NEW YORK CITY DEPARTMENT OF HEALTH AND MENTAL HYGIENE Oxiris Barbot, MD Commissioner 2020 Advisory #8 COVID-19 Update for New York City • • Outpatient testing must not be encouraged, promoted or advertised. Persons with COVID-like illness not requiring hospitalization should be instructed to stay home. It is safer for the patients and health care workers and testing does not currently change clinical management or recommendations about staying home.  Hospital systems may create alternate testing venues to offload their emergency departments. • • • • • • • • • • • This minimizes risk of transmission to others, especially healthcare workers (HCWs) There is a national shortage of personal protective equipment (PPE), collection swabs, and viral transport media supplies and it is critical that laboratory testing be prioritized for hospitalized patients There is no reason to test asymptomatic persons or mild-to-moderately ill persons who are not hospitalized, including HCW or first responders Testing may play a more significant role after the pandemic has peaked PRESERVE PPE for HCWs providing medically necessary care for hospitalized patients Like other jurisdictions with general community transmission of COVID-19, New York City (NYC) is facing a critical shortage of PPE PPE stockpile supplies in NYC are extremely limited and must be released based on strict criteria to preserve healthcare functions Refer to NYC Health Department and CDC guidance on crisis strategies for preserving PPE Be aware of new Occupational Safety and Health Administration (OSHA) approved measures to preserve PPE supply There is no reliable data that use of NSAIDS or ACE inhibiters for patients with COVID19 like illness is harmful Instructions for how to volunteer for NYC Medical Reserve Corps are included in this HAN March 20, 2020 Dear Colleagues, We are in a challenging time as the COVID-19 pandemic rapidly accelerates in New York City. Healthcare providers will need to make critical decisions that are far different than the normal practice of medicine and will likely require applying different standards of care during the next several weeks to months. Learning from the experience of our colleagues in other countries hardest hit by COVID-19, and watching the pandemic unfold in NYC, impacts on our healthcare system will continue to worsen. As the number of persons requesting testing for COVID-19 increases, the supply of personal protective equipment (PPE) diminishes. Many healthcare facilities are experiencing high patient volumes that will likely increase in the coming days and weeks. There are few options available to find N95 respirators and surgical masks along with other PPE. Healthcare resources must be saved to treat the sickest patients who require inpatient and critical care. Mild and moderately ill persons with COVID-19 who seek testing are exposing others in healthcare settings including other patients and healthcare staff. At this point in the pandemic, demand for unnecessary testing is contributing to the rapidly diminishing supply of PPE and leading to a decreasing supply of swabs and viral transport media used to collect diagnostic specimens for COVID-19 testing. Additionally, some healthcare facilities in parts of the city, especially emergency departments (EDs), have seen a surge of visits due to influenza-like illness attributed to COVID-19. Emergency medical care should be reserved for persons who are severely ill, and persons with milder illness need to be strongly encouraged to stay home. COVID-19 like illness includes any new onset (in last 7 days) of subjective or measured (≥100.4oF or 38.0oC) fever OR cough OR shortness of breath OR sore throat that cannot be attributed to an underlying or previously recognized condition. In children, fever with sore throat may be attributable to conditions other than COVID-19 (e.g., strep throat) and parent/guardian should consult a healthcare provider to determine if medical evaluation is needed. To preserve PPE for HCW providing medically necessary care for hospitalized patients, the NYC Health Department is directing healthcare facilities to IMMEDIATELY STOP TESTING NON-HOSPITALIZED PATIENTS FOR COVID-19 unless test results will impact the clinical management of the patient. In addition, do not test asymptomatic people, including HCWs or first responders. COVID-19 testing is only indicated for HOSPITALIZED PATIENTS. Implement measures to prevent unnecessary in-person healthcare visits by people with mild or moderate illness. EDs should only receive severely ill patients or those who require immediate emergency care. Individual hospital systems may create alternate testing venues to offload their emergency departments. Outpatient testing must not be promoted or advertised outside of these strategies. People with mild or moderate illness should be discouraged from leaving their home for testing. MANAGING PPE NEEDS This health alert is geared toward healthcare workers including EMS. Guidance for other first responders is a priority and will be provided by their respective agencies. STOCKPILE Currently, PPE in the NYC stockpile that is available to healthcare facilities and providers in NYC includes N95 respirators, N95 respirators that are labelled expired, face masks, eye protection (goggles and face shields), gloves, and isolation gowns. Due to the overwhelming demand for supplies, severe shortages in the supply chain, and limited stockpiled resources, requests for PPE will be prioritized based on the facility type and stratified by the type of patient care provided. At this time, only requests from hospitals, emergency medical services (EMS), nursing homes, and dialysis centers will be considered. Supplies are prioritized for healthcare providers and facilities that are providing direct patient care in inpatient settings or in specific settings whose staff cannot maintain 6 feet of separation from a patient. If you are: • A hospital, you may request N95s, face masks, eye protection, isolation gowns, and gloves. • A nursing home, you may request facemasks; if you have ventilator patients, you may request N95s, goggles, face shields, gloves and isolation gowns. • An EMS provider, you may request N95s, face masks, eye protection, isolation gowns, and gloves. • A dialysis center, you may request face masks. Facilities should contact their respective associations to make a request from the stockpile. Unfortunately, at this time, if you do not fall into one of these facility types, your request will be denied. STRATEGIES FOR OPTIMIZING THE SUPPLY OF PPE To manage shortages or the complete lack of PPE supplies, facilities should use a variety of interventions to work within the contingency and crisis capacity scenarios. General interventions to minimize the need for PPE may include: • Implement telemedicine options whenever possible. • Install physical barriers (e.g., glass or plastic windows) at reception areas to limit contact between triage personnel and potentially infectious patients. • Restrict number of HCWs entering rooms with COVID-19 patients and bundle care activities. • Use PPE recommended by the NYC Health Department for caring for patients with COVID-19. • Educate and train staff on correct PPE use and appropriate donning and doffing procedures. Contingency and crisis strategies have been developed by the NYC Health Department and the CDC. Refer to this guidance using the links provided: For goggles or face shields, facemasks, and gowns: • Refer to CDC’s detailed guidance on strategies for contingency and crisis capacity for eye protection • Refer to CDC’s detailed guidance on how to optimize gowns supply during contingency and surge capacity • Refer to CDCs detailed guidance on how to optimize facemasks supplies following contingency and surge capacity strategies For N95 respirators: • NYC Health Department strategies to conserve respiratory PPE can be found online. • CDC recommends that N95s that have exceeded their manufacturer-designated shelf life should be used only as outlined in the Strategies for Optimizing the Supply of N95 Respirators. • More information about the use of expired respirators when supplies are low can be found on the CDC website as well as guidance on what to check to make sure they are still good. • Refer to CDC’s detailed guidance on how to optimize N95 respirator supplies including contingency and crisis strategies • Information on the use of N95 respirators beyond the manufacturer’s shelf life can also be accessed online • On March 14th, the Occupational Safety and Health Administration (OSHA) released Temporary Enforcement Guidance - Healthcare Respiratory Protection Annual Fit-Testing for N95 Filtering Facepieces During the COVID-19 Outbreak. The guidance can be found online. A fit test is required for anyone wearing a respirator to protect against COVID-19. Annual fit test can be temporarily suspended if the employee has already been fit tested to that respirator. UPDATED GUIDANCE FOR ASYMPTOMATIC HCW WHO TEST POSITIVE FOR COVID-19 Given current shortages in PPE, collection swabs, viral transport media and testing reagents, DO NOT TEST asymptomatic and/or exposed HCWs. However, if testing is done against public health recommendations, asymptomatic HCWs who have a positive test result for COVID-19 should NOT go to work. The HCW should monitor their health at home for COVID-19 like illness for a total of 7 days from the date of specimen collection. If the HCW remains symptom free, they may return to work. If the HCW develops COVID-19 like illness during the 7-day self-monitoring period, they will need to self-isolate for an additional 7 days from symptom onset or until they have been afebrile for 72 hours off antipyretics, whichever is longer, before they return to work. Refer to NYC Health Department Guidance online for details on COVID-19 like illness and guidance on self-isolation specific to HCWs. NYC COVID-19 CASE AND SYNDROMIC SURVEILLANCE DATA Surveillance data on the COVID-19 pandemic impact in NYC are updated each weekday morning with data from the preceding day regarding persons with confirmed COVID-19 and persons seeking care at NYC EDs for influenza like illness as well as the number hospitalized for influenza-like-illness and pneumonia for persons over 18 years of age. See latest summary data below. Note that the data likely do not reflect the true number of positive COVID-19 cases in NYC because of limited testing and therefore may overrepresent the proportion of COVID-19 cases in NYC requiring hospitalization. SHOULD INDIVIDUALS WITH COVID-19-LIKE ILLNESS AVOID NSAIDS OR ACE INHIBITORS? At this time, there are no reliable data to support claims that the use of non-steroidal antiinflammatories (NSAIDs) may contribute to poorer outcomes in persons with COVID-19. Additionally, the American College of Cardiology (ACC) released a statement that “currently there are no experimental or clinical data demonstrating beneficial or adverse outcomes with background use of Angiotensin-converting enzyme (ACE) inhibitors, angiotensin-receptor blockers (ARBs) or other renin– angiotensin–aldosterone system (RAAS) antagonists in COVID-19 or among COVID-19 patients with a history of cardiovascular disease treated with such agents. The Heart Failure Society of America (HFSA), ACC, and American Heart Association (AHA) recommend continuation of RAAS antagonists for those patients who are currently prescribed such agents for indications for which these agents are known to be beneficial, such as heart failure, hypertension, or ischemic heart disease.” WANT TO HELP? JOIN THE NYC MEDICAL RESERVE CORPS (MRC) As the pandemic progresses, there will be a need to organize volunteers to assist with the expected overwhelming demands on the NYC healthcare system. The NYC MRC is a community-based corps of over 9,000 medical and non-medical volunteers with a mission to strengthen public health, improve emergency response capabilities and build community resilience in NYC. NYC MRC is managed under the NYC Health Department and has served as a valuable staffing resource for emergency response and nonemergency public health and community resilience activities in NYC since its inception in 2004. NYC MRC volunteers represent a variety of professions, including Physicians, Physician Assistants, Nurse Practitioners, Registered Nurses, Midwives, EMTs/Paramedics, Podiatrists, Pharmacists, Dentists, Dental Hygienists/Assistants, Respiratory Therapists, Physical Therapists, Occupational Therapists, Veterinarians, Optometrists, Chiropractors, Medical Assistants, Social Workers (LMSW, LCSW) Psychologists, Psychoanalysts, Licensed Mental Health Counselors & Marriage and Family Therapists, Medical Students, as well as other healthcare professionals and non-medical volunteers. The NYC MRC can mobilize volunteers for non-emergency public health or community resilience activities, and rapidly deploy volunteers for emergency response operations. NYC MRC can recruit and select volunteers for assignments based on many criteria, such as profession, languages spoken and home address. To become a member of the NYC MRC, follow these instructions. The outbreak of COVID-19 is evolving rapidly. NYC healthcare providers and institutions are reminded to check COVID-19 resources available on the NYC Health Department provider webpage and the CDC website. Thank you for all you are doing to help NYC get through this unprecedented medical and public health crisis. Sincerely, Demetre Daskalakis, MD, MPH Deputy Commissioner 21 "?11 The data in this report reflect events and activities through 5:30 pm. on March 19, 2D2D. All data in this report are preliminary and subject to change as cases continue to be investigated. This data includes all patients treated at NYC facilities. NYC COMB-19 case summary: Total Cases Number of Continued Cases 3954 Age Group - 1Bto49 - to 54 9261123943] - 55 and over - Unknown 3 Age 50 and over - Yes 1?25 No 2225 Sex - Female 1530 - Male 2315 - Unknown 9 Borough - Bronx 496 - Brooklyn 1195 - Manhattan 1 033 - ?ue-ans 1042 - Staten Island - Unknown 4 Deaths 26 NYC Emergency Department Surveillance Data through March 18, 2020. 100% of EDs reporting In?ugm Susan I 20192020 I 2010-2019 I 20122010 2010201? Health Daily In?uenza-like Illness Pneumonia Visits to NYC Emergency Departments: 2016-2020 1500 [Llhl . - I 1' r- '5 0 31042020 oct1.1s Nmr1.1s 0001.19 Jan1.20 Mar1.20 Apr1.20 May1.2l] 1DUD BBQ Number of Hospital Admissions with Influenza-like Illness Pneumonia 25G 20G 15$ IOU 0:11.19 0661.19 not?! ?$1.20 Apl1.20 MaytEO