PUBLIC HEALTH DIVISION Acute and Communicable Disease Prevention Kate Brown, Governor 800 NE Oregon St, Suite 772 Portland, OR 97232 Voice: 971-673-1111 Fax: 971-673-1100 TTY: 971-673-0372 March 16, 2020 Provisional guidance for health systems regarding COVID-19 testing Federal and Oregon Health Authority (OHA) guidance recently expanded the criteria for COVID-19 testing, deferring testing decisions in large part to clinicians. Given growing availability of commercial testing options, and less dependence on the Oregon State Public Health Laboratory for testing, providers should soon have access to more expanded testing based on clinical judgment. Public Health approval is not needed for this testing. The Oregon State Public Health Laboratory (OSPHL) continues to prioritize testing for symptomatic healthcare workers, people who might have exposed others at high risk, patients requiring hospitalization who meet certain criteria, and those with epidemiological links, such as contact with a confirmed COVID-19 case. These criteria are described below. OSPHL has capacity to test 80 specimens per day. Testing through Commercial Laboratories Outpatient clinics 1. Clinicians in the community can order COVID-19 testing at their discretion through commercial labs, including LabCorp and Quest Diagnostics. a. Clinicians do not need to routinely notify the local public health authority (LPHA) or OHA when evaluating patients with respiratory illness or ordering COVID-19 testing. b. Given the still limited availability of COVID-19 testing and the prevalence of influenza, an influenza test should be completed and determined to be negative prior to ordering COVID-19 testing. 2. Criteria that could be considered in decisions about whether to test for COVID-19 include. a. Epidemiologic risk factors for illness or subsequent spread i) Close contact with suspected or confirmed COVID-19 case: * within 6 feet of a person ill with COVID-19 for a prolonged period (>1 hour). -OR* direct contact with secretions of an ill COVID-19 case (e.g., being coughed on) ii) Travel to affected areas www.cdc.gov/coronavirus/2019-ncov/travelers/index.html iii) Residence or employment in a healthcare or long-term care facility iv) Potential exposure of large numbers of people at high risk for severe illness, for example, in settings like healthcare, long-term care facilities, jail/prison or shelters 1 OHA 2267 (03/19/2020) b. Clinical presentation i) Symptoms of acute respiratory illness (cough, dyspnea) with or without fever ii) (During influenza season) negative testing for influenza. 3. Patients presenting with respiratory symptoms should be masked. Providers should use standard, contact, and droplet precautions with eye protection for the evaluation or treatment of a patient with respiratory symptoms. 4. If a patient does not have a clinical need to be sent to the emergency department or a hospital, do not send them there. a. Patients with respiratory symptoms should be advised to self-isolate at home until 72 hours after both fever and cough (if present) resolve, without the use of feverreducing medications. b. Discuss a plan to seek appropriate medical care should symptoms worsen. 5. Avoid any aerosol-generating procedures, including respiratory therapy treatments (i.e., nebulized medications), that are not immediately required for patient care. a. Collection of nasopharyngeal (NP) and oropharyngeal (OP) swabs is not considered an aerosol- generating procedure. Inpatient facilities 1. Clinicians in the community can order COVID-19 testing at their discretion through commercial labs, including LabCorp and Quest Diagnostics. a. Clinicians do not need to routinely notify the local public health agency (LPHA) or OHA when evaluating patients with respiratory illness or ordering COVID-19 testing. b. An influenza test should be completed prior to ordering COVID-19 testing. Testing through Oregon State Public Health Laboratory 2. For expedited testing approval for COVID-19 testing at the Oregon State Public Health Laboratory: a. A patient who meets all three of the following criteria will be approved for testing: i. Clinical need for admission to an inpatient facility; ii. Evidence of viral lower respiratory infection; and iii. Tested negative for influenza. b. For such patients, clinicians must submit an electronic request for testing through a Confidential Oregon Morbidity Report, found at www.healthoregon.org/howtoreport: i. Click the button for “Online Morbidity Report.” ii. Select COVID-19. iii. Answer all three clinical questions. iv. Complete all of the requested information. v. Public health officials will review the electronic submission for record-keeping. c. A completed Virology/Immunology Test Request form must accompany the specimen. See Section 5.a. for details. d. For such patients, you do not need to call your local public health authority or Oregon Health Authority for approval. 2 OHA 2267 (03/19/2020) 3. Patients not meeting the criteria in #2 may be considered for COVID-19 testing at OSPHL if they meet any of the following criteria: i. Fever or symptoms of lower respiratory illness (e.g., cough, dyspnea), and close contact with a laboratory-confirmed COVID-19 patient in the 14 days before symptom onset; ii. Fever and symptoms of lower respiratory illness (e.g., cough, dyspnea), and history of travel from affected geographic areas with widespread COVID-19 transmission in the 14 days before symptom onset; or iii. Fever with severe acute lower respiratory illness (e.g., pneumonia, ARDS) requiring hospitalization and without alternative explanatory diagnosis (e.g., influenza). iv. On a case-by-case basis, testing of other patients may be considered. a. For such patients, clinicians must contact the OHA epidemiologist on call (971-6731111, option 3) to obtain approval prior to submitting specimens to OSPHL. 4. Collecting specimens a. Specimens should be collected under appropriate precautions: i. Nasopharyngeal swabs should be collected under standard, contact and droplet precautions with eye protection. 1. The healthcare provider should be wearing full contact and droplet precaution personal protective equipment, including a facemask, eye protection, gown and gloves. ii. Induction of sputum and collection of other specimens involving aerosolgenerating procedures should be collected under standard, contact and airborne precautions with eye protection. 1. If available, place the patient in an airborne infection isolation room (AIIR). 2. The healthcare provider should be wearing full airborne precaution personal protective equipment, including a respirator (N95 or better), eye protection, gown and gloves. b. OSPHL will test 1 specimen per patient. i. Specimen priority in descending order is bronchoalveolar lavage fluid or endotracheal aspirate, then sputum, then nasopharyngeal swab, then nasal wash. ii. If more than 1 specimen is received, OSPHL will typically test only the highest- priority one. c. Refrigerate specimens (2°–8° C) until they can be sent to OSPHL. If >72 hours is anticipated for specimen storage/transport prior to testing, freeze at -70°C or below. 5. Sending specimens and forms a. Complete specimen collection guidance and the Test Request Form are available at www.oregon.gov/oha/PH/LABORATORYSERVICES/Pages/COVID-19.aspx i. Complete the OSPHL Virology/Immunology Test Request form. In the “OTHER/MOLECULAR” section, mark the checkbox indicating “Other,” and type or write in “2019-nCoV” or “COVID- 19” on the line provided. ii. Incorrectly completed or incomplete test request forms cause a delay in testing. iii. Transport specimens at refrigerated temperatures (2°–8° C). 3 OHA 2267 (03/19/2020) iv. Send specimens so as to be received at OSPHL during expanded business hours. 1. Monday–Friday, between 7:00 AM and 5:00 PM. 2. Saturday and Sunday, between 10:00 AM and 12:00 noon. 6. Clinical care of patients being tested and healthcare infection prevention a. Use standard, contact and droplet precautions with eye protection when caring for patients with suspected or confirmed COVID-19 patients (facemask, eye protection, gown and gloves). b. Use standard, contact and airborne precautions with eye protection when performing aerosol-generating procedures (N95 respirator or better, eye protection, gown and gloves) c. For more details, please see OHA’s Provisional Guidance: Clinical Care and Healthcare Infection Prevention and Control for COVID-19 at healthoregon.org/hcpcovid19. 4 OHA 2267 (03/19/2020)