Ministry of Health COVID-19 Quick Reference Public Health Guidance on Testing and Clearance This information can be used to help guide decision making on testing and clearance of contacts of cases or individuals suspected or confirmed to have COVID-19. This information is current as of May 2 2020 and may be updated as the situation on COVID-19 continues to evolve. Who should be tested for COVID-19? Please refer to the COVID-19 Provincial Testing Guidance Update. Diagnosing COVID-19 In a symptomatic patient in whom COVID-19 is suspected, only a single (1) NP swab is required for laboratory testing. Laboratory confirmation of COVID-19 infection is performed using a validated assay, consisting of a positive nucleic acid amplification test (NAAT; e.g. real-time PCR or nucleic acid sequencing) on at least one specific genome target. • • • A single positive result is sufficient to confirm the presence of COVID-19. In a case with no known exposures, a single negative result in a suspected case is sufficient to exclude COVID-19, at that point in time. Depending on the clinical scenario (i.e. persistent, new or worsening symptoms), repeat testing can be considered. In a symptomatic case currently within their 14-day self-isolation as a result of a known exposure, a single negative result is sufficient to exclude COVID-19 at that point in time. However, the individual should remain in self-isolation for the rest of their 14-day period, and if symptoms change or worsen, consider the need for repeating testing. Testing of asymptomatic individuals (i.e., have never had symptoms) is not generally recommended at this time, and beyond the priority list within the COVID-19 Provincial Testing Guidance Update, prioritization should first be given to symptomatic over asymptomatic individuals. • If an individual who has never had symptoms is tested and is negative, a single negative is sufficient to exclude COVID-19 at that time. However, if symptoms develop in the future then additional testing should be considered. • If an individual who has never had symptoms tests positive, this should be managed as a confirmed case of COVID-19. Version 6.0 May 2, 2020 Management of individuals who have not been tested • • If individual is asymptomatic and has no exposure risk o Provide reassurance and information for Ontario COVID-19 website If individual is asymptomatic, but has exposure risk o Provide information on self-monitoring and self-isolation for 14 days from exposure risk Criteria for when to discharge someone from isolation and consider ‘resolved’ • For each scenario, isolation after symptom onset should be for the duration specified provided that the individual is afebrile, and symptoms are improving. Absence of cough is not required for those known to have chronic cough or who are experiencing reactive airways post-infection. • Once a case is discharged from isolation, their case status should be updated to ‘resolved’. • If an individual has tested positive but has never had symptoms, isolation recommendations should be based on date of specimen collection. After an individual completes their isolation period, they should continue to practice physical distancing measures as recommended for everyone at this time. • The guidance below is based on the observation that some people with more severe illness may have prolonged detection of viral RNA which may indicate the potential for longer viral shedding; for ease of use, “severe illness” has been defined as having required hospitalization for their COVID-19 illness. Version 6.0 May 2, 2020 Approaches to Clearing Cases Non-Test Based Approach Waiting 14 days from symptom onset (or 14 days from when swab was taken if persistently asymptomatic) Test Based Approach Two consecutive negative specimens collected at least 24 hours apart. When to Use Instructions Appropriate for most individuals who have recovered from Can discontinue isolation at 14 days after symptom onset (or 14 mild to moderate illness (i.e., never hospitalized) including: days from positive test collection date if never had symptoms), o o health care workers (unless otherwise directed by their employer/Occupational Health and Safety) individuals who live in congregate settings (e.g., long-term care homes, shelters) provided that the individual is afebrile and symptoms are improving. Absence of cough is not required for those known to have chronic cough or who are experiencing reactive airways post-infection. To remove individuals from isolation who had severe illness Continue isolation until 2 consecutive negative specimens (specifically, were hospitalized for their COVID-19 illness), collected at least 24 hours apart. and o Testing for clearance testing may begin after the individual o who remain in hospital after symptom improvement; OR Absence of cough is not required for those known to have o who are being discharged from hospital to continue chronic cough or who are experiencing reactive airways isolating in a congregate living setting (e.g., long- post-infection. term care homes, shelters) o has become afebrile and symptoms are improving. If swab remains positive, test again in approximately 3-4 days. If swab is negative, re-test in 1-2 days (and at least 24 hours apart). o Tick the box labelled ‘For clearance of disease’ on the PHO Laboratory COVID-19 Test Requisition, or clearly write this on the requisition if submitting to another laboratory. Notes: If test based clearance is not feasible in any scenario, the non-test based clearance approach may be used. Individuals who were hospitalized and are being discharged home, can be cleared from isolation using a non-test based approach. Version 6.0 May 2, 2020 Recommendations for Health Care Workers Return to Work • • • Health care workers (HCWs) should follow isolation and clearance with a non-test based approach unless they have required hospitalization during the course of their illness, in which case a test based approach is preferred. Some HCWs may be directed to have test based clearance by their employer/Occupational Health and Safety. Symptomatic HCWs awaiting testing results must be off work Asymptomatic HCWs awaiting testing results may continue to work using the appropriate precautions recommended by the facility, which will depend on the reason for testing In exceptional circumstances where clinical care would be severely compromised without additional staffing, an earlier return to work of a COVID-19 positive HCW may be considered under work self-isolation recognizing the staff may still be infectious. Work self-isolation means maintaining self-isolation measures outside of work for 14 days from symptom onset (or 14 days from positive specimen collection date if consistently asymptomatic) to avoid transmitting to household members or other community contacts. While at work, the HCW should adhere to universal masking recommendations, maintain physical distancing (remaining greater than 2m/6 ft from others) except when providing direct care, and performing meticulous hand hygiene. These measures at work are required to continue until non-test based clearance (or test based clearance if required by employer/Occupational Health and Safety). The HCW should ideally be cohorted to provide care for COVID-19 positive patients/residents if possible. The HCW on work self-isolation should not work in multiple locations. Symptoms Test Result Instructions Yes Positive • Work self-isolation could start after a minimum of 72 hours after illness resolving, defined as resolution of fever and improvement in respiratory and other symptoms Yes Negative • • May return to work 24 hours after symptom resolution If the HCW was self-isolating due to an exposure at the time of testing, return to work should be under work self-isolation until 14 days from last exposure . Never symptomatic at time of test Positive • If there has been a recent potential exposure (e.g., tested as part of an outbreak investigation or other close contact to a case), work self-isolation (i.e., return to work) could start after a minimum of 72 hours from the positive specimen collection date to ensure symptoms have not developed in that time, as the positive result may represent early identification of virus in the pre-symptomatic period If there has been no known recent potential exposures (e.g., tested as part of surveillance and no other cases detected in the facility or on the unit/floor, depending on the facility size), there is no minimum time off from the positive specimen collection date as it is unclear when in the course of illness the positive result represents (i.e., consistently asymptomatic HCWs can continue working in work self-isolation until 14 days from specimen collection date). • Version 6.0 May 2, 2020