COVID-19 Update for Orange County Providers
July 02, 2020
COVID-19 daily case counts and the number of those hospitalized with the disease have increased in Orange County in recent weeks. Over 14,000 cases have been reported in Orange County, with over 340 deaths. Approximately half of all county deaths have occurred in residents of skilled nursing facilities. The heaviest illness burden of disease is being seen in Orange County’s Latino/Hispanic population, particularly in the cities of Santa Ana and Anaheim, though recently the Orange County Health Care Agency has seen a pronounced increase in infection among White residents.  Updated county surveillance data can be found at: https://occovid19.ochealthinfo.com/coronavirus-in-oc

As a result of the increase in COVID-19 transmission in Orange County, the county is one of 19 where the California Department of Public Health (CDPH) required closure on July 1 of indoor operations in multiple facilities including dine-in restaurants, wineries and tasting rooms, movie theaters, family entertainment centers, zoos, museums, and cardrooms. CDPH’s guidance can be found at https://www.cdph.ca.gov/Programs/CID/DCDC/Pages/COVID-19/Guidance-on-Closure-of-Sectors-in-Response-to-COVID-19.aspx .

Orange County providers should consider COVID-19 testing for any person who presents with symptoms suggestive of the disease.
Identifying Suspect Cases of COVID-19
T esting and contact tracing capacities have increased substantially in the county. In additional to consistent social-distancing and mask-wearing by residents, control of COVID-19 spread will require consistent identification and isolation of cases and quarantine of close contacts. Any patient with symptoms consistent with COVID-19 should be considered for testing.

Fever or chills, cough and shortness of breath are the most common initial symptoms.  Fatigue, muscle pain, headache, new loss of taste or smell, vomiting or diarrhea, and/or nasal congestion are also seen. CDC recommendations for clinical evaluation can be found at https://www.cdc.gov/coronavirus/2019-ncov/hcp/clinical-care.html .

Providers are particularly recommended to test symptomatic patients in high risk groups, including:
  • Hospitalized patients
  • Persons 65 years of age or older or with underlying health conditions
  • Residents of congregate settings such as skilled nursing facilities, homeless shelters, and jails
  • Healthcare workers
  • First responders

To spare personal protective equipment (PPE) and minimize infection control risks, low risk patients who are experiencing mild symptoms can be referred to county drive through facilities, which can be found at:

The increase in COVID-19 disease in the county has driven an increase in demand for testing. Low risk, mildly ill persons with COVID-19 symptoms who are not able to access testing should isolate as if they have COVID-19 according to the recommendations below.
Testing of Asymptomatic Patients
Testing of asymptomatic patients is most useful for containing outbreaks in specific populations, particularly congregate living settings such as skilled nursing facilities and homeless shelters.  

Asymptomatic community close contacts to known cases can be tested according to CDC guidance, which can be found at: https://www.cdc.gov/coronavirus/2019-ncov/hcp/testing-overview.html .  But these close contacts will still need to be quarantined for 14 days after last exposure to the case, whatever the test result. With the increased demand for testing in the county, OCHCA does not recommend that asymptomatic close contacts be routinely tested. To assure efficient use of resources, asymptomatic contacts should not be directed to local emergency rooms for testing. 
Quarantine and Isolation Recommendations
OCHCA is reaching out to confirmed COVID-19 cases to provide isolation guidance and identify close contacts. Medical providers are asked to assist with this process by educating cases about isolation precautions for themselves and quarantine recommendations for their close contacts.   Close contacts (anyone who has been within 6 feet of the case for 15 minutes or more) are recommended to self-quarantine for 14 days. Guidance on home isolation and quarantine can be found at: https://www.cdc.gov/coronavirus/2019-ncov/if-you-are-sick/quarantine-isolation.html .

For those who need isolation due to homelessness or for those unable to safely isolate to avoid exposing high-risk household contacts, OCHCA can assist with arranging temporary lodging in hotels.
Discontinuation of Transmission-Based Precautions for Symptomatic Patients with COVID-19
OCHCA recommends that patients with COVID-19 infection have isolation precautions discontinued using CDC’s symptom-based strategy:
  • At least 3 days (72 hours) have passed since recovery defined as resolution of fever without the use of fever-reducing medications and improvement in respiratory symptoms (e.g., cough, shortness of breath); AND
  • At least 10 days have passed since symptoms first appeared

This symptom-based strategy also should be used to determine when infected healthcare providers (HCP) can return to work. When returning to work, HCPs should also wear a facemask (not a cloth face covering) for source control at all times while in the healthcare facility until all symptoms are completely resolved or at baseline.

The CDC’s test-based strategy requires a combination of resolution of fever and improvement of symptoms for 72 hours and at least two negative consecutive results from PCR testing of specimens collected at least 24 hours apart. However, because patients who are no longer infectious may continue to be PCR-positive for extended periods, this strategy frequently leads to prolonged isolation periods and is not routinely recommended by OCHCA.

Guidance discontinuation of isolation for outpatients can be found at: https://www.cdc.gov/coronavirus/2019-ncov/hcp/disposition-in-home-patients.html

Return to work recommendations for healthcare providers with COVID-19 infection can be found at: https://www.cdc.gov/coronavirus/2019-ncov/hcp/return-to-work.html
Discontinuation of Transmission-Based Precautions for Asymptomatic Patients with COVID-19
Asymptomatic patients with laboratory-confirmed COVID-19 should remain in isolation until 10 days have passed since the date of their first positive COVID-19 diagnostic test, assuming they have not subsequently developed symptoms. 
  COVID-19 Testing Recommendations
  • The CDC considers nasopharyngeal (NP), oropharyngeal (OP), nasal mid-turbinate, or nasal specimens to be acceptable specimens for testing initial diagnostic testing for SARS-CoV-2. 
  • OCHCA recommends NP or nasal swab testing when it is available for patients with symptomatic infection, as the cumulative evidence has indicated that NP specimens are the most sensitive of upper respiratory tract, but nasal swabs have similar sensitivity and are easier to obtain.  
  • PCR testing of upper respiratory specimens in symptomatic patients is unknown but estimated to be in the range of 60-80%. A negative test should not be interpreted to rule out COVID-19 infection. 
  • PCR testing of lower respiratory specimens such as sputum, or bronchoalveolar lavage or tracheal aspirate specimens, may increase sensitivity and should be performed in addition to NP testing if available, especially if there is high clinical suspicion for COVID-19.
 
Treatment Recommendations
Infectious Diseases Society of America (IDSA) has developed guidelines on the treatment of COVID-19 which are regularly updated as new clinical data become available. These testing recommendations can be found at: https://www.idsociety.org/practice-guideline/covid-19-guideline-treatment-and-management/
Specific recommendations from these guidelines include the following:
 
  • Among hospitalized patients with severe* COVID-19, the IDSA panel recommends use of remdesivir.
  • For consideration in a situation of limited remdesivir supply: remdesivir appears to demonstrate the most benefit in those with severe COVID-19 on supplemental oxygen rather than in patients on mechanical ventilation or extracorporeal mechanical oxygenation (ECMO).
  • The panel suggests glucocorticoids for use among hospitalized patients with severe* COVID-19.
  • Among hospitalized patients with COVID-19 without hypoxemia requiring supplemental oxygen, the panel suggests against the use of glucocorticoids.
  • The panel recommends that, because of uncertainty regarding its risks and benefits, hydroxychloroquine/chloroquine should be only used in the context of a clinical trial.
  • Because of the lack of evidence of effectiveness and potential for toxicity, the panel suggests against hydroxychloroquine/chloroquine plus azithromycin combination outside of a clinical trial.
  • Among patients who have been admitted to the hospital with COVID-19, the panel recommends COVID-19 convalescent plasma only in the context of a clinical trial. The panel recommended additional clinical trials to inform the benefit of convalescent plasma treatment.

*Severe illness is defined as patients with SpO2 ≤ 94% on room air, and those who require supplemental oxygen, mechanical ventilation, or ECMO.
Contact Information
Please contact Communicable Disease Control Division at 714-834-8180 with questions or concerns. Please note that this number is now operational 24/7 for medical providers. Please do not share this number with patients.

Case Numbers are updated daily on our website at: www.ochealthinfo.com/novelcoronavirus
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