Interim guidance: Public health management of cases and contacts associated with novel coronavirus disease 2019 (COVID-19)

February 13, 2020

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Context

The Public Health Agency of Canada (PHAC), in collaboration with Canadian public health experts has developed this interim guidance for federal/provincial/territorial (F/P/T) public health authorities (PHA) in the event that a case of novel coronavirus disease (COVID-19) is suspected or confirmed within their jurisdictions.

The strategy outlined in this guidance is containment (i.e. to reduce opportunities for transmission to contacts in the community) and is based on the assumption that the virus is primarily spread while the case is symptomatic.  This guidance is based on current available scientific evidence and expert opinion and is subject to change as new information on transmissibility and epidemiology becomes available. This guidance builds upon relevant Canadian guidance developed for the current and previous coronavirus outbreaks (e.g. MERS CoV and SARS-CoV), in addition to available guidance from the World Health Organization (WHO)Reference 1. It should be read in conjunction with relevant P/T and local legislation, regulations and policies. This guidance has been developed based on the Canadian situation; therefore, may differ from guidance developed by other countries. For information regarding the current global status of COVID-19, visit the Canada.ca and WHO web site.

Recommendations: Case management - confirmed, probable cases and Persons Under Investigation (PUI)

Case management

An interim national case definition for COVID-19Reference 2 has been developed, specifically for confirmed cases, probable cases and Persons Under Investigation (PUI), as well as associated reporting requirements. P/T public health authorities (PHA) should report confirmed and probable cases of COVID-19 nationally to the PHAC within 24 hours of their own notification.

It will be important for front line health care providers to notify PHAs of any cases (confirmed or probable), and PUI in accordance with jurisdictional reporting requirements. PHAs will need to provide overall coordination with health care providers and provincial laboratories for the management of the case/PUI and to establish communication links with all involved health care providers for the full duration of the observation period. Cases/PUI whose clinical condition does not require hospital care may be cared for in the home environment as long as effective isolation and appropriate monitoring (i.e., for worsening of illness) can be provided. If transferring a case/PUI from home to a hospital, it will be important to notify the receiving facility prior to the individual’s arrival to ensure appropriate IPC measures are in place.

COVID-19-specific infection prevention and control (IPC) guidance has been developed for acute health care settings.

Clinical management

At this time, there is no specific treatment for cases of COVID-19 infection. However, supportive treatment should be based on the patient’s clinical condition at the discretion of the treating health care provider. Guidance on the clinical management of severe acute respiratory infection when a case of COVID-19 is suspected is available from the WHO.Reference 3 

Public health management in the home environment

For cases/PUI being cared for in the home environment, the following measures and activities are recommended. It is recognized that once the investigation is completed PUI should be managed based on their final disposition (i.e., ruled-out based on laboratory testing, or probable or confirmed case).

Recommendations to PHA:

Recommendations for the case/PUI and caregivers:

Personal hygiene

How to prevent the spread of infection to household contacts or the community

How to care for the case/PUI as safely as possible

Healthcare workers: 

For caregivers and others sharing the living environment: 

Where, when and how to seek medical attention

Recommendations: Contact management of probable and confirmed cases

Considering the context for this guidance is containment of the virus, close contacts of confirmed and probable cases occurring in Canada should be identified and managed as per the recommendations in this document and an individual risk assessment by the PHA, until the containment objective is achieved or a new objective becomes necessary (e.g., if sustained person to person transmission is occurring in the community). Consideration should be given to excluding contacts from high-risk settings (e.g., hospitals, schools, crowded public spaces) for the 14-day monitoring period.

The purpose of contact management is:

Public health management of contacts is divided into three categories depending on type of exposure.

Category A: Public health management for close contacts of cases

For the purpose of identifying the appropriate individuals for public health monitoring, a close contact is defined as a person who:

  • provided care for the case , including healthcare workers, family members or other caregivers, or who had other similar close physical contact without consistent and appropriate use of personal protective equipment, OR
  • who lived with or otherwise had close prolongedFootnote * contact (within 2 metres) with a probable or confirmed case while the case was ill, OR
  • had direct contact with infectious body fluids of a probable or confirmed case (e.g., was coughed or sneezed on) while not wearing recommended personal protective equipment

Adapted from the US Centers for Disease Control and Prevention: Interim Guidance for Healthcare Professionals, Criteria to Guide Evaluation of Patients Under Investigation (PUI) for 2019-nCoV, accessed January 29, 2020

Reference *

As part of the individual risk assessment, consider the duration of the contact's exposure (e.g., a longer exposure time likely increases the risk), the case's symptoms (coughing or severe illness likely increases exposure risk) and whether exposure occurred in a health care setting.

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Recommendations to PHA, applicable to the monitoring period, which is 14 days following last unprotected contact:

For the duration of the monitoring period, advise the close contact to:

Category B: Incoming travellers from Hubei province, China

Recommendations to PHA, applicable to the monitoring period, which is 14 days following their departure from Hubei province, China:

For the duration of the monitoring period, the incoming traveller should be advised to:

Category C: Incoming travellers from other areas of China

Recommendations to PHA, applicable to the monitoring period, which is 14 days following their departure from mainland China:

Contact tracing for airplane passengers

The following guidance is adapted from the European Centre for Disease Prevention and Control (ECDC) Risk assessment guidelines for infectious diseases transmitted on aircraft (RAGIDA): Middle East Respiratory Coronavirus (MERS-CoV)Reference 8 last updated January 22, 2020, which the ECDC recommends could be used in response to the current COVID-19 outbreak, until new evidence becomes available.

Decisions related to contact tracing air travellers who may have been exposed to a case of COVID-19 on a flight should be made on a case by case basis by the public health authority to which the case is notified, considering the case’s classification (e.g. confirmed) and the type and severity of symptoms during the flight. As there is no direct evidence at present regarding transmission risk in relation to flight duration, these recommendations apply regardless of the length of the flight.

Contact tracing efforts should focus on those seated within a 2 metre radius of the case, as this is the accepted exposure risk area for droplet transmission.  Contact tracing by PHA in order to identify passengers in the exposure risk area should occur if a confirmed case of COVID-19 was symptomatic during the flight, and if it can be conducted within 14 days of the flight.

Contact tracing efforts should, at a minimum, focus on:

Public health authorities may wish to request the aircraft seat map from airlines to best target the contact tracing efforts. If the seat map isn’t available, PHAs may wish to trace economy class passengers seated in the 5 seats surrounding the case in all directions, up to and including 3 rows in front and 3 rows behind the case. In business class, due to seat spacing this may only involve tracing passengers in the 2 surrounding rows due to the space between seats. Public health authorities may also wish to confirm that the case sat in the assigned seat for the duration of the flight, and ask about the case’s movements during the flight.

Public health authorities should consider expanding the scope of their contact tracing if the case had severe symptoms, such as persistent coughing and sneezing, or had diarrhea or vomiting during the flight.

In the event that a crew member is a confirmed case and was symptomatic during the flight, passengers seated in the area served by that crew members, as well as the other crew members, should be traced.

The Public Health Agency of Canada’s Office of Border and Travel Health can assist public health authorities in obtaining a flight manifest however it should be noted that flight manifests are not kept indefinitely and do not contain contact information on all travellers. If contact tracing is not feasible, a public advisory to notify the public of the potential exposure may be considered.

References  

Reference 1

WHO. Home care for patients with suspected novel coronavirus (nCoV) infection presenting with mild symptoms and management of contacts. [Online] 4 February 2020. [Accessed on 7 February 2020] https://www.who.int/publications-detail/home-care-for-patients-with-suspected-novel-coronavirus-(ncov)-infection-presenting-with-mild-symptoms-and-management-of-contacts

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Reference 2

PHAC. Interim National Case Definition: Novel Coronavirus (2019-nCoV). [Online] 6 February 2020. [Accessed on 7 February 2020] https://www.canada.ca/en/public-health/services/diseases/2019-novel-coronavirus-infection/health-professionals/national-case-definition.html

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Reference 3

WHO. Clinical management of severe acute respiratory infection when novel coronavirus (nCoV) infection is suspected. [Online] 11 January 2020. [Accessed on 17 January 2020] https://www.who.int/internal-publications-detail/clinical-management-of-severe-acute-respiratory-infection-when-novel-coronavirus-(ncov)-infection-is-suspected

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Reference 4

Canadian Public Health Laboratory Network. Protocol For Microbiological Investigations Of Severe Acute Respiratory Infections (SARI). [Online] 2013. [Accessed: 16 January 2020] https://www.canada.ca/en/public-health/services/emerging-respiratory-pathogens/protocol-microbiological-investigations-severe-acute-respiratory-infections-sari.html

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Reference 5

WHO. Home care for patients with suspected novel coronavirus (nCoV) infection presenting with mild symptoms and management of contacts. [Online] 4 February 2020. [Accessed on 7 February 2020] https://www.who.int/publications-detail/home-care-for-patients-with-suspected-novel-coronavirus-(ncov)-infection-presenting-with-mild-symptoms-and-management-of-contacts

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Reference 6

PHAC. Infection prevention and control for novel coronavirus (2019-nCoV): Interim guidance for acute healthcare settings. [online] February 4, 2020. [Accessed February 7, 2020] https://www.canada.ca/en/public-health/services/diseases/2019-novel-coronavirus-infection/health-professionals/interim-guidance-acute-healthcare-settings.html

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Reference 7

WHO. Home care for patients with suspected novel coronavirus (nCoV) infection presenting with mild symptoms and management of contacts. [Online] 4 February 2020. [Accessed on 7 February 2020] https://www.who.int/publications-detail/home-care-for-patients-with-suspected-novel-coronavirus-(ncov)-infection-presenting-with-mild-symptoms-and-management-of-contacts

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Reference 8

ECDC. Risk assessment guidelines for infectious diseases transmitted on aircraft (RAGIDA) - Middle East Respiratory Syndrome Coronavirus (MERS-CoV). [Online] 22 January 2020. [Accessed on 31 January 2020] https://www.ecdc.europa.eu/en/publications-data/risk-assessment-guidelines-infectious-diseases-transmitted-aircraft-ragida-middle

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Footnotes

Footnote a

Decisions on discontinuing isolation should be made by the PHA in conjunction with the case's health care providers, considering both the clinical and laboratory findings. The WHO suggests that two negative tests for COVID-19, conducted 24 hours apart, be considered as laboratory evidence that the case is no longer communicable; however, laboratory testing parameters have yet to be established.

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Footnote b

Due to the theoretical possibility that animals in the home could be infected by the virus that causes COVID-19, it is recommended that cases also refrain from contact with pets.

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Footnote c

To maintain its effectiveness, the diluted bleach solution should be prepared daily

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