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

February 13, 2020

On this page

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

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-19^{Reference 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:

• For a case, conduct active daily monitoring of the case’s health status for duration of illness (and until they have met the criteria set by the PHA for discontinuing isolation)
• For a PUI, conduct active daily monitoring of the PUI’s health status until laboratory investigation has confirmed or ruled out infection with the novel coronavirus that causes COVID-19.  If confirmed, follow the advice for a case
• Provide public health advice to the case/PUI and household (or co-living setting) contacts on individual measures including:
  • personal hygiene
  • how to prevent the spread of infection to household contacts or the community
  • how to care for the case as safely as possible
  • where and when to seek medical attention
• Facilitate appropriate laboratory testing by the health care provider in consultation with the provincial Public Health Laboratory (PHL).  As per relevant laboratory guidance and identified protocols, ensure that appropriate specimens from a case are forwarded to the respective PHL. The PHL will then coordinate the submission of specimens to the National Microbiology Laboratory for further testing, as necessary. Include exposure/travel history with specimens being sent. Refer to Protocol for Microbiological Investigations of Severe Acute Respiratory Infections (SARI) for details on specimen collection and handling, and consultation with the PHL microbiologist on-call. Refer also to additional laboratory guidance provided by PHLs^{Reference 4}

Recommendations for the case/PUI and caregivers:

Personal hygiene

• The case/PUI and all members of the household setting should follow good respiratory etiquette and hand hygiene practices
• Hand washing with plain soap and water is the preferred method of hand hygiene in the community, since the mechanical action is effective at removing visible soil and microbes
• If soap and water are not available, the use of alcohol-based hand sanitizers (ABHS) with at least 60% alcohol is recommended; for visibly soiled hands, remove soiling with a wipe first, followed by use of ABHS
• Respiratory etiquette refers to covering the mouth and nose during coughing or sneezing, using surgical/procedure masks, tissues, or flexed elbow followed by hand hygiene. Discard tissues and disposable materials used to cover the nose or mouth, preferably in a plastic-lined container, before disposal with other household waste. If the mask gets wet or dirty with secretions, it should be changed immediately

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

• The case/PUI should limit their contact with others, as much as possible – this includes household members and visitors
• The case/PUI should be isolated at home while symptomatic (i.e. not leave the home unless directed to do so to seek medical care) until symptoms have resolved and the person is feeling well enough to resume normal activities, and has met the clinical and/or laboratory criteria set by the PHA for discontinuing isolation^{Footnote a}
• Place the case/PUI in a well-ventilated (e.g., windows open if weather permits) room by themselves^{Footnote b}, if possible, and use a separate bathroom if available
• If the case/PUI cannot be separated from others, they should follow respiratory etiquette and use a surgical/procedure mask while others are in the same room
• Shared spaces (e.g. kitchens, bathrooms) should be kept well ventilated, if possible
• People in the household should avoid sharing toothbrushes, cigarettes, eating utensils, drinks, towels, washcloths or bed linen
• Other types of possible exposure to contaminated items should be avoided. Dishes and eating utensils should be cleaned with soap and water after use
• High-touch areas such as toilets, bedside tables and door handles should be cleaned daily using regular household cleaners or diluted bleach^{Footnote c} (one part bleach to nine parts water^{Reference 5}); clothes, handkerchiefs and bedclothes of the case/PUI can be cleaned using regular laundry soap and water (60-90°C).  Use disposable gloves and protective clothing (e.g. plastic aprons, if available) when cleaning or handling surfaces, clothing, or linen soiled with body fluids

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

Healthcare workers: 

• For healthcare workers providing health care services in the home, virus-specific IPC guidance for acute health care settings is applicable^{Reference 6}
• In addition to Routine Practices, healthcare workers should follow Contact and Droplet precautions when within two metres of the case/PUI
• For aerosol-generating medical procedures (e.g., case is receiving nebulized therapy) the use of Additional Precautions, including using a N95 respirator, is recommended
• Medical equipment should be cleaned, disinfected or sterilized in accordance with Routine Practices

For caregivers and others sharing the living environment: 

• If direct contact care must be provided, the case should wear a surgical/procedure mask and follow respiratory etiquette
• The caregiver providing direct contact care to the case/PUI should also wear a procedure/surgical mask and eye protection when within two metres of the case/PUI and perform hand hygiene after contact
• Masks should not be touched or handled during use.  If the mask gets wet or dirty with secretions, it should be changed immediately.  After discarding the mask, hand hygiene should be performed
• Direct contact with body fluids, particularly oral, and respiratory secretions should be avoided. Use disposable gloves to provide oral or respiratory care, and when handling stool, urine and waste, if possible. Perform hand hygiene following all contact
• Anyone who is at higher risk of developing complications from infection should avoid caring for or come in close contact with the case/PUI. This includes people with underlying chronic or immunocompromising conditions^{Reference 7}
• Persons caring for a case/PUI should monitor themselves for any signs of illness for 14 days from last close contact

Where, when and how to seek medical attention

• PHAs should advise a case/PUI and/or their family or household members when and where to seek additional care, appropriate mode of transportation (e.g. ambulance. private vehicle), and any other appropriate IPC precautions to be followed, including notifying the receiving facility prior to their arrival. 

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:

• primarily to facilitate rapid identification of new cases and to support containment by:
  • identifying and isolating any symptomatic contacts as quickly as possible; and
  • reducing the opportunity for transmission to others in the community by providing contacts with information regarding infection prevention and control measures they should follow, and what to do if they develop symptoms; and
• secondly, to gain a better understanding of the epidemiology of this novel coronavirus

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

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

• Close contacts should self-isolate at home, with the parameters to be set by the PHA based on an individual risk assessment, with consideration given to excluding the contact from high-risk settings (e.g., hospitals, schools, crowded public spaces)
• Active monitoring of symptoms, ensuring daily contact
• Any contact who develops symptoms within the monitoring period should be considered a “Person under investigation” and from an IPC perspective should be managed as a case. If transferring a PUI from the community to an acute care facility, it will be important to notify the receiving facility prior to arrival to ensure appropriate IPC measures are in place

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

• Follow good respiratory etiquette and hand hygiene practices
• Self-monitor for the appearance of symptoms, particularly fever and respiratory symptoms such as coughing or shortness of breath
• Take and record temperature daily and avoid the use of fever reducing medications (e.g., acetaminophen, ibuprofen) as much as possible. These medications could mask an early symptom of COVID-19; if these medications must be taken, advise the PHA
• Follow relevant advice provided under the Case Management section above
• Isolate within the home as quickly as possible should symptoms develop, and contact the local public health authority for further direction, which will include where to go for care, the appropriate mode of transportation to use, and IPC precautions to be followed

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:

• Incoming travellers from Hubei province will be advised to self-isolate and connect immediately with their PHA
• Monitoring (frequency and method to be determined by PHA)
• PHA should set the parameters of self-isolation based on an individual risk assessment, with consideration given to excluding the contact from high-risk settings (e.g., hospitals, schools, crowded public spaces)

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

• Follow good respiratory etiquette and hand hygiene practices
• Self-monitor for the appearance of symptoms, particularly fever and respiratory symptoms such as coughing or shortness of breath
• Take and record temperature daily and avoid the use of fever reducing medications (e.g., acetaminophen, ibuprofen) as much as possible. These medications could mask an early symptom of COVID-19; if these medications must be taken, advise the PHA
• Isolate themselves within the home setting as quickly as possible should symptoms develop, and contact the local public health authority for further direction, which will include where to go for care, the appropriate mode of transportation to use, and IPC precautions to be followed

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:

• Incoming travellers from other areas of China will be provided with information on self-monitoring for symptoms and who to call should symptoms develop
• Self-isolation is not required
• No active monitoring by PHA
• Self-isolate as quickly as possible should symptoms develop, and contact the local PHA for further direction, which will include where to go for care, the appropriate mode of transportation to use, and IPC precautions to be followed
• Avoid crowded public spaces and places where rapid self-isolation upon onset of symptoms may not be feasible

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:

• passengers seated within two metres of the index case AND
• crew members serving the section of the aircraft where the index case was seated AND
• persons who had close contact with the index case, e.g. travel companions or persons providing care

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.