COVID-19 in Orange County: Updated Recommendations for Isolation Precautions
July 23, 2020
The transmission and disease burden of COVID-19 continue to be substantial in Orange County. Over 30,000 cases have been reported in the county, with over 500 deaths. Approximately half of all county deaths have occurred in residents of skilled nursing facilities, though deaths in members of the general community have increased in recent weeks. Disease is being seen across races and ethnicities and in cities throughout the county.

Updated county surveillance data can be found at: https://occovid19.ochealthinfo.com/coronavirus-in-oc
Updated Guidance for When to Discontinue Isolation and Transmission-Based Precautions
CDC’s updated guidance, released on July 17, 2020, no longer recommends use of PCR testing to decide when to discontinue isolation precautions at home and transmission-based precautions in healthcare settings, except for rare exceptions.  For patients who are severely immunocompromised, a test-based strategy could be considered in consultation with an infectious diseases expert. For all other symptomatic patients, a symptom-based strategy is recommended. For mild to moderate diseases, home isolation and healthcare transmission-based precautions can be discontinued when:

At least 10 days have passed since symptoms first appeared
AND
At least 24 hours have passed since last fever without the use of fever-
reducing medications (previous recommendation was “at least 72 hours
afebrile”)
AND
Other symptoms have improved (previous recommendation was
“improvement in respiratory symptoms”)
 
Patients with severe to critical illness* or who are severely immunocompromised should have precautions continued until 20 days after symptom onset with fever and symptom improvement. Orange County recommends a more cautious approach to release from transmission-based precautions in residents of long-term care facilities (LTCF) and other congregate living facilities for older adults (e.g., memory care units); see attached document here, under section 3.c ., for guidance.

Asymptomatic patients with laboratory-confirmed COVID-19 should have precautions continued until 10 days have passed since the date of their first positive COVID-19 diagnostic test, assuming they have not subsequently developed symptoms. Asymptomatic severely immunocompromised patients should have precautions continued for 20 days after their initial positive SARS-CoV-2 diagnostic test.

*CDC defines a patient as having severe illness when they have one or more of the following characteristics: respiratory frequency >30 breaths per minute, SpO2 <94% on room air at sea level (or, for patients with chronic hypoxemia, a decrease from baseline of >3%), ratio of arterial partial pressure of oxygen to fraction of inspired oxygen (PaO2/FiO2) <300 mmHg, or lung infiltrates >50%. Critical Illness is defined as respiratory failure, septic shock, and/or multiple organ dysfunction.
 
The above guidance also applies to infected healthcare providers (HCPs) who are returning to work. HCPs who return to work while still symptomatic should wear a facemask for source control at all times while in the healthcare facility until all symptoms are completely resolved or at baseline. After this time period, they should revert to their facility policy regarding universal source control during the pandemic.

Medical providers are asked to educate cases about home isolation precautions as well as quarantine recommendations for the cases’ close contacts. Close contacts (those who have been within 6 feet of a case for 15 minutes anytime during the 48 hours before symptom onset until isolation) are recommended to self-quarantine for 14 days. According to Orange County health officer order, all patients with COVID-19 and all close contacts are directed to adhere to isolation and quarantine guidance respectively. Guidance on home isolation and quarantine can be found at: https://www.cdc.gov/coronavirus/2019-ncov/if-you-are-sick/isolation.html .

For those who need assistance in finding an appropriate site for isolation due to homelessness, or for those unable to safely isolate to avoid exposing high-risk household contacts, OCHCA can assist with arranging temporary lodging in area hotels.

CDC’s updated guidance for discontinuation of home isolation can be found at: https://www.cdc.gov/coronavirus/2019-ncov/hcp/disposition-in-home-patients.html Their guidance for discontinuation of transmission-based precautions can be found at: https://www.cdc.gov/coronavirus/2019-ncov/hcp/disposition-hospitalized-patients.html A decision memo which outlines the research and reasoning used to inform these guidance updates can be found at: https://www.cdc.gov/coronavirus/2019-ncov/hcp/duration-isolation.html
Testing for COVID-19
Any patient with symptoms consistent with COVID-19 should be considered for testing.

Fever or chills, cough and shortness of breath are the most common initial symptoms. Fatigue, muscle pain, headache, new loss of taste or smell, vomiting or diarrhea, sore throat and/or nasal congestion are also seen. CDC recommendations for clinical evaluation can be found at: https://www.cdc.gov/coronavirus/2019-ncov/hcp/clinical-care.html

Providers are particularly recommended to test symptomatic patients in high risk groups, including:
  • Hospitalized patients
  • Persons 65 years of age or older or with underlying health conditions
  • Residents of congregate settings such as skilled nursing facilities, homeless shelters, and jails
  • Healthcare workers
  • First responders
Testing of Low Risk, Mildly Ill Patients
To spare personal protective equipment (PPE) and minimize infection control risks, low risk patients who are experiencing mild symptoms can be referred to county drive through facilities, which can be found at: https://occovid19.ochealthinfo.com/covid-19-testing

The increase in COVID-19 disease in the county has driven an increase in demand for testing. Difficulties in obtaining testing and delays in reporting of results are being reported by both providers and patients. Low risk, mildly ill persons with COVID-19 symptoms who are not able to access testing should isolate for at least 10 days as if they have COVID-19 and follow up with their provider if symptoms worsen.
Testing of Asymptomatic Patients
Testing of asymptomatic patients is most useful for containing outbreaks in specific populations, particularly congregate living settings such as skilled nursing facilities and homeless shelters.

Asymptomatic community close contacts will still need to be quarantined for 14 days after last exposure to the case, whatever the test result. With the current limitations of testing capacity in the county, OCHCA does not recommend that asymptomatic close contacts be routinely tested. 
General Testing Recommendations
  • Authorized assays for viral testing include those that detect SARS-CoV-2 nucleic acid or antigen
  • The CDC considers nasopharyngeal (NP), oropharyngeal (OP), nasal mid-turbinate, or nasal specimens to be acceptable specimens for testing initial diagnostic testing for SARS-CoV-2. 
  • OCHCA recommends NP or nasal swab testing when available for patients with symptomatic infection, as the cumulative evidence has indicated that NP specimens are the most sensitive of the upper respiratory tract, but nasal swabs have similar sensitivity and are easier to obtain
  • PCR testing of upper respiratory specimens in symptomatic patients is unknown but estimated to be in the range of 60-80%. Studies of rapid antigen tests have indicated that they are similarly sensitive or less sensitive compared to PCR tests. A negative PCR or antigen test should not be interpreted to rule out COVID-19 infection. 
  • PCR testing of lower respiratory specimens such as sputum, or bronchoalveolar lavage or tracheal aspirate specimens, may increase sensitivity and should be performed in addition to NP testing if available, especially if there is high clinical suspicion for COVID-19.
 
Contact Information
Please contact Communicable Disease Control Division at 714-834-8180 with questions or concerns. Please note that this number is now operational 24/7 for medical providers. Please do not share this number with patients.
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