As more COVID-19 tests become available, the Centers for Disease Control and Prevention (CDC) is broadening its criteria to test more symptomatic patients regardless of travel history or a known exposure to another case. The move comes as the outbreak response shifts from containment to broader social mitigation strategies, such as social distancing and banning large gatherings.

“With expanding spread of COVID-19, additional areas of geographic risk are being identified and the criteria for considering testing are being updated to reflect this spread,” the CDC stated in a health alert.1 In addition to public health labs, the Food and Drug Administration has granted emergency use authorization for more tests in clinical laboratories.

“Clinicians should use their judgment to determine if a patient has signs and symptoms compatible with COVID-19 and whether the patient should be tested,” the CDC stated. “Most patients with confirmed COVID-19 have developed fever and/or symptoms of acute respiratory illness (e.g., cough, difficulty breathing).”

Priorities for testing include:

  • hospitalized patients who have signs and symptoms compatible with COVID-19 in order to inform decisions related to infection control;
  • other symptomatic individuals, such as older adults (age 65 years) and individuals with chronic medical conditions and/or an immunocompromised state that may put them at higher risk for poor outcomes (e.g., diabetes, heart disease, receiving immunosuppressive medications, chronic lung disease, chronic kidney disease);
  • any persons, including healthcare personnel, who, within 14 days of symptom onset, had close contact with a suspect or laboratory-confirmed COVID-19 patient, or who have a history of travel from affected geographic areas within 14 days of their symptom onset.

Test for Flu as Well

“There are epidemiologic factors that may also help guide decisions about COVID-19 testing,” the CDC stated. “Documented COVID-19 infections in a jurisdiction and known community transmission may contribute to an epidemiologic risk assessment to inform testing decisions. Clinicians are strongly encouraged to test for other causes of respiratory illness (e.g., influenza).”

As this story was filed, the CDC was estimating that flu had led to about 350,000 hospitalizations and 20,000 deaths during the 2019-2020 season. Thus, many facilities have posted signs telling patients to cover coughs and sneezes and practice hand hygiene while waiting to check in.

“We believe in respiratory hygiene and etiquette,” says David Weber, MD, hospital epidemiologist and associate chief medical officer at the University of North Carolina Health Care in Chapel Hill. “If they are coughing or sneezing, they are given a mask and [told to] stay six feet away from other people the droplet spread distance. They are given tissues and asked to sneeze into them and throw them away. Then as soon as we are able, we move them to a private room. We are not just worried about COVID-19, but also transmission of flu and other respiratory diseases.”

Patients are screened at every hospital entrance, including those just coming in for an X-ray or a blood draw, he says.

“If we had a case [of COVID-19] admitted, we would put a monitor outside the room 24/7 to make sure that healthcare providers and everyone going in the room are logging in and out,” Weber says. “And to make sure someone doesn’t inadvertently go into the room without the proper personal protective equipment and that they don and doff it correctly.”

Mildly ill patients should be encouraged to stay home and contact their healthcare provider by phone for guidance about clinical management, the CDC recommends. Patients who have severe symptoms, such as difficulty breathing, should seek care immediately. Older patients and individuals who have underlying medical conditions or are immunocompromised should contact their physician early in the course of even mild illness.

Walk-in patients typically seen at clinics and emergency departments should be encouraged to call ahead if they may have been exposed during travel, says Michael Bell, MD, deputy director of the CDC Division of Healthcare Quality Promotion.

“If you receive such a call, we are telling healthcare systems that those individuals should be asked to put a mask on before they arrive,” he says. “Any assessment should be done in a place where they are not exposing other healthcare staff or patients.”

Protective equipment is only one factor in safe and appropriate care.

“Use nurse triage lines, call lines, advice lines for people who don’t require hospital care,” he says. “Include the option of symptomatic people waiting in their vehicles to be assessed. We do it when we are waiting for a table at [a restaurant]. We should be able to do it in the emergency department simply use their cell phones to bring them in one at a time.”

REFERENCE

  1. CDC. Updated guidance on evaluating and testing persons for coronavirus disease 2019 (COVID-19). CDC Health Alert Network. March 8, 2020. https://emergency.cdc.gov/han/2020/han00429.asp?deliveryName=USCDC_511-DM22106