why?Ifairbornetransmissionwasthemostcommonmodeoftransmission,wewouldhaveobservedahigherattackrateandhigherpercentageofpriorinfectionfromserosurveys.

• Circumstancesunderwhichairbornetransmission ofSARS‐CoV‐2appearstohaveoccurredinclude:• Enclosedspaceswithinwhichaninfectiouspersoneitherexposedsusceptiblepeopleatthesametimeortowhichsusceptiblepeoplewereexposedshortlyaftertheinfectiouspersonhadleftthespace.

• Prolongedexposuretorespiratoryparticles,oftengeneratedwithexpiratoryexertion(e.g.,shouting,singing,exercising)thatincreasedtheconcentrationofsuspendedrespiratorydropletsintheairspace.

• Inadequateventilationorairhandling thatallowedabuild‐upofsuspendedsmallrespiratorydropletsandparticles.

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ScientificBrief:SARS‐CoV‐2andPotentialAirborneTransmissionKeyTakeaways:

• Thesetransmissioneventsappearuncommonandhavetypicallyinvolvedthepresenceofaninfectiouspersonproducingrespiratorydropletsforanextendedtime(>30minutestomultiplehours)inanenclosedspace.Enoughviruswaspresentinthespacetocauseinfectionsinpeoplewhoweremorethan6feetawayorwhopassedthroughthatspacesoonaftertheinfectiouspersonhadleft.

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ScientificBrief:SARS‐CoV‐2andPotentialAirborneTransmission

KeyTakeaways:

• Whatyoucandotoprotectyourself?• Socialdistancing,useofmasksinthecommunity,handhygiene,surfacecleaninganddisinfection, ventilation and avoidanceofcrowdedindoorspaces areespeciallyrelevantforenclosedspaces.Atthistime,thereisnoindicationofageneralcommunityneedtousespecialengineeringcontrols,likethoseputinplacetoprotectagainstmeaslesinahealthcaresetting.

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BestPracticesforK‐12Schools

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GuidanceshouldbefoundthroughDESE(DepartmentofElementaryandSecondaryEducation)• DESE:ProtocolsforRespondingtoCOVID‐19Scenarios• DESE:COVID‐19InformationandResources• DESE:FrequentlyAskedQuestion• DESE:ReturningtoSchoolSafely,Together• DESE:COVID‐19Guidance/OntheDesktopMessages

Otherresources?• CDC:SchoolsandChildCarePrograms• CDC:ToolkitforK‐12Schools• AdditionalInformationforSchoolHealthOffices• Parents/[email protected]

ResourcesforElementaryandSecondarySchools

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CloseContactDefinitionClosecontactisdefinedas:a) Beinglessthan6feetfromaconfirmedorclinicallydiagnosedCOVID‐19case

foratleast15minutes,whilethecasewassymptomaticorwithinthe2daysbeforesymptomonset.Closecontactcanoccuranywhere.Examplesincludecaringfor,livingwith,visiting,orsharingahealthcarewaitingareaorroomwithaconfirmedorclinicallydiagnosedCOVID‐19case.

OR

b) HavingdirectcontactwithinfectioussecretionsofaconfirmedorclinicallydiagnosedCOVID‐19case(e.g.,beingcoughedon)whilenotwearingrecommendedpersonalprotectiveequipmentorPPE(e.g.,gown,gloves,facemask,eyeprotection). 28

CloseContact&Risk• TherewillbescenariosthatdonotmeetthedefinitionofCloseContactperourcutoff,butthatdoesnotmeanthecontactwasn’texposed.Weneedacutoff,andweneedguidancetohelppeoplereducerisk,whichiswhywesay6feet.• Otherthingsthataffectrisk:

• Enclosedvs.Openspaces.• Activitiesthatexpeldroplets(singing,exercising,playinganinstrument,yelling,etc.)

• Wefocusourfollow‐upeffortson“closecontacts”becausetheyareatthegreatestrisk.

• Peoplecanreducetheirriskbypracticingriskminimizingbehaviors,butwewouldstillconsiderthemexposed.

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IdentifyingCloseContactsinSchoolSettings• Whenlookingatschoolsettingssuchastheclassroom,aschoolnurseshouldconsultwiththeteacher(andpossiblytheindexcase)toidentifyhowwellsocialdistancingandassignedseatingwasmaintained,howeverifstudentsandstaffarefollowingthoseprecautions,thisgeneralguidanceapplies:• Wewouldconsiderstudentsandstaffspending>15minutescumulativeoverthecourseoftheschooldaywithinlessthan6ftasclosecontacts.

• Atthistime,wewouldnotconsiderstudentsatdesksspacedexactly6feetorgreaterapartasclosecontacts.

• Whilemasksareconsideredanimportantriskreductiontool,theydonoteliminateexposureforthoseseatedlessthan6ftapart.

• Schoolbusenvironmentsarelessthanoptimalduetotheenclosedspace. Wewouldconsiderstudentsseatedlessthan6ftapartasclosecontactsiftheircumulativeexposurefortheday> 15minutes. (Sothiscouldbecumulativeacrossamorningandafternoonride.) 30

IdentifyingCloseContactsinSchoolSettings

• Q.Whatarespecificproceduresforidentifyingclosecontactsatschool‐ isit4surroundingdeskevenifare6feetapartor2deskoneitherside,etc.?

• A.Theschoolshouldidentifythestudent’sorstaffmember’spossible“closecontacts”basedontheassignedseatingchartsandproximityrelatedtoclassactivities.Closecontactswillbedefinedasonlythosewhohavebeenwithin6feetofdistanceoftheindividualforatleastfifteenminutes,whilethepersonwasinfectious.Thisdefinitionisforstudents,teachersandotherstaff.

• Considerstudentsandstaffmemberswhowereclosecontactsinclass,otherschoolspaces,ontheschoolbus,oratextracurricularactivities.

• Page9ofDESE’sprotocol:http://www.doe.mass.edu/covid19/on‐desktop/protocols/• *UpdatedSeptember14,2020*

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DefinitionsandGuidelinesStudentswearingmasks

• MasksorfacecoveringsareamongthemostcriticalcomponentstoreducethetransmissionofCOVID‐19.Studentsingrade2andabovearerequiredtowearamask/facecoveringthatcoverstheirnoseandmouthatalltimes,withtheexceptionofmealsandmaskbreaks.Wheneverpossible,studentsinpre‐kindergartenthroughgrade1whocansafelyandappropriatelywear,remove,andhandlemasksshoulddoso.Evenifstudentsarespacedsixfeetapartinclassrooms,theuseofmasksisstillrequiredunlessstudentsareeatinglunchortakingamaskbreak.

• Maskbreaksshouldoccurwhenstudentscanbesixfeetapartandideallyoutsideoratleastwiththewindowsopen.Studentsinkindergartenandgrade1arestronglyencouragedtowearmasksorfaceshields.Masks/facecoveringsmustbewornbyeveryoneonthebusduringschoolbustransportation

ANoteonMaskWearing:• Clothmaskwearingisariskreductiontool,butdoesnotmeannoexposureoccurred.Thehopewouldbethatmasks

reducedthespreadofrespiratorydropletswhiletwoindividualsareinclosecontact,butthecontactisstillaclosecontactifitmeetsourdefinition.

• Aclosecontactthatworeaclothmaskwouldstillneedtoquarantine.Aconfirmedcasewearingaclothmaskcouldstillexposeothersthroughclosecontact.

• Clothmasksreduceriskbutdonotpreventexposurecompletely.

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DefinitionsandGuidelinesPhysicaldistancingguidelines• DESErecommendsthatdistrictsaimfor6feetofdistancewherefeasible.When6feetisnotfeasible,3feetisanacceptableminimumaslongasstaffandstudentswearmaskscoveringthenoseandmouthatalltimes.Ifthe3feetminimumisappliedonthebus,allstaffandstudentsregardlessofagemustwearmasksatalltimes.Pleasenotethatdecisionstoapplya3‐feetminimumwilllikelyincreasethenumberofclosecontactsassociatedwiththeoccurrenceofacase.

Medicalwaitingroom• AsnotedinpreviousDESEguidance,schoolsmustestablishaseparateroomforstudentsexhibitingCOVID‐19symptomsorwhomayhavelearnedaboutapositivetestresultwhileatschool,whilewaitingtobepickedupbyafamilymember.Thisspacemustbesupervised.Iffeasiblegivenspaceandstaffingconstraints,schoolsareencouragedtoprovideindividualstudentswiththeirownwaitingroom.Ifmorethanonestudentisinthesamewaitingroomatatime,eachstudentmustbeatleast6feetapart(andshouldbespacedasfarapartaspossible)andwearingasurgicalmask(non‐N95andnon‐cloth)whileinthemedicalwaitingroom. 33

DefinitionsandGuidelines• Policyofwhenaclosecontactmayreturntoschool

• Allclosecontactsshouldbetestedbutmustself‐quarantinefor14daysafterthelastexposuretothepersonwhotestedpositive,regardlessoftestresult.

• Policyofwhenastudent/staffpersonmayreturntoschoolafterCOVID‐19symptoms

• IfastudentorstaffmemberhasCOVID‐19‐likesymptoms,theymayreturntoschoolaftertheyhavetestednegativeforCOVID‐19,haveimprovementinsymptoms,andhavebeenwithoutfeverforatleast24hourswithouttheuseoffeverreducingmedications.

• IfastudentorstaffmemberpresentsCOVID‐19‐likesymptomsandchoosesnottobetested,theymayreturntoschool10daysfromstartofsymptoms,aslongastheirsymptomshaveimprovedandtheyhavebeenwithoutfeverforatleast24hourspriortotheirreturntoschoolwithouttheuseoffeverreducingmedication.

• DefinitionofCOVID‐19relatedfever• Overthesummer,thethresholdforaCOVID‐19relatedfeverbytheCentersforDiseaseControlandPrevention(CDC)hasbeenupdatedfromgreaterthan100.4˚Ftogreaterthan100.0˚F.Asaresult,goingforward,afeverasaCOVID‐19symptomwillbedefinedas100.0˚Forhigher.

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• Previous guidance was discordant with some MDPH guidance (particularly around contact identification, quarantine protocols, etc.)

Previous guidance Updated guidance

DESE Summer Guidance was Updated August 19, 2020

• Updated Guidance Aug 19 clarifies a number of key points that are now aligned with MDPH.

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• All students in an elementary classroom would be defined as close contacts.


Definition of a close contact

• A close contact will be defined as only those who have been within 6 feet of distance of the COVID-19 positive individual for at least fifteen minutes, while the person was infectious.

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• A close contact may return to school if they test negative for COVID-19, are asymptomatic and are wearing a mask.


Policy of when a close contact may return to school

• All close contacts should be tested but must self-quarantine for 14 days after the last exposure to the person who tested positive, regardless of test result.

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• A symptomatic individual should self-isolate for 14 days and until asymptomatic.


Policy of when a student/staff person may return to school after COVID-19 symptoms

• A symptomatic individual may return to school 10 days from the start of symptoms, as long as their symptoms have improved and they have been without fever for at least 24 hours prior to their return to school.

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• There is no specific capacity limit for medical waiting room, but all students in the medical waiting room must be as far apart as possible, and no less than 6 feet.


Medical waiting room

• If feasible, schools are encouraged to provide individual students with their own waiting room. If more than one student is in the same waiting room at a time, each student must be 6 feet apart and wearing a surgical mask.

DESEguidanceforSchoolNurses• Q.SchoolNurseGuidance– isthereaspecificdocument?

• A.Yes.https://www.mass.gov/doc/information‐for‐school‐health‐offices/download

• ReviewsPPEforschoolnurses,iftheyhavetoprovidenebulizingtreatmentsatschoolforchildrenwithasthma,providesguidancethatschoolnursesfallasHCPandcancontinuetoworkpostexposureiftheyareasymptomatic,reportingandcommunicationwiththeLBOH

https://www.mass.gov/doc/information‐for‐school‐health‐offices/download

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DESEguidanceforSchoolNursesNotifyingLocalBoardsofHealth• SchoolnursesmustnotifytheLBOHofeveryconfirmedcaseofCOVID‐19diagnosedintheschoolcommunity(bothstudentsandstaff),ifthenursehasnotalreadybeennotifiedofsuchbytheLBOH.

• ParentreportofalaboratoryconfirmedcaseissufficientforLBOHnotification,aswellasaproviderdiagnosedpresumedpositivecase.ThisinformationwillassistLBOHwithconductingcontacttracing.

• Inregionalschooldistrictsandcollaborativeswherestudentsmaycomefrommultiplemunicipalities,theLBOHcorrespondingtothestudent’smunicipalityofresidenceshouldalsobenotified.

• Inthecaseofresidentialschools,theLBOHcorrespondingtothelocationoftheschool(e.g.,thestudent’sresidence)shouldbenotified.Iftheresidentialschoolstudentlivesathomeontheweekends,thatmunicipality’sLBOHshouldalsobecontacted.


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DESEguidanceforSchoolNursesMAVENuseincontacttracingefforts

• MAVENaccessshouldberestrictedtopublichealthofficialsactingintheirpublichealthcapacity.Schoolnurseswhohavebeenactingaspublicagentstodocontacttracingwillneedtoseparatethoseactivitiesfromtheirschoolnursingduties.

• However,somedistrictsmaychoosetodesignateaschoolnursetoCOVID‐19casemanagementandcontacttracingactivitiesandaLBOHmaychoosetoexecuteanMOUwiththeschooldistrictforthatpurpose.• Inthatcase,thedesignatedschoolnurseshouldobtainlimitedaccesstoMAVENforschool/districtstudents/staffonlyandonlyforCOVID‐19.

https://www.mass.gov/doc/information‐for‐school‐health‐offices/download 43

DESEguidanceforSchoolNursesCommunicationbetweenSchoolNursesandLocalBoardsofHealth• IntheabsenceofaschoolhealthstaffpersonwithaccesstoMAVEN,LBOHstaffwithaccesstoMAVENcanandshouldcommunicatepositivecasesintheschoolcommunitytoadesignatedhealthcareprofessionalinthatschoolcommunityforthepurposesofcontacttracingandclosecontactnotification.

• ThedesignatedschoolhealthprofessionalcanandshouldsharestudentandstaffinformationwiththeLBOHforcontacttracingintheeventofapositivecaseofCOVID‐19intheschoolcommunity.

• SchoolhealthstaffandLBOHstaffshouldcommunicatepriortothestartofschooltoidentifydesignatedstaffconductingcontacttracingeffortsandtodevelopcommunicationprotocolsfortheircommunity.


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DESEguidanceforSchoolNursesConfidentiality• Massachusettslawalsoallowsthedisclosureofpersonallyidentifiableinformation(PII)forthepurposesofdiseasepreventionandcontrol,andlocalhealthauthoritiesroutinelycommunicatewithschoolnursesaroundotherreportablediseasesforthepurposesofdiseasepreventionandcontrolintheschoolsetting.

• NeithertheHealthInsurancePortabilityandAccountabilityAct(HIPAA)PrivacyRulenortheFamilyEducationalRightsandPrivacyAct(FERPA)preventthedisclosureofpersonallyidentifiableinformationforthepurposesofdiseasepreventionandcontrol.

• HIPAAspecificallyallowspublichealthreportingandaccesstoPHIforpublichealthactivitieswithoutrequiringanindividual'sauthorization.

• FERPAclearlyallowsforthedisclosureofPHIfromtheeducationalrecordwithoutpriorconsentoftheparent/guardianinthecaseofapublichealthemergency.


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InSummary• Anyfollow‐upforstudentsorstaffwillbeacoordinatedeffortbetweentheLBOHandtheschoolnurse.

• Goodcommunicationbetweenthetwoentitiesinbothdirectionswillbecrucialinidentifyingcasesandcontactsintheschoolcommunity.

• CasesandcontactsassociatedwithaschoolshouldbereportedfromLBOHtoSchoolNurse,orSchoolNursetoLBOH,dependingonwhoreceivestheinformationfirst.

• Sharinginformationonaneedtoknowbasisisallowed(andoftenneeded)toensurediseasepreventionandcontrol.• Keyplayers:LBOHs,Schoolnurses,possiblyteachersasrequired

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HowToTrackSchoolAssociatedCasesQuestion Package 2: Demographics

• Employment Information • Make sure to complete full employment location information for staff.

• Be sure to include school name and address.

• Full employer name info is not required for students (just staff)

• Occupation• Select student or teacher 47

HowToTrackSchoolAssociatedCasesQuestion Package 5: Risk/ Exposure/Control &

Prevention

• Employed at, enrolled at, admitted to, or visited a group setting? • YES

• Where is the Facility located?• Facility Name & Location

• Facility Type• School (Boarding)• School (college/University)• School (Elementary/Middle)• School (Secondary/Vocational)• School‐based clinic

• Expose Others in this setting?• Yes/No

• Employee of facility listed above?• Yes (staff)• No (student)

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MAVENNotesforSchoolCases• Workwiththeschoolnurse(andpossiblytheteacher)toobtainalistofcontactsfromtheclassroomorschoolsetting.(Don’tforgetlunchandrecessbuddies)• CreateContactEventsforeachidentifiedclosecontact.

• Lettersshouldgooutfromtheschoolnursetoidentifiedcontacts,butLBOHshouldstillcheckinwithfamiliestoanswerquestionsandprovidequarantineguidance.

• Ifcontactsliveinothertowns,makesuretonotifytheappropriateLBOHs.

• LinktheMAVENContactstotheIndexCase.• AClusterEventdoesnotneedtobecreatedunlesstwoormorerelatedcasesareidentifiedfollowingthisexposure.

• IfyouhavequestionsoncreatingaclusterorifaclustereventSHOULDbecreated,calltheEpiprogramat617‐983‐6800.

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MAVENNotesforSchoolCases• RemembertocompletetheRiskQuestionPackageinformationforcases–thisiswherewewilltracktheassociationwithaschoolsetting.• AdditionalInformation(LearningSetting):Recordinformationabouttheschoollearningmodel– isthechildattendingfulltimeinperson,isthechildfulltimeremote,aretheyhybrid(parttimeinschool,parttimeremote),aretheyinaremotepodofstudents(remotelearninginasmallgroupsetting)?

• WorkingonanupdatetoMAVENtotrackthisinaquestion,fornowpleaseindicateinthenotes.

• Thisinformationwillbeveryhelpfulindeterminingdifferentrisksassociatedwithdifferentschoolmodels.

• Alsorecordinformationaboutthesettingforschoolteachers/staff.Aretheyteachingfromtheschoolbuilding(butstudentsareremote)?Aretheyteachinginperson5daysperweek,orhybridinperson/remote,etc.

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TemplateLettersAvailable1. CloseContactsTemplateLetter(Forclosecontacts)

• Thistemplatecanbeusedforidentifiedclosecontactsandcanoutlinespecificdatesofquarantine.

2. GeneralNotificationTemplateLetter(Notclosecontacts)• Thistemplatecanbeutilizedforageneralnotificationifaschoolorclassroombelievestheyshouldprovidenoticetoadditionalmembersoftheirschoolcommunity,eveniftheywerenotidentifiedasclosecontacts.(Examplesincludetheremainingstudentsinaclassroomthatarenotclosecontactsbutwouldbenefitfromareminderonbestpractices,tobewatchfulforsymptomsregardless,andtoassurefamiliesregardinghealthandsafetymeasuresbeingundertakenbyschool.)

• Thisletterisnotrequired,andschoolsshoulddecideifitisappropriatetosendbaseduponlocalcircumstances.

• DESEhasprovidedtheirowntemplateletters(throughtheirCommunicationsToolkitdistributedtoschooladmins).DPHalsohastemplateletterscoveringtheabovecategories. 51

DelaysinMAVENReporting• Q.Ifaschoolgetsacallfromaparentthatachildispositive(orisacontactinquarantine),buttheinformationisnotyetinMAVEN,whatshouldbedone?

• A.Itisreasonabletoactonaparent’sreportandbeginfollow‐up.AschoolnurseshouldnotifytheLBOHanddiscussnextsteps.

• Ifapossibleexposureoccurredintheschoolsetting,weDOwanttoverifythelaboratoryconfirmation.

• LBOHcancallorderingprovidertoverifypositivetest&date.• ResultscanbefaxedtoISISbyproviderifyouidentifyasignificantdelay.

• WorkcanbegininMAVEN• YoucanalsocreatetheMAVENevent(itwouldgoinasasuspecttostart)ifyouhavethecorrectinformationonthe

patient(exactname,dob,andaddress)soyoucanstarttrackingnotes.

• Thelabreportshouldeventuallycomeinandappendtotheeventyoucreatedifitisanexactmatch.

• Alwayslooktoseeifthepersonisinthereearlierwithanunclassifiedevent(previousnegativelab)andaddyournotestothatevent,asthatfirsteventwillbeupdatedwiththepositivelabonceitcomesin. 52

StafffromOtherTowns:WhichLBOH?• Q.AschoolteacherlivesinTownXandisapositivecasebutworksintownY'sschooldepartment.WhatistownY'sLHDrole?

• A.Wewouldtreatthissimilarlytoothersituationswhereacaselivesin1townandworksinanother.

• LBOHofresidenceistheprimaryforfollow‐up.(TownX)• Ifaschoolworkplaceisidentifiedinanothertown:SHARE,TASK,andCALLtheotherTownLBOH.• Ensuretheschoolhasbeeninformedaboutthecase(eitherdirectlyorthroughtheschoolLBOH).

• SchoolnurseandSchoolLBOH(TownY)shouldpartneronanyinschoolfollow‐upthatneedstooccur.• LBOHofresidencemayhaveinformationtohelpaftertheyinterviewthecase,buttheschoolnurseandtheschoolLBOH(TownY)shouldensure/confirmthisinformationisobtainedandactedonappropriately.

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TestingContacts• Q.Closecontactsthattestnegativeshouldquarantinefor14dayscorrect? Shouldtheywait4‐5daysafterthelastdateofexposuretogettested?

• A.Yes,contactsmustquarantineafull14days,eveniftheytestnegative.

• MDPHdoesn’trecommendaspecificdayfortestingcontacts.Anytimeinthe14dayquarantine(butdefinitelyifyoudevelopsymptoms)isfine.

• DESEsaystotestafteratleastday4or5.• 50%ofpeoplewilldevelopsymptomsby5daysafterexposure.

• However,thisalsomeans50%ofpeoplewillnothavebecomeillbythispoint.

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TestingofContacts

• Rememberthatpeoplecantestpositiveupto14days.• Testingonlyidentifiesthepresenceofvirusatthetimeofthetest. Itispossiblethatsomeonecantestnegativebecausetheyareveryearlyintheirinfectionwhentheirsampleiscollected.Insuchsituations,theycouldtestpositivelaterandtransmitthevirustoothers.

• Stateguidancedoesn’tgiveanexacttimeframefollowingexposure.• Ifsymptomatic,gettestedrightaway.• Ifasymptomatic,gettestedassoonasyoucanafterbeingnotified.Butanegativeteststillmeansyouhavetocompletethe14dayquarantineperiod.• IfyoudevelopsymptomsAFTERyourfirstnegativetest,gettestedagain.• Ifyoustayasymptomaticforthedurationofquarantine,noadditionaltestingisneeded.

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