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February 28, 2020, 15:05 ET (3:05 PM ET)
Update and Interim Guidance on Outbreak of Coronavirus Disease 2019 (COVID-19)
The Centers for Disease Control and Prevention (CDC) continues to closely monitor and respond to the COVID-19 outbreak caused by the novel coronavirus, SARS-CoV-2.
This CDC Health Alert Network (HAN) Update provides updated guidance on evaluating and testing persons under investigation (PUIs) for COVID-19. It supersedes guidance provided in CDC's HAN 427 distributed on February 1, 2020.
The outbreak that began in Wuhan, Hubei Province, has now spread throughout China and to 46 other countries and territories, including the United States. As of February 27, 2020, there were 78,497 reported cases in China and 3,797 cases in locations outside China. In addition to sustained transmission in China, there is evidence of community spread in several additional countries. CDC has updated travel guidance to reflect this information (https://www.cdc.gov/coronavirus/2019-ncov/travelers/index.html).
To date, there has been limited spread of COVID-19 in the United States. As of February 26, 2020, there were a total of 61 cases within the United States, 46 of these were among repatriated persons from high-risk settings. The other 15 cases were diagnosed in the United States; 12 were persons with a history of recent travel in China and 2 were persons in close household contact with a COVID-19 patient (i.e. person-to-person spread). One patient with COVID-19 who had no travel history or links to other known cases was reported on February 26, 2020, in California. The California Department of Public Health, local health departments, clinicians, and CDC are working together to investigate this case and are identifying contacts with whom this individual interacted.
CDC, state and local health departments, other federal agencies, and other partners have been implementing measures to slow and contain transmission of COVID-19 in the United States. These measures include assessing, monitoring, and caring for travelers arriving from areas with substantial COVID-19 transmission and identifying cases and contacts of cases in the United States.
Recognizing persons at risk for COVID-19 is a critical component of identifying cases and preventing further transmission. With expanding spread of COVID-19, additional areas of geographic risk are being identified and PUI criteria are being updated to reflect this spread. To prepare for possible additional person-to-person spread of COVID-19 in the United States, CDC continues to recommend that clinicians and state and local health departments consider COVID-19 in patients with severe respiratory illness even in the absence of travel history to affected areas or known exposure to another case.
Local or state health departments, in consultation with clinicians, should determine whether a patient is a PUI for COVID-19. The CDC clinical criteria for COVID-19 PUIs have been developed based on available information about this novel virus, as well as what is known about Severe Acute Respiratory Syndrome (SARS) (https://www.cdc.gov/sars/clinical/guidance.html) and Middle East Respiratory Syndrome (MERS) (https://www.cdc.gov/coronavirus/mers/interim-guidance.html#evaluation). These criteria are subject to change as additional information becomes available.
See the criteria to guide evaluation of PUI for COVID-19 at https://www.cdc.gov/coronavirus/2019-ncov/hcp/clinical-criteria.html.
These criteria are intended to serve as guidance for evaluation. In consultation with public health departments, patients should be evaluated on a case-by-case basis to determine the need for testing. Testing may be considered for deceased persons who would otherwise meet the PUI criteria.
Additional information is available in CDC's updated Interim Healthcare Infection Prevention and Control Recommendations for Patients with Confirmed COVID-19 or Persons Under Investigation for COVID-19 in Healthcare Settings (https://www.cdc.gov/coronavirus/2019-ncov/infection-control/control-recommendations.html).
Data to inform the definition of close contact are limited. Considerations when assessing close contact include the duration of exposure (e.g., longer exposure time likely increases exposure risk) and the clinical symptoms of the person with COVID-19 (e.g., coughing likely increases exposure risk, as does exposure to a severely ill patient). Special consideration should be given to healthcare personnel exposed in healthcare settings, as described in CDC's Interim U.S. Guidance for Risk Assessment and Public Health Management of Healthcare Personnel with Potential Exposure in a Healthcare Setting to Patients with COVID-19 (https://www.cdc.gov/coronavirus/2019-ncov/hcp/guidance-risk-assesment-hcp.html).
Clinicians should immediately implement recommended infection prevention and control practices (https://www.cdc.gov/coronavirus/2019-ncov/infection-control/control-recommendations.html) if a patient is suspected of having COVID-19. They should also notify infection control personnel at their healthcare facility and their state or local health department if a patient is classified as a PUI for COVID-19. State health departments that have identified a PUI or a laboratory-confirmed case should complete a PUI and Case Report form through the processes identified on CDC's Coronavirus Disease 2019 website (https://www.cdc.gov/coronavirus/2019-ncov/php/reporting-pui.html). State and local health departments can contact CDC's Emergency Operations Center (EOC) at 770-488-7100 for assistance with obtaining, storing, and shipping appropriate specimens to CDC for testing, including after hours or on weekends or holidays. Currently, diagnostic testing for COVID-19 is being performed at state public health laboratories and CDC. Testing for other respiratory pathogens should not delay specimen testing for COVID-19.
For initial diagnostic testing for SARS-CoV-2, CDC recommends collecting and testing upper respiratory tract specimens (nasopharyngeal AND oropharyngeal swabs). CDC also recommends testing lower respiratory tract specimens, if available. For patients who develop a productive cough, sputum should be collected and tested for SARS-CoV-2. The induction of sputum is not recommended. For patients for whom it is clinically indicated (e.g., those receiving invasive mechanical ventilation), a lower respiratory tract aspirate or bronchoalveolar lavage sample should be collected and tested as a lower respiratory tract specimen. Specimens should be collected as soon as possible once a PUI is identified, regardless of the time of symptom onset. See Interim Guidelines for Collecting, Handling, and Testing Clinical Specimens from Patients Under Investigation (PUIs) for COVID-19 (https://www.cdc.gov/coronavirus/2019-nCoV/lab/guidelines-clinical-specimens.html) and Biosafety FAQs for handling and processing specimens from suspected cases and PUIs (https://www.cdc.gov/coronavirus/2019-ncov/lab/biosafety-faqs.html).
More information is available at the COVID-19 website: https://www.cdc.gov/coronavirus/2019-ncov/index.html.
The Centers for Disease Control and Prevention (CDC) protects people's health and safety by preventing and controlling diseases and injuries; enhances health decisions by providing credible information on critical health issues; and promotes healthy living through strong partnerships with local, national, and international organizations.
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