Infection Control for Long-term Care and COVID-19 Updates

HAI/AR Team, Healthcare Safety Group

Michael Fischer, MD, MPH & TM

Susana Baumann, MPH, CIC

COVID-19 & Texas DSHS Response

• State Medical Operations Center fully activated• Guidance document team• Literature review team• Call center (dial: 211)

• HAI Epidemiologists have a representative in the SMOC to assist with the clinical guidance team

• Currently serving as on-call epidemiologists for respective regions

DSHS Response

Where to start?

https://www.dshs.texas.gov/coronavirus/

Case Counts

• As of March 24, 2020• DSHS reporting of cases follow a new methodology to better represent real-

time reporting of cases

Texas Case Counts: https://txdshs.maps.arcgis.com/apps/opsdashboard/index.html#/ed483ecd702b4298ab01e8b9cafc8b83

https://www.dshs.texas.gov/coronavirus/

Case CountsNew Methodology (as of 03/24/2020)

• DSHS updated the method of reporting COVID-19 cases in Texas to provide the public with more timely information.

• The DSHS daily case count now includes all cases reported publicly by local health departments around the state. With the change, Texas is now reporting an additional 305 cases of COVID-19.

• The case counts do not include people who were repatriated from:

• China or • A cruise ship on U.S. government flights to JBSA-Lackland in

San Antonio.

• Data produced by the Texas Department of State Health Services, Laboratory and Infectious Disease Services.

• This dashboard will be updated daily by 12 Noon. Data displayed are current as of 8pm for the prior day.

https://txdshs.maps.arcgis.com/apps/opsdashboard/index.html#/ed483ecd702b4298ab01e8b9cafc8b83

Texas DSHS COVID-19Dashboard/Map

• https://txdshs.maps.arcgis.com/apps/opsdashboard/index.html#/ed483ecd702b4298ab01e8b9cafc8b83

• Data produced by the Texas Department of State Health Services, Laboratory and Infectious Disease Services.

• This dashboard will be updated daily by 12 Noon. Data displayed are current as of 8pm for the prior day.

https://www.cdc.gov/coronavirus/2019-ncov/cases-updates/cases-in-us.html

Updated March 25, 2020

CDC - Situation Summaryhttps://www.cdc.gov/coronavirus/2019-ncov/cases-updates/summary.html

https://www.cdc.gov/coronavirus/2019-ncov/cases-updates/cases-in-us.html

Updated March 25, 2020

Based upon available information to date, those at high-risk for severe illness from COVID-19 include:

• People aged 65 years and older

• People who live in a nursing home or long-term care facility

• Other high-risk conditions could include:• Chronic lung disease or moderate to severe asthma• Serious heart conditions• Immunocompromised including cancer treatment• People of any age with

• Severe obesity (body mass index [BMI] >40)• Certain underlying medical conditions, particularly if not well controlled,:

• Diabetes• Renal failure• Liver disease

• People who are pregnant should be monitored since they are known to be at risk with severe viral illness, however, to date data on COVID-19 has not shown increased risk

• Many conditions can cause a person to be immunocompromised, including cancer treatment, smoking, bone marrow or organ transplantation, immune deficiencies, poorly controlled HIV or AIDS, and prolonged use of corticosteroids and other immune weakening medications

High-Risk Individuals:

Coronavirus Self-Checker on the CDC’s Symptoms & Testing• https://www.cdc.gov/coronavirus/2019-ncov/symptoms-testing/index.html

Symptoms may appear 2-14 days after exposure • Fever• Cough• Shortness of breath

COVID-19 - Symptoms

The clinical spectrum of COVID-19:• Asymptomatic• Mild disease with non-specific signs• Symptoms of acute respiratory illness• Severe pneumonia with respiratory failure and septic shock

Interim Criteria to Guide Testing of Persons Under Investigation (PUIs)Texas Public Health Laboratories - Testing Criteria

Clinical Features & Epidemiologic Risk Fever1 or signs/symptoms of lower respiratory illness (e.g., cough or shortness of breath) AND Any person, including health care workers2, who has had close contact3 with

a laboratory-confirmed4 COVID-19 patient within 14 days of symptom onset

Fever1 and signs/symptoms of lower respiratory illness (e.g., cough or shortness of breath)5 AND

A history of travel from affected geographic areas6 (see below) within 14 days of symptom onset

ORAn individual(s) with risk factors that put them at higher risk of poor outcomes7

Fever1 and signs/symptoms of lower respiratory illness (e.g., cough or shortness of breath) requiring hospitalization5 AND No source of exposure has been identified

1 Fever may be subjective or confirmed. 2 For healthcare personnel, testing may be considered if there has been exposure to a person with suspected COVID-19 without

laboratory confirmation. Because of their often extensive and close contact with vulnerable patients in healthcare settings, even mild signs and symptoms (e.g., sore throat) of COVID-19 should be evaluated among potentially exposed healthcare personnel. Additional information is available in CDC’s Interim U.S. Guidance for Risk Assessment and Public Health Management of Healthcare Personnelwith Potential Exposure in a Healthcare Setting to Patients with Coronavirus Disease 2019 (COVID-19).

3 Close contact is defined as—a)being within approximately 6 feet (2 meters) of a COVID-19 case for a prolonged period of time; close contact can occur while

caring for, living with, visiting, or sharing a healthcare waiting area or room with a COVID-19 case, – or –b)having direct contact with infectious secretions of a COVID-19 case (e.g., being coughed on).

https://dshs.texas.gov/coronavirus/healthprof.aspx

Notice Regarding Testing and Submission of Specimens for COVID-19 to the DSHS Austin Laboratory

As of March 20, 2020, the Texas DSHS Laboratory has made the following changes to the COVID-19 Specimen Collection and Submission Instructions located on the DSHS Laboratory website:

• These instructions apply only to the DSHS Austin Laboratory. For information regarding submission to other Public Health Laboratories in Texas, contact your local health department.

• We recommend sending only a single Nasopharyngeal swab in VTM. Please see additional language under the section, “Specimen Types.”

• A sample G-2V submission has been added to clarify instructions to fill out the form.

• ALL specimens for COVID-19 testing require preapproval. Contact your Local Health Department or DSHS Public Health Region to ensure patient meets Person Under Investigation (PUI) criteria for testing and to obtain DSHS approval to test. Specimens MUST meet DSHS PUI criteria and have a state specific PUI identification number for testing prior to shipping and WILL NOT be tested without prior approval. Please DO NOT ship specimens prior to receiving this approval.

Updated 3/20/2020

Testing and Submission of Specimens to DSHS Austin Lab

https://www.dshs.state.tx.us/coronavirus/healthprof.aspx

As of March 13, the following private labs are offering, or will shortly begin offering, COVID-19 testing:

• Quest• CPL• Mayo• LabCorp• ARUP

Laboratory Testing – Private Labs

• Coronavirus Disease 2019 (COVID-19) Local Health Entities

https://www.dshs.state.tx.us/regions/2019-nCoV-Local-Health-Entities/

Contact information for the Local Health Entity for your jurisdiction.

Updates to CDC GuidanceAs of March 23, 2020

CDC Guidance

• Texas DSHS is following CDC guidance for infection control• Visit https://www.dshs.state.tx.us/coronavirus/ for the latest updates• E-mail coronavirus@dshs.texas.gov for COVID questions• Dial 2-1-1 and choose option 6 for the COVID call center

• Guidance changing rapidly• Guidance in unprecedented situations (e.g., PPE shortages)• Guidance specifically for long-term care facilities

• Find this guidance on Texas DSHS website, links to CDC

Texas DSHS COVID-19Dashboard/Map

Stop the Spread of Germs flyer• https://www.dshs.state.tx.us/coronavirus/

docs/StopSpreadofGerms-English.pdf

CDC information on how COVID-19 is spread• https://www.cdc.gov/coronavirus/2019-

ncov/about/transmission.html

• Nursing homes and other long-term care facilities can take steps to assess and improve their preparedness for responding to COVID-19.

• The COVID-19 Preparedness Checklist for Nursing Homes and other Long-Term Care Settings [PDF – 1 MB] should be used as one tool to develop a comprehensive COVID-19 response plan, including plans for:

1. Rapid identification and management of ill residents2. Considerations for visitors and consultant staff3. Supplies and resources4. Sick leave policies and other occupational health considerations5. Education and training6. Surge capacity for staffing, equipment and supplies, and postmortem care

COVID-19 Preparedness Checklist for Nursing Homes and other Long-Term Care Settings:

https://www.cdc.gov/coronavirus/2019-ncov/healthcare-facilities/prevent-spread-in-long-term-care-facilities.html

• Major recommendations• Restrict non-essential visitors• Essential visitors should be screened prior to entry

(temperature, symptoms, travel, contact with confirmed COVID) except emergency services personnel

• Screening of residents who leave facility and return

• Review emergency preparedness policies• Elements should include:

• Universal precautions• Staffing and contingency plans• Ensuring uninterrupted supplies (linens, medicine, food)

Infection Control Guidelines

• Personal Protective Equipment• CDC has urged facilities to strategize PPE use, defined 3 tiers:

• Conventional Capacity • Contingency Capacity• Crisis Alternate Strategies

• All of the tiers (except conventional) address • Use of N95 respirators beyond the manufacturer-designated shelf life for

training and fit testing• Extended use of N95 respirators

• Refers to the practice of wearing the same N95 respirator between patients• Limited re-use of N95 respirators for tuberculosis

Infection Control Guidelines

CDC LTC Assessment Tool

Thank you!

Susana Baumann, MPH, CICHAI Epidemiologist Region 9/10

O: 512-776-6545 C: 512-422-0606

Michael P. Fischer, MD, MPH & TMAntibiotic Stewardship Expert

O: 512-776-6338 F: 512-776-7616