Follow-up for Positive COVID-19 Cases and their Close Contacts

Tools for LBOHs

Hillary Johnson, MHS, Infectious Disease EpidemiologistScott Troppy, MPH, PMP, CIC, Surveillance EpidemiologistAlex DeJesus, MPH,CIC, Infectious Disease Epidemiologist

Bureau of Infectious Disease and Laboratory SciencesMA Department of Public Health

September 29, 2020

Topics Today• MAVEN Online Status Map

• MAVEN COVID-19 Immediate Workflow – please continue to check on your cases

• MAVEN statistics for August (On-Call and Emails) and Webinar Numbers

• Key Documents

• Last Week’s Recap

• Quick Friday Office Hours Summary

• Isolation & Quarantine

• Refresher/Review

• Jurisdictions Review

• MAVEN Skills – Share, Task, Call

• Daycares Review• All contacts need Contact Events

• Cluster Events only if exposure occurred in facility

• Your Questions

Thanks to Michele Schuckel from Weston!

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Tuesday Webinars for COVID-19 Case Investigation and Follow-up

• Discussing New Guidelines, MAVEN Updates, Changes in Protocols, New Tools, Case Investigation FAQs, Follow-up Procedures.

Tuesdays @ 11am

MAVEN Help has Guidance Documents and Previous Webinars:

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

MDPH Epi Program: 617-983-6800MDPH MAVEN Help Desk: isishelp@mass.govMDPH Food Protection Program: 617-983-6712 CTC Help Desk: 857-305-2828COVID19CommunityTracingCollaborativeQuestions@mass.gov

*NEW! MAVEN Office Hours w/Hillary & Scott:

Fridays 11:00-12:00• Open Q&A. Not a formal presentation.• Send us your questions or ask us live. • No requirement to attend. Pop in, pop out. • You’ll need to register via Scott’s email.

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Updates for today, Tuesday, 9/29MAVEN Status Map – four towns offline

Florida, Holland, New Ashford and Chesterfield

LBOH Immediate Workflow – COVID-19 event only –please check your workflow and clear out the workflow

MAVEN Statistics for On-Call and Emails sent to the MAVEN Help Desk (isishelp@state.ma.us)

Webinar Stats for our Tuesday/Friday gatherings

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MAVEN Status Map as of 9/29/2020Chesterfield, Florida, Holland, New Ashford,

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Immediate Notification workflow (COVID-19 Only)

UPDATE: COVID-19 Immediate Notification Workflow -724 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)

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On-Call Events, MAVEN Help DeskCOVID-19 Weekly Webinars

Statistics

Reed Sherrill, Surveillance EpidemiologistScott Troppy, Surveillance Epidemiologist

Bureau of Infectious Disease and Laboratory SciencesMA Department of Public Health

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MAVEN User Requests & Training3/1/2020 - 9/28/2020

Status CountPending Users 202Processed Users 1,238Total New Users Trained Or In Process 1,440Total MAVEN Users 1,357*

*these data is accurate as of 9/28/2020 at 12:30PM.

Pending = User has submitted a URF and is in the training process.Processed = Trained internal and external staff with VG MAVEN accounts created and MAVEN accounts created by ISIS staff and then access granted appropriate access. Total MAVEN Users = Includes MDPH, LBOH, CTC, Higher Ed, Infection Prevention and other trained staff*Total New Users Trained/in process exceeds total MAVEN users due to retraining and/or individuals coming offline and back on again

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MAVEN On-Call Events8/1/2020 – 8/31/2020

Program Area CountDivision of Global Populations 16Epidemiology 473Immunization (COVID-19) 1,358Informatics and Surveillance (ISIS) 294Total On-Call MAVEN Events 2,144

*these data is accurate as of 9/28/2020 at 12:30PM

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MAVEN On-Call Events3/1/2020 – 8/31/2020

Program Area CountDivision of Global Populations 54Epidemiology 2,468Immunization (COVID-19) 21,892Informatics and Surveillance (ISIS) 1,537Total On-Call MAVEN Events 25,951

*these data is accurate as of 9/28/2020 at 12:30PM

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Year Total On-Call Events Created

2015 6,739

2016 12,830

2017 12,605

2018 9,296

2019 10,652

So far in 2020 (Jan 1 –Aug 31)

27,843

For Reference what our call volume usually looks like….

*these data is accurate as of 9/28/2020 at 12:30PM

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MAVEN Help Desk Emails3/15/2020 – 8/31/2020

Month Count

March 2,383April 7,816May 7,603June 6,602July 5,231August 6,280Total Emails received 35,915

*these data is accurate as of 9/28/2020 at 12:30PM

isishelp@state.ma.us12

Tuesday and Friday Webinars for COVID-19 Investigations/Follow-up

lead by Hillary Johnson and Scott Troppy

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Tuesday’s Webinar Attendance4/7 – 9/22/2020

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Note: As of 7/3 we will only be hosting our Tuesday, 11-12:15 webinars

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*4/8 was a special Wednesday Introductory Contact Tracing Training

**9/18 started Friday Office Hours

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Summary of Key Guidance & Tools• 9/2/2020 Updated COVID-19 Case Classification Manual

• Serology positive labs are now classified as “suspect” cases.• http://www.maventrainingsite.com/maven-help/pdf/case-classification-manual/COVID19__09022020_FINAL.pdf

• Date: 8/22/2020: - COVID-19 PCR and Antibody Testing Public Health Response Recommendations

• Table describes different Public Health Actions based upon different testing results.• Big take home: PCR & Antigen positive patients should be treated like cases.• Serology + cases no longer require public health follow-up. • http://www.maventrainingsite.com/maven-help/pdf/COVID-

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

• Date 8/10/2020: Follow-up for Positive Antigen Test Results• http://www.maventrainingsite.com/maven-help/pdf/Antigen%20Results%20Follow-up%20Guidance_ver1.0_August_10.pdf.

• Date: 8/9/2020: Updated Isolation & Quarantine Guidelines Documents• 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: Updated MA Testing Guidance • https://www.mass.gov/doc/covid-19-testing-guidance/download• Update says to get a PCR with ANY Antigen test• Also says no need to test again in 90 days after initial diagnosis.

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Summary of Key Guidance & Tools

• Date: 7/24/2020 - Gov. Baker issued COVID-19 Order No. 45 which issues a mandatory 14 day quarantine period for travelers to MA (including MA residents who traveled outside of MA and are returning). • If travelers (including returning MA residents) don’t fit into one of the 3 Exemption Categories, must quarantine.

• There is a form to fill out online. https://www.mass.gov/forms/massachusetts-travel-form

• A negative PCR test within 72 hours of travel can excuse you from quarantine.

• https://www.mass.gov/guidance/guidance-for-travelers-arriving-in-the-commonwealth-of-massachusetts

• Updated FAQs: https://www.mass.gov/info-details/covid-19-travel-order#potential-other-traveler-scenarios-

• Date: Aug 16, 2020 – Updated CDC Guidance on Duration of Isolation & Precautions for Adults with COVID-19• 10 Day Isolation Period now has more data supporting it.

• Ignore most additional PCR tests up to 3 months after initial illness onset.

• No need to quarantine up to 3 months after initial illness onset.

• https://www.cdc.gov/coronavirus/2019-ncov/hcp/duration-isolation.html

• Date: May 7, 2020 – Occupational Exposure & Return to Work Guidance• 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 – A quick recap for 9/28.

• 9/22 – last week we discussed a variety of interjurisdictional questions and scenarios –particularly around Colleges :

• Discussed the 3 step process for sharing MAVEN events across Jurisdictions:

1. SHARE

2. TASK

3. CALL

• MAVEN Skills Checklist

• Can you perform these MAVEN tasks?

• 4 Common MAVEN Higher Ed Scenarios

• Review last week’s presentation – most of your questions will be answered.

• 9/22 – DAYCARES• Key Resources

• Expectations for Daycare Tracking and Cluster Follow-up

Check out last week’s Presentation on Daycares and Jurisdictions in MAVEN Help

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Friday Office Hours Summary

• Antigens Need PCRs. Can we force labs to perform PCRs?

• Alas, we cannot require PCRs at different labs and Urgent Cares (we do not determine which tests private companies offer). We can only recommend and share the state testing guidance.

• However, you CAN ask for a PCR from your symptomatic students.

• Recommend communicating the preferred test NOW to your student body should they need to be tested in the future (instead of retroactively asking for an additional test after the fact).

• Date: 8/7/2020: Updated MA Testing Guidance

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

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Friday Office Hours Summary

• Best date to be tested after exposure? When should a contact of a case get tested in their 14 day quarantine after exposure?

• MDPH doesn’t recommend a specific day. Anytime in the 14 day quarantine (but definitely if you develop symptoms) is fine.

• DESE suggests a sweet spot of after at least day 4 or 5.

• 50% of people will develop symptoms by 5 days after exposure.

• However, this also means 50% of people will not have become ill by this point.

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Friday Office Hours SummaryQ. With everything opening back up, is there any distinction between Essential Workers and Non-Essential Workers going forward?

• A. As of this moment, there is relatively outdated language on this issue. Resultingly, the main distinction for essential workers designation has to do with exposures and quarantine requirements.

• Essential Workers can theoretically continue to work during their quarantine period following a COIVD-19 exposure (provided they are not symptomatic and do not test positive as a case themselves).

• This exception is for working essential services. They should still observe quarantine for outside of work hours.

• An essential service may decide they have adequate coverage and not have an employee work during a quarantine.

• Non-essential workers must abide by normal quarantine requirements following exposures.

• NO ONE MAY WORK IF THEY ARE A CONFIRMED CASE OF COVID-19. THEY MUST COMPLETE THEIR ISOLATION PERIOD.

Likely update coming to reduce this broad category to just HCWs (who can continue to work after an occupational exposure). Daycare and school staff (like admin and teachers) are not intended to be exempt from quarantine at this time (although a school nurse should be a treated like a HCW in this capacity).

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Isolation & Quarantine – A Review

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Isolation vs. Quarantine

ISOLATION• For symptomatic people.

• For Confirmed COVID-19 Cases.

• Prevents people from infecting others

• LASTS UNTIL THE PERSON IS NO LONGER CONTAGIOUS

• Use CDC Discontinuation of Isolation Guidance

QUARANTINE• For asymptomatic people who

have had an exposure (i.e. travelers from high risk areas, close contacts of confirmed cases, etc.)

• Prevents people from infecting others in the event they develop symptoms

• LASTS FOR 14 DAYS FROM LAST EXPOSURE. (If you don’t develop illness, you are then released.)

CASES CONTACTS

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Updated Isolation & Quarantine Guidance

Summary of July 17 CDC Updates: (Testing & Isolation)

• Confirmed PCR+ Recovered cases can continue to test PCR+ for 12 weeks after symptom onset, thus:

• No action needed on any tests up to 3 months after original onset or test date.

• No quarantine needed if exposed up to 3 months after original onset or test date.

• Recommend no longer using test-based strategy (because they will test PCR+ for a long time and it doesn’t have anything to do with infectious replication-competent virus).

• Use Symptom Based or Time-Based strategy.

• Symptom-based strategy for discontinuation of isolation: (slightly tweaked) to 10 days & 24 hours fever free and symptoms have improved.

• Isolation and precautions can generally be discontinued 10 days after symptom onset and resolution of fever for at least 24 hours, without the use of fever-reducing medications, and with improvement of other symptoms.

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Discontinuation of Isolation Guidance

At least 24 hours have passed since recovery defined as

resolution of fever without the use of fever-reducing medications, and

improvement in other symptoms (e.g., cough, shortness of breath);

and At least 10 days have passed since

symptoms first appeared.

resolution of fever without the use of fever-reducing medications, and

improvement in other symptoms (e.g., cough, shortness of breath);

and

Negative PCR results from at least 2 specimens collected >24 hours apart

Symptom-Based Strategy Test -Based Strategy

If Patient Ever Had Symptoms:

OR

Symptoms need to have

resolved before starting testingUse Symptom

Onset Date = Day 0

Not Recommended for most scenarios

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Discontinuation of Isolation Guidance

At least 10 days have passed since the date of their first positive COVID-19 diagnostic test.

Assumes no symptoms ever developed.

Negative PCR results from at least 2 specimens collected >24 hours apart

Assumes no symptoms ever developed.

Time-Based Strategy Test -Based Strategy

If Patient NEVER Had Symptoms:

Use Test Collection Date = Day 0

OR

Not Recommended for most scenarios

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Determining Infectious Period – for Case• Notes:

• Symptom Onset Date = Day Zero (for determining when Case can exit Isolation)

• Use full days, not times of day.• If a case had a morning meeting, then developed a sore

throat that night, consider that Day Zero and people in that morning meeting exposed.

• Example, a confirmed case developed a cough in the evening on Thursday, April 2.• Symptom Onset Date = Thursday, April 2.

• (Do not worry about time of day. This full day is the onset.)

• Infectious Period Start date = Tuesday, March 31.• We would be looking for any close contacts/exposures

from Tuesday March 31st on. • Infectious Period End date = when case is no longer

infectious (usually when they are discharged from isolation)• Return to normal activities= Day 11• For Contact Tracing: You can likely just go to when

they entered isolation (no more contact with others).

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

Apr 12 Apr 13 Apr 14 Apr 15 Apr 16 Apr 17 Apr 18

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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Determining Quarantine Period –for Contact

• You must identify an exposure date to determine a quarantine period.• Exposure Date = Day Zero.• Quarantine Period is Day 1 through the end of Day 14, returning to activities on Day 15.• Example:

• Exposed on March 29th. (DAY 0)• Quarantine Period (Day 1- Day 14): March 30 – April 12.• Quarantine is Over (Day 15): April 13th.

• Notes:• Have a calendar handy. Count the days out loud.• Use full days, not times of day.• Contact will already be in Quarantine Period when you contact them. Make sure they start

quarantine immediately.

Sun Mon Tues Wed Thurs Fri Sat

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

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

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

DAY 7 DAY 8 DAY 9 DAY 10 DAY 11 DAY 12 DAY 13

Apr 12 Apr 13 Apr 14 Apr 15 Apr 16 Apr 17 Apr 18

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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Determining Quarantine Period –for Household Contact

• For determining ANY quarantine period, you must determine the contact’s last exposure to the infectious person. That is Day Zero.

• For Household Members who cannot completely separate, (children, spouse, roommates, etc.), they are “in quarantine” while continuously exposed to the case.

• However, their FINAL 14 Day Countdown of Quarantine does not begin until they are no longer being continuously exposed.

• In other words, their final 14 day Quarantine begins after their LAST/Final exposure to someone infectious. • If the CONTACT cannot separate from the CASE, then the

Case must stop being infectious (be released from isolation). That will determine the contact’s final exposure date.

• Index case’s last day in Isolation (Day 10) = Day 0 (Final Exposure) for counting out the quarantine.

Sun Mon Tues Wed Thurs Fri Sat

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

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

DAY 10

Day 0

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

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

DAY 7 DAY 8 DAY 9 DAY 10 DAY 11 DAY 12 DAY 13

Apr 12 Apr 13 Apr 14 Apr 15 Apr 16 Apr 17 Apr 18

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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Your Questions: Discontinuation of Isolation Guidance• Q. Is it required that symptoms have RESOLVED or IMPROVED for 24

hours? Please clarify.

• A. Fever needs to be resolved without medications. Additional symptoms should be “improved.”

• Example: cough may not have gone away entirely, but should be markedly improved (occasional cough, not paroxysms/coughing fits).

• PER CDC July 17 Updates:

• Changed from “at least 72 hours” to “at least 24 hours” have passed since last fever without the use of fever-reducing medications.

• Now says “Improvement in symptoms” (not just “respiratory”) to address expanding list of symptoms associated with COVID-19.

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Your Questions

Q. My case recovered but their employer asked for a test before returning to work and it was still positive. What to do?

• A. According to our current guidance, if this patient met the symptom based strategy for exiting isolation and is no longer symptomatic, they are good to go. We know people will test positive via PCR for a while and it does not correlate to viral culture (live virus) so we would not consider them infectious. MDPH discourages workplace testing for returning to work.

• Per Massachusetts COVID-19 COMMAND CENTER: Non-Healthcare Workers: Occupational Exposure & Return to Work Guidance, Revised May 7, 2020:

• Employers should not require a COVID-19 test result or a healthcare provider’s notefor employees who are sick to validate their illness, qualify for sick leave, or to return to work.

• https://www.mass.gov/doc/non-healthcare-workers-occupational-exposure-return-to-work-guidance/download

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Updated Isolation & Quarantine Guidance

• Studies have not found evidence that clinically recovered persons with persistence of viral RNA have transmitted SARS-CoV-2 to others.

• These findings strengthen the justification for relying on a symptom based, rather than test-based strategy for ending isolation of these patients,• We don’t want people who are no longer infectious (current evidence) kept

unnecessarily isolated and excluded from work or other responsibilities.

Test-based strategy is no longer recommended for most people (unless the goal is to discontinue

isolation prior to the 10 day criteria).

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MAVEN Skills Needed For Cross-Jurisdictional Situations:

Do you know how to:

Update an address? 1st Step: Current Address (Participant Tab) 2nd Step: Official Address (Demographics Question Package)

SHARE an event? full read/write access for Single User full read/write access for User Group

Create a TASK? Do you know how to assign a task to someone/group? Do you know how to complete a task yourself?

Can you look up a COMMUNICATION EVENT for another town? Can you update your OWN communication event?

These are fundamentals for working across jurisdictions. Make sure you can do these by reviewing 9/15 Webinar,

Using MAVEN Help Tip Sheets, or calling 617-983-

6800.

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MAVEN Jurisdictional Scenarios

• If a MA case or contact is quarantining or isolating in a MA jurisdiction other than where they usually reside:

1. SHARE: The LBOH for the town where the case or contact usually resides should share the event with the LBOH where the case or contact is temporarily staying in Maven• SHARING gives access to the event.

2. TASK: Notify the receiving LBOH via a Task.• Tasking will send an email notification to the receiving LBOH with your notes/guidance for

the task.

• The benefit of a task is the receiving LBOH can mark it complete once follow-up (quarantine or isolation monitoring) is done. This action would send an email back to the original person who assigned the task to let them know it has been completed.

3. Best Practice (Call): Follow-up with a phone call to the LBOH. This will help, particularly if there needs to be coordination on follow-up.

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Two Step Process for Interjurisdictional Partnerships

• To Share an Event: Within the case or contact’s Maven event select “Share Event” located on the left side of Maven then navigate to “Add Event Share”:• Type= View & Update Full

• User Group= Select the appropriate LBOH group

• Save

• To Task an Event: Within the case or contact’s Maven event, go to the “Tasks” tab• Add task

• Type= Assignment

• Description: Case/Contact Isolating/Quarantining in your town

• Assign to group: Select the appropriate LBOH group

• Save

Step 1: Give LBOH Access to Event via Sharing. Step 2: Notify the LBOH via Tasking.

Best Practice: Follow-up with a Call. (See Communication Event for contact info.)

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Updating the Official Address: this also changes if YOU can view it

• If you are completely changing the official address for a case away from your own town, you will lose viewing/read/write access to the event as soon as the official address is changed.

• To prevent this, SHARE with your own LBOH prior to updating the address (when you still have full access).

• You can then update/review/consult on the case going forward as needed.

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Scenario 1: Paul the Fitchburg State student

• Paul is a Fitchburg State University student who has spent the summer at his parents’ house in East Longmeadow.

• Paul arrives at his off-campus apartment in Fitchburg and is tested the next day at university health services. He tests positive.

• Fitchburg State (correctly) uses Paul’s Fitchburg address when reporting the positive lab and Paul appears in MAVEN as a Fitchburg case.

• Fitchburg BOH, who is the designated contact tracer for the university, investigates the case and learns that Paul has returned to his parents’ house in East Longmeadow to isolate. Paul will be returning to Fitchburg when his isolation period ends.

• What is the official address where we count this case?

• How does Fitchburg BOH notify East Longmeadow that Paul is temporarily isolating in E. Longmeadow?

• Who is responsible for Paul’s isolation and documenting everything in MAVEN?

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Scenario 1: Paul the Fitchburg State studentPaul: Lives and was tested in Fitchburg, but temporarily goes to E. Longmeadow for isolation.

• Fitchburg BOH manages the case (including identifying Paul’s close contacts) and leaves Paul’s official address as his Fitchburg address.

• Paul is a Fitchburg resident even if he was only there for a couple days because that is where he lives for the majority of the year.

• Fitchburg BOH enters Paul’s temporary East Longmeadow address in MAVEN and notifies the East Longmeadow BOH as a courtesy.

• Current/Temp Address: Fitchburg BOH adds the East Longmeadow address to the Participants tab but does not go into the Demographic question package to change this to the official address.

• Share, Task, Call: Fitchburg BOH shares the event and tasks it to the East Longmeadow BOH. They also place a call to the East Longmeadow BOH.

• Fitchburg BOH is ultimately responsible for making sure Paul isolates correctly and all the data is entered into MAVEN. This can be a partnership with E. Longmeadow – which is why the phone call to discuss follow-up is critical.

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Interjurisdictional Guidance

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DAYCARES

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Key Childcare Documents & Resources

• The Department of Early Education and Care (EEC) oversees childcare and recreational camp settings and is the primary author for their guidance documents and their protocols.

•

Key Reopening and Safety Documents:

• https://eeclead.force.com/apex/EEC_ChildCareEmergencyHealthGuidance

• The Playbook: COVID-19 Child Care Playbook: Implementing the Minimum Requirements for Health and Safety

• FAQ: https://eeclead.force.com/resource/1594914614000/FAQ_Min_Req

• Childcare providers have also been given this email address to submit questions:Childcare.Covid19@mass.gov. This email goes to the MDPH Division of Epidemiology.

• Dr. Katherine Hsu has been designated EEC’s childcare epidemiologist, at Katherine.hsu@mass.gov or 617-983-6948.

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Daycare Risk Variables (cases & contacts)

Question 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

• Daycare (child)

• Employee of facility listed above?

• Yes (staff)

• No (child) 43

Childcare Facilities & COVID-19Daycare facility related issues will generally come to your attention in one of the following two ways:

1. You receive a confirmed index case through normal MAVEN reporting.

a. The case is in a staff member who works at, or a child who attends, a daycare.

• Identifying this link to a daycare requires you to conduct the interview and determine this information.

b. The case has Close Contacts that attend a daycare (as children or staff members).

• Identifying this link to a daycare requires you to conduct the interview and determine this information.

2. MDPH receives a report from the Daycare Provider about a positive (Through EEC Required Reporting).

a. MDPH may update the relevant Index Case events in MAVEN (or create them if they have not yet been created through normal lab reporting),

• MDPH will update notes in MAVEN regarding the initial report (and their preliminary follow-up), but this will not be a completed index case interview and LBOH should proceed as you normally would for cases and/or clusters.

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Summary of Current EEC Reporting Process for Licensed Childcare Providers

1. MA Licensed and Funded Childcare Providers are required to report each incident of the following via a web-based DPH COVID-19 Positive Reporting Form which lives behind theirLicensing Education Analytic Database (LEAD) Portal Login.

• Confirmed COVID-19 cases in Staff• Confirmed COVID-19 cases in Children• Confirmed COVID-19 cases in Household Contacts of Children

2. Epi Program Also Receives Copy of Report: Once a report is submitted via this form from the Daycare to EEC, MDPH Epi program receives a copy of the report.

3. Epi Calls Back Childcare Reporter: Provides immediate guidance to Childcare Provider (determine if exposures occurred and if notifications and exclusions/quarantines are applicable). May provide template letters as needed. Try to verify confirmed case/MAVEN reporting for documenting follow-up.

4. MAVEN Updates as Needed: Epi may create DAYCARE Cluster if appropriate, update MAVEN notes, link relevant MAVEN individual events, and notify relevant LBOHs for follow-up. This may require an additional call to the case/case’s family to verify appropriate MAVEN events & correct guidance.

This EPI follow-up is for immediate response/guidance. Continued follow-up is the responsibility of LBOHs.

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Notes about the EEC Reporting Process

• MDPH provides immediate guidance based upon the information available at the time of report.

• Helps determine if there was an exposure in the facility.

• Advises on isolation and quarantine (based upon the information presented).

• May provide template letters for notifying families and staff.

• Documents initial guidance in MAVEN.

• However, follow-up and additional control measures are the responsibility of the LBOH.

• LBOH for the Daycare Facility should ensure all contacts are created in MAVEN and additional LBOHs are notified as required.

1. Confirmed COVID-19 cases in Staff2. Confirmed COVID-19 cases in Children3. Confirmed COVID-19 cases in Household Contacts of Children

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Daycare Talking Points

• Children or staff identified as a contact to a confirmed case should be excluded from daycare for their full quarantine period.

• Remember that a household contact (such as a child) may have a prolonged quarantine if they are not able to completely separate from the confirmed case(s) in their household.

• Testing is recommended for identified contacts.

• Remember, a NEGATIVE test during quarantine does not end quarantine early. Any contacts must still complete their full 14 day quarantine even if they tested negative earlier in that 2 weeks.

• Not all quarantined children will be tested (for various reasons). If they remain asymptomatic and have no indication of infection, they may return to daycare at the completion of their quarantine period.

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Daycare Talking Points

• Daycare Exposures will likely involve multiple LBOHs.

• If the facility is in Town A, that is the primary LBOH for follow-up and providing guidance to the daycare.

• Children or staff who attend the daycare (contacts and cases) may live in other jurisdictions. • Remember to share events and add “affected towns” in the cluster event.

• The confirmed case may live in another jurisdiction. LBOH may call MDPH if they are having trouble confirming a situation/case for possible exposure.

• Create contact events for all identified children who attend daycares and other school programs that are exposed.

• Younger household contacts may not have been a priority in the past for creating their own events, but this is particularly important as we navigate this new daycare landscape and may need to share events across jurisdictions. 48

When to Create a Daycare Cluster in MAVEN• If a staff member or child in a daycare tests positive, and there is an exposure in

the facility, a Daycare Cluster Event should be created.

• Cluster Naming: DAYC_FACILITYNAME_TOWN. • Ex: DAYC_HAPPYFEET_LAWRENCE

• Ex: DAYC_LITTLEBEANS_STOW

• Facilities will need cluster events for EACH distinct cluster, even if in the same facility.• So an exposure/cluster in the infant room would be a different cluster than an unrelated

exposure/cluster a month later in the 3 year old classroom.

• Cluster name may need to include a classroom or program to distinguish between unrelated events.

• If a case is confirmed in a child or staff member, but they were not in attendance at the daycare facility while infectious (no exposure), a Cluster Event would not be created.

Because of the EEC reporting requirement, MDPH will likely be the first to know about a Daycare Exposure, and we will create MOST of the Daycare Clusters by default (although LBOH could be the initial creator as well).

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Daycare Associated Cases & Their Contacts Need Follow-up

• If there is an exposure in a facility, the LBOH should obtain a list of identified contacts and create full contact events for each contact.

• If the Provider submitted their EEC report right away, MDPH may have provided day-of initial guidance (help determine that there was an exposure and next steps).

• However LBOH will be responsible for creating the CONTACT EVENTS for each exposed student and staff member.

1. Contact the Daycare Provider to obtain the list of exposed contacts.

Required info for Daycare Contact Creation:1. Full Names, 2. Addresses, 3. DOBs, 4. Race & Hispanic Status, 5. Phone #s, 6. Dates of attendance, 7. Guardian Names.

You will need exposure dates to determine quarantine period.

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Daycare Associated Cases & Their Contacts Need Follow-up• Each exposed child/staff member needs a MAVEN Contact Event created.

• The Daycare should provide immediate notification to identified contacts (template letters are available to assist with this), however the LBOH for the Daycare should create the MAVEN Contacts and alert relevant LBOHs.

• Contacts cannot return to Daycare until they are released from quarantine by LBOH.

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Daycare Associated Cases & Their Contacts Need Follow-upDaycare Facility LBOH creates the Contact Events:

• Creating the Linked Contacts (task for LBOH of daycare facility)• Create the Contact Events (link to your case & the Daycare cluster = 2 links each)

• For Contact Events from Other Towns:• If you create with the correct official town initially, you don’t have to share it with them (but

you could share with your own LBOH). Remember, only you (not your colleague) can see it.

• Task & Call – to make sure the other LBOH knows about the event and will complete the follow-up.

• Ex: I’m Cambridge LBOH. Daycare is in Cambridge. I need to create all the contact events (get list from daycare provider).

• Create an Arlington Contact (daycare attendee). Arlington can see it automatically. I can see it, but my fellow Cambridge nurse cannot see it. I share with Cambridge LBOH users so my colleagues can see too.

• Task Arlington & Call – let them know about the daycare contact. Arlington will follow through quarantine, recommend testing, and release from quarantine once can return to daycare.

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Template Letters Available

1. Close Contacts Childcare Template Letter (For close contacts)• This template can be used for identified close contacts and can outline specific dates of quarantine.

2. General Notification Template Letter (Childcare Facility – not close contacts)• This template can be utilized for a general notification if a facility believes they should provide notice to additional

members of their childcare community, even if they were not identified as close contacts. (Examples include to families and staff of students in unaffected classrooms.)

3. General Suspect Case Notification Letter (Childcare Facility – FYI for community following a suspect case that has not yet been confirmed)

• This template can be utilized by a facility if they believe they have a potential scenario that has not yet been confirmed, but they wish to notify their community at this time. While MDPH does not generally recommend notifications without lab-confirmed evidence, there may be instances where providers still feel pressure to provide updates or information, and this template may be useful.

4. In Home Childcare Provider Quarantine (Letter for In Home Providers who need to close due to their own exposure unrelated to the Childcare Program)

• This template may be used in the case of an in-home childcare provider or a member of their household being identified as a close contact and needing to quarantine, which leaves the home childcare program unable to operate due to staffing or location issues. This template lets the families know that, while there was no known exposure in the childcare setting, the childcare provider will need to temporarily close to complete quarantine. 53

DAYCARE CLUSTER REMINDERS• For a CHILDCARE CLUSTER Facility in YOUR TOWN: You are the LBOH

responsible for creating the exposed (students and staff) contact events. Contact the Childcare Provider for a complete list and create the Contact Events in MAVEN.

• Link to the CLUSTER Event AND

• Link to the Index Case that exposed them

• LBOHs with DAYCARE Contact Events: You should follow up with the contact/family to ensure they understand the duration of quarantine. You are the final authority for releasing them from Quarantine and back to Daycare.

• Be watchful for evidence of IN FACILITY transmission: Alert MDPH (via 617-983-6800) if you identify significant transmission in a daycare.

Daycare Clusters are only created if there was exposure in the Daycare Facility while a case was infectious.

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Your Questions

• Q. When we link a person as a contact who had a previous negative test, they are not classified as a contact (their existing event is Unclassified). What do we do?

• A. Only MDPH can update a case classification status. Email event ID to isishelp@mass.govor call 617-983-6800 and we can update the status to CONTACT.

• Q. Please go over again how to "keep" an outsider visible to you before sharing with their primary residence jurisdiction.

• A. Share the event with yourself/LBOH PRIOR to switching official address.

• Q. What should a LBOH do when we’ve been alerted to a positive result, but MAVEN has not been updated (significant delay in reporting)?

• A. If you are working with a case or a contact that says they are positive, you can call the provider to verify. You can also request that results get faxed to ISIS if there is a significant delay. ISIS Fax 617-983-6813

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Your Questions: Schools k-12

• Q. Does a symptomatic child with an alternative diagnosis, such as a strep throat, still need a COVID test before returning to school?

• A. In order to protect schools from the introduction of COVID, testing of symptomatic individuals should be the default practice. Students with acute onset of new symptoms (especially respiratory symptoms such as cough, shortness of breath, sore throat) or fever should almost always receive a negative COVID test before returning to school. Health care providers have clinical discretion to consider chronic illnesses or symptoms such as headache and abdominal or gastrointestinal symptoms and use clinical judgment to defer testing when an alternative cause is firmly established.

• Department of Elementary & Secondary Education

• Frequently Asked Questions, Week of September 21, 2020 http://www.doe.mass.edu/covid19/

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