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 Epidemiologist

Bureau of Infectious Disease and Laboratory SciencesMA Department of Public Health

June 30, 2020

Topics Today• MAVEN Status Map

• MAVEN Review

• Immediate Workflow

• Final Review Workflow

• Your Questions

• Masks

• Tasks

• Workflows

• Contacts

• Essential Workers

• Misc.

• Your comments welcome on future webinars! 2

Updates for today, Tuesday, 6/30

• MAVEN Status Map – one town to go

• COVID-19 Immediate Notification Workflow – please review and clear out all COVID cases in this workflow

• Updated LBOH Final Review Workflow – we have removed COVID-19 events

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MAVEN Status Map as of 6/30/2020

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Immediate Notification workflow (COVID-19 Only)

• UPDATE: We have updated the COVID-19 Immediate Notification Workflow

• This will allow proper notification of all new COVID-19 events for your jurisdiction.

• Please review all events/cases in this workflow and complete your Step 1- LBOH Notification to “Yes” to clear out this workflow.

• If you are retaining ownership then complete Steps 2 (Investigation Started) & 3 (LBOH Investigator (name, lboh, phone number)

• When you are done then complete Steps 4 (CRF Complete) & 5(Final Review)

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LBOH Final Review Workflow

• LBOH Final Review Workflow: We have updated the workflow to only show non-COVID-19 cases that are still pending. Please review this workflow and complete or close out any older events/cases.

• Once you complete Step 5 these non-COVID cases will be removoed

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MAVEN Help

Section

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Tuesday Webinars Going Forward

• Isolation of Cases and Quarantine of Contacts is the goal until that strategy changes/evolves.

• MAVEN is the main reporting source and where you should document your work.• Send Cases to CTC for follow-up if not:

• Hospitalized, Deceased, or linked to a Cluster Facility

• Focusing on Priority Activities

• Clusters in Facilities in your community need your help.• Call Epi Program to create cluster events.

Tuesdays @ 11am will continue in July

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@state.ma.usMDPH Food Protection Program: 617-983-6712 CTC Help Desk: 857-305-2828COVID19CommunityTracingCollaborativeQuestions@mass.gov

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Your Questions: Masks

• Q. Can we discuss workplace exposure as it relates to mask wearing vs 6 foot separation and close contacts?

• A. Cloth mask wearing is a risk reduction tool, but does not mean no exposure occurred. The hope would be the masks reduced the spread of respiratory droplets while the two colleagues were in close contact, but the contact is still a close contact.

• A close contact that wore a cloth mask would still need to quarantine. A confirmed case wearing a cloth mask could still expose others through close contact.

• Cloth masks reduce risk but do not prevent exposure completely.

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Close Contact & Risk • Q. Can you go over close contact - is it close contact if you are wearing a

mask and more than 15 minutes and closer than 6 ft, etc.?

• A. We give a clear cutoff of >10-15 consecutive minutes within 6 feet of an infectious individual to give us a starting point to work with.

• Cloth masks are a risk reduction tool. They do not completely prevent exposure.• If a case and contact wore cloth masks together, you would still consider the contact exposed and

need to quarantine – but hopefully they have reduced their chances of developing illness by wearing those masks.

• Timing is linear. • The more time you spend with a case, the greater your risk for exposure and infection. The person

who sits next to a case for 4 hours is at a greater risk of infection than the person who sat next to the case for 20 minutes, but we would consider them both close contacts that need to quarantine.

• Space is linear as well.• The person who sits right next to a case is at greater risk than the person who sits 6 ft away, and that

person is at greater risk of exposure than the person who is 8 feet away.

Remember, all these elements are “and” components of risk reduction not “or.” Nothing replaces anything else. They all help, and together help more in reducing risk.

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Close Contact & Risk • There will be scenarios that do not meet the definition of Close Contact per

our cutoff, but that does not mean the contact wasn’t exposed. We need a cutoff, and we need guidance to help people reduce risk, which is why we say 6 feet. (Data supports using this metric.)

• Other things that affect risk:• Enclosed vs. Open spaces.• Activities that expel droplets (singing, exercising, playing an instrument, yelling, etc.)

• We focus our follow-up efforts on “close contacts” because they are at the greatest risk. • People can reduce their risk by practicing risk minimizing behaviors, but we would still

consider them exposed. • Ex: A hair dresser and client are masked and gloved, but the hair dresser then tests positive.

• The client was still exposed and should quarantine (but hopefully has reduced their risk of developing illness by wearing masks and other things)

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Your Questions: Contacts in MAVEN

• Can you please confirm: for close contacts that are NOT positive- we just complete Question Package 6 (contact monitoring)?

• A. The big data points for contacts are in QP6, which include the exposure date, the last day of quarantine, and the Contact Monitoring Status (and if you do additional check-in assessments, you can track the contact’s symptoms here – but not required).

• You still need to complete Admin QP1 steps 1-5.

• Demographic information is important

• (Particularly if this Contact becomes a case down the road.)

• Correct Address

• Race & Hispanic Status

• Occupation

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6 Question Packages

Confirmed/Probable/Suspect/Contact

What’s linked? Go here to see/link to contacts or a cluster event.

Lab Tab to see lab

tests

View Wizard

Patient Person Details (address, phone)

Electronic Trail for this event. Who

has entered data? Where did this

case come from?

This View of a COVID event looks the same

for cases and contacts. They all have the same

Question Packages Available.

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Confirmed/Probable/Suspect/Contact

What’s linked? Go here to see/link to contacts or a cluster event.

Lab Tab to see lab

tests

View Wizard

Patient Person Details (address, phone)

Electronic Trail for this event. Who

has entered data? Where did this

case come from?CONTACTS: Fill Out

1. Administrative2. Demographic

6. Contact Monitoring

Confirmed/Probable Cases: Fill Out 1. Administrative2. Demographic

3. Clinical5. Risk/Exposure

6. Contact Monitoring (just status)14

What’s Needed in MAVEN for Contacts?• At assignment, make sure your contact information is in the Admin QP.

• Step 1 - LBOH acknowledged• Step 2 – Investigation Started = YES• Step 3 - Step 3 - LBOH/Agency Investigator:• Complete dropdown of your name and phone, etc.

• Enough Identifying Information to Contact Them.• Address & Gender (Participants Tab)• Race & Hispanic Status (Demographic QP#2)• Occupation (Demographic QP#2)

• Contact Monitoring Question Package (QP#6)• Contact Monitoring Status

• In Progress – you’ve notified this contact and they are in quarantine.• Left Blank – we wonder what’s going on• Completed – The quarantine is complete.• Transfer – needs to go to another jurisdiction (update the notes so we know).

• Last Potential Exposure Date (helps establish quarantine period)• Last Day of Required Monitoring (14 days after exposure)

• In this question package, you can track daily temps, but this is not required.

• Once the 14 day quarantine/monitoring period is over and the contact is done, CRF Reviewed in the Admin Question Package willclear the contact from the CONTACT workflow.• Make sure all notes are updated.• Step 4 - Case Report Form Completed: Yes• Completed by: LBOH

1. Notify Contact 1. give them information on how

to quarantine and for how long.

2. Make sure they have a plan for contacting their provider if symptoms develop.

2. Create Contact’s MAVEN Event.3. Check back in at end of Quarantine

and update and sign off on case.

If you are creating a contact for another town, make sure to give them your contact

info and SHARE the index case.

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MAVEN FAQs

How do you sign off on CONTACTS after 14 days? Is there a Wizard for Contacts?

• CONTACT events over 2 weeks old (done with quarantine) can be signed off after a last check-in.

• Contact Monitoring Question Package

• Contact Monitoring Status= Completed

• Admin Question Package

• Complete Steps 1-5 to move these along.

• The COVID Wizard is for all COVID events (Contacts or Cases). You can fill out the appropriate variables in the Wizard View as well.

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What Should LBOH Complete in MAVEN for Cases

Data Entry in MAVEN

• Participants Tab (edit Person button)• Gender• Address (confirm address is correct for facility

residents. Confirm address is correct for HCWs that live elsewhere (not at facility)).

• QP2 - Demographic• Race• Is case Hispanic?• Employer Name & Occupation (for HCP or “retired” for

residents, etc.)

• QP3 – Clinical • Symptom variables (onset date & symptoms) • Underlying illness• Clinical complications• Was case hospitalized?

• Hospital Name

• Outcome:• Died or Recovered. This is where deaths are captured.

•

• Question Package 5: Risk/Exposure/Control & Prevention• “Employed at, admitted to, or visited a healthcare

Setting?”• Yes/No/Unk• Where is the facility located? (facility name & town OR

facility name & full address?) • “Is case a healthcare worker?”

• “Does the case have direct patient care responsibilities?” & • “Worker type?”

• Contact Monitoring Status in QP6 needs to be =COMPLETED. • This maven variable will need to be updated to Contact

monitoring status: “completed” by LBOH once patient is no longer in isolation and no longer under Transmission Based Precautions.

• All confirmed events will remain on the First Responders Reports until this variable is completed, indicating the patient is no longer infectious to others.

Most of this can be completed in Wizard

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Your Questions: HCWs & Serology

• Q. How do we treat hospital/employee serology testing results?

• A. We treat hospital/employee serology test results the same way we do others.

• Consult the Serology Interpretation Guide (June 1): http://www.maventrainingsite.com/maven-help/pdf/Serology%20Interpretation%20for%20LBOH_ver3.0_June1.pdf

• If you just have a serology result, remember to interview and see if they have had symptoms in last 14 days. If not, they do not need to isolate. If they HAVE had recent symptoms, we would follow-up accordingly.

• Remember with HCWs and other Essential Employees: Their only ‘special treatment’ is following an exposure. They can potentially continue to work if they remain asymptomatic and do not test positive.

• However, there is NO exception for an essential employee who is a CASE. Cases must isolate if indicated. If a HCW tests positive, they do not get to continue working. Also, symptomatic HCWs should isolate (even if pending test results). No one with symptoms should be working.

• Future guidance on essential workers and the ability to work during quarantine may change, so stay tuned.

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Your Questions: Long Recoveries

• Q. I have had questions about when to complete/sign off on a case on Maven when they have long recoveries at long term care facilities.

• A. You can complete most of the variables for a case in MAVEN. The last items pending sign off are the Admin QP steps 4 & 5 (completing the CRF (Case Report Form)), and the Contact Monitoring Status=Complete in Risk QP6. These should occur when a patient comes off transmission based precautions.

• This can take a while for some patients and facilities. If you are just waiting for a few residents at some facilities, you can finish most of the data entry and set yourself a calendar reminder to check in with the facility every few days.

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Your Questions: Address Changes

• Q. What is the protocol for changing address if someone’s permanent address is out of state? Do we need to email ISIS?

• A. If you have a confirmed or probable case you investigate and determine after interview it needs to be updated to an official address out of state, update all the information/notes in the MAVEN event and update the official address.

• Remember, changing an official address is a two step process.

1. Edit address in the Participant’s Tab

2. “Select Official Address” hyperlink in the Demographic QP

• If you have correctly updated the official address to Out of State, you do not need to email ISIS. ISIS will identify out of state cases and send the full report to the applicable state health department. If you have any issues or are not sure you correctly updated an address, email isishelp@state.ma.us.

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Your Questions:

• Q. Under workflow "my group open tasks" What is this? Looks like the cases are complete but still in workflow?

• A. Tasks are another feature of MAVEN. Some LBOHs use tasks frequently for lots of functions – like supervisors assigning different follow-up activities.

• You can task an individual MAVEN user OR a MAVEN Group (the same way you could share an event).

• Case “assignments” are also in the form of tasks, so you may have lots of tasks in a task workflow if cases were assigned to your LBOH User Groups.

• You could mark them complete in bulk or individually.

• The same process could be used for “Shared with Me” workflows. You can unshare and it would remove that event from your workflows.

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Tasks also have workflows

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Task Tab shows any tasks for an event. Most common is

“assignment.” You can update the task status to Completed and it will

exit your tasks workflow.

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Your Questions:• What do we do if we identify a new +PCR in a previously confirmed case

that originally tested PCR positive & recovered >6-8 weeks ago?

• A. We do not yet have a good way to identify these situations automatically in MAVEN, however if you identify them and have questions on follow-up, please let us know.

• An extra new lab created a new event instead of appending to the old event.

• Email ISIS to merge the two events.

• You may simply notice the new lab.

• Someone may have brought it to your attention (the case, provider, etc.)

• We want to know :

• Why was this person tested again?

• Did they have new symptoms? (What are they? When onset? – put in notes for now)

• Did they have any new exposures?

• If patient is symptomatic and you think this could be a reinfection, the patient should isolate. Call 617-983-6800 if you have any questions on case management.

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Your Questions: Contacts

• Q. For contacts of Positive COVID-19 cases, are we recommending that they get tested and how long should they quarantine?

• A. Yes! May 13, 2020 State Guidance recommends testing of contacts right away (in their 14 day quarantine period).

• They should then continue to isolate for the rest of their 14 day quarantine period.

• They only need to be tested again if they later develop symptoms.

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Recommendation for Routine Molecular Testing of People Identified as Close Contacts to COVID‐19 Cases

• Close contacts, regardless of symptoms associated with COVID-19, should be tested as soon as possible after they are notified of their exposure to COVID-19.

• Testing should be done by PCR or other molecular test from a nasopharyngeal, nasal, or oral swab or a sputum sample. Serologic (antibody) testing is not appropriate for this use.

• The contact is required to quarantine for the full 14 days, even following a negative test result.

• Have a low threshold for symptoms (even after the negative test) and retest if someone starts to show illness during the rest of quarantine.

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Close Contacts & Testing Questions

Q. What if a close contact tests negative but develops symptoms at a later date? Should they test again?

• A. Yes, the contact should seek additional testing if and when they later develop symptoms, even if they initially obtained testing and were negative shortly after being identified as a contact but before symptoms developed.

• Contacts only need to be tested once if they never develop symptoms through the rest of their quarantine. But if they end up developing symptoms, the recommendation is to be tested again.

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Close Contacts & Testing Questions

Q. We have had a few children identified as contacts that couldn’t get tested because of their age. What should we do?

• A. The guidance to test contacts does not have an age component, so it is still recommended even for children. That being said, we are also hearing it is difficult for children to obtain testing.

• Ultimately, if they have no symptoms develop and they complete their quarantine period, they could return to normal activities, even if we didn’t get them tested in the interim.

• So do what you can do. The most important part is maintaining the appropriate quarantine and having a low threshold for identifying symptoms should they develop.

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“Test Pass” for Contacts

• New document that identified contacts of COVID-19 Cases can bring to provider office to obtain testing.

• Goal: Increase testing access for contacts (particularly if asymptomatic).

• Word document – can be edited by LBOH to add your town contact info/seal.

• In MAVEN Help COVID-19 Case Follow-up Tools Folder

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Your Questions: Essential Workers

• Q. Is the isolation period for non essential workers and essential workers the same or different?

• A. It is the same.• There may be some old documentation where we separated out HCWs, essential workers and

asymptomatic people, etc. but the Table for Discontinuing Isolation and Returning to work is the same in both documents here:

• DPH Guidance, updated May 7: Healthcare Personnel: Occupational Exposure & Return to Work Guidance

• DPH Guidance, updated May 7: Non-Healthcare Workers: Occupational Exposure & Return to Work Guidance

• If symptoms were present: You can use a Symptom Based Strategy or a Test Based Strategy to discontinue isolation.

• If no symptoms were present: You can use a Time Based Strategy or a Test Based Strategy.

Current List of Essential Services: https://www.mass.gov/info-details/covid-19-essential-services

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Your Questions- Ending Isolation

• Can you clarify when someone can come back to work via the Symptom Based Strategy?

• A. If using a Symptom Based Strategy to determine ending isolation, they must meet ALL of the following criteria:

❑ At least 3 days (72 hours) have passed since recovery defined as resolution of fever without the use of fever-reducing medications and

❑ Improvement in respiratory symptoms (e.g., cough, shortness of breath); and,

❑ At least 10 days have passed since symptoms first appeared.

• So at a MINIMUM, a patient would be isolated for 10 days from their symptom onset date. But it could be more. 31

Where is the Official Discontinuation of Isolation Guidance? Revised May 7, 2020

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Updated Discontinuation of Isolation Guidance!

❑At least 3 days (72 hours) have passed since recovery defined as

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

❑ improvement in respiratory 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 respiratory 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 testing

Use Symptom Onset Date

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Updated 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.

Note, because symptoms cannot be used to gauge where these individuals are in the course of their illness, it is possible that the duration of viral shedding could be longer or shorter than 10 days after their first positive test.

❑ 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

OR

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Summary of New Guidance & Tools• Date: June 1, 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: For serology positive individuals, ask about recent symptoms. Those individuals should be isolated and

their contacts quarantined. Serology positive but no recent symptoms do not require further public health follow-up at this time.

• Date: May 13, 2020 - Testing of Persons with Suspect COVID-19• Updated Testing Guidance saying who should be tested.

• Includes language stating we should test CONTACTS to COVID-19 right away.• Discourages serology testing.

• BUT, if you ARE going to get serology testing, get a PCR at the same time.

• Date: May 11, 2020 - Recommendation for Routine Molecular Testing of People Identified as Close Contacts to COVID‐19 Cases• Recommendation to Test Contacts identified through contact tracing – regardless of symptoms.

• They still need to isolate a full quarantine period, even if their test comes back negative early in quarantine.

• Date: May 7, 2020 – Occupational Exposure & Return to Work Guidance• HCW & Non-HCW discontinuation of Isolation Guidance.

• Describes strategies for ending isolation for cases.• Also outlines requirements for quarantine for contacts• (While there are two documents (HCW & non-HCW), the key table on the front page is identical and tells key information)

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

https://www.mass.gov/doc/notification-to-test-contacts-regardless-of-symptoms-0/download

http://www.maventrainingsite.com/maven-help/pdf/Serology%20Interpretation%20for%20LBOH_ver3.0_June1.pdf

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

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