KAREN L. SMITH, MD, MPH
Director and State Public Health Officer

EDMUND G. BROWN JR.
Governor

Health and Human Services Agency
California Department of Public Health

AFL 20-09

January 23, 2020

TO:

All Facilities

SUBJECT:

Health Update and Interim Guidance – 2019 Novel Coronavirus (nCoV)

All Facilities Letter (AFL) Summary

This AFL provides information on the 2019 Novel Coronavirus (2019-nCoV)
This AFL contains the latest Centers for Disease Control and Prevention (CDC) information on 2019-nCoV including infection control guidance, criteria for evaluation of Patients Under Investigation (PUIs), and recommendations for reporting, specimen collection, and testing. It is likely that CDC will update its guidance in the coming weeks, so please check for updates on CDC’s 2019-nCoV webpage.
At this time there are no confirmed 2019-nCoV cases in California.

NOTE: This AFL is no longer in effect and is for historical purposes only

Background

An outbreak of pneumonia of unknown etiology in Wuhan, China was reported to the World Health Organization (WHO) on December 31, 2019, and a novel coronavirus was soon identified as the cause. On January 21, 2020, CDC announced the first U.S. case in a traveler who had returned from Wuhan.

What is known:

Limited person-to-person spread is occurring.
Some healthcare workers in China have reportedly been infected.
Although severe and fatal illness has been reported in some patients, many have had milder illness and do not require hospitalization.
On January 21, 2020, CDC updated its interim travel health notice for people traveling to Wuhan, China from “Level 1, Practice Usual Precautions" to “Level 2, Practice Enhanced Precautions".
CDC has implemented symptom screening of travelers arriving from Wuhan, China at three United States airports (San Francisco International Airport, Los Angeles International Airport, and John F. Kennedy International Airport in New York); screening will soon expand to Atlanta Hartsfield-Jackson International Airport and Chicago O'Hare International Airport.
Disembarking travelers with symptoms potentially consistent with 2019-nCoV infection are being referred for further evaluation at health care facilities.
Asymptomatic travelers are given written instructions regarding steps to take if they become ill in the 14 days after arrival from Wuhan, including calling ahead to a health care facility and explaining that they have traveled from Wuhan.
There is no vaccine or specific treatment for 2019-nCoV infection.
An investigational new drug known as remdesivir may be requested via CDC for compassionate use in severely ill patients. Please contact the CDC Emergency Operation Center at 770-770-488-7100 to request remdesivir.

What is not yet known:

Attack rate of the virus, or how easily and sustainably this virus spreads person-to-person.
Incubation period of 2019-nCoV infections; current recommendations are based on the known incubation period of 2-14 days for other coronaviruses.
Whether infected persons are infectious before they show clinical signs and symptoms.
Spectrum of clinical illness associated with 2019-nCoV.

Recommendations for Healthcare Facilities

Although airports are screening travelers from Wuhan at entry, it is possible travelers who become ill in the days following their arrival may present for care at health care facilities in the community. The California Department of Public Health (CDPH) is encouraging all healthcare facilities to:

Obtain a travel history for all patients presenting with fever and acute respiratory illness.
Place signage, implement travel history screening at triage, and review procedures for immediately placing symptomatic patients with a positive travel history in a surgical mask and private room, ideally an airborne infection isolation room (AIIR), wherever possible.
Immediately contact your local health department (PDF) and your facility's infection preventionist if a patient may meet CDC's criteria for PUI.
Review infection control guidance for potential 2019-nCoV patients. Ensure facility infection control policies are consistent with the CDC's Interim Infection Control Precautions for Patients Under Investigation for 2019-nCoV.
Review procedures for collection of laboratory specimens for 2019-nCoV testing and laboratory biosafety guidelines; your local health department will work closely with the CDPH Viral and Rickettsial Disease Laboratory (VRDL) and the CDC to coordinate testing.

Critetia for a Person Under Investigation (PUI) for 2019-nCoV

Patients in the United States who meet the following criteria should be evaluated as a PUI in association with the outbreak of 2019-nCoV in Wuhan City, China.

Clinical Features	&	Epidemiologic Risk
Fever¹ (>38°C/100.4°F) and symptoms of lower respiratory illness (e.g., cough, difficulty breathing)	and	In the last 14 days before symptom onset, a history of travel from Wuhan City, China. – or – In the last 14 days before symptom onset, close contact² with a person who is under investigation for 2019-nCoV while that person was ill.
Fever¹ (>38°C/100.4°F) or symptoms of lower respiratory illness (e.g., cough, difficulty breathing)	and	In the last 14 days, close contact² with an ill laboratory-confirmed 2019-nCoV patient.

Clinical Features

Epidemiologic Risk

Fever¹ (>38°C/100.4°F) and symptoms of lower respiratory illness (e.g., cough, difficulty breathing)

and

In the last 14 days before symptom onset, a history of travel from Wuhan City, China.

– or –

In the last 14 days before symptom onset, close contact² with a person who is under investigation for 2019-nCoV while that person was ill.

Fever¹ (>38°C/100.4°F) or symptoms of lower respiratory illness (e.g., cough, difficulty breathing)

and

In the last 14 days, close contact² with an ill laboratory-confirmed 2019-nCoV patient.

¹Fever may not be present in some patients, such as those who are very young, elderly, immunosuppressed, or taking certain fever-lowering medications. Clinical judgment should be used to guide testing of patients in such situations.

²Close contact is defined as:

a) being within approximately 6 feet (2 meters), or within the room or care area, of a novel coronavirus case for a prolonged period of time while not wearing recommended personal protective equipment or PPE (e.g., gowns, gloves, NIOSH-certified disposable N95 respirator, eye protection); close contact can include caring for, living with, visiting, or sharing a health care waiting area or room with a novel coronavirus case.

– or –

b) having direct contact with infectious secretions of a novel coronavirus case (e.g., being coughed on) while not wearing recommended personal protective equipment.

Please contact your local health department (PDF) immediately if a PUI is identified, or if patient's status as a PUI is uncertain.

The above criteria are intended to serve as guidance for evaluation and testing. Patients should be evaluated and discussed with the local public health department on a case-by-case basis if their clinical presentation or exposure history is equivocal (e.g., uncertain travel or exposure). Patients who meet PUI criteria should also be evaluated for common causes of respiratory infections and community-acquired pneumonia.

Testing for viral respiratory pathogens should be performed by molecular methods, e.g., multiplex viral respiratory testing via real reverse transcription polymerase chain reaction (RT-PCR); viral cultures should not be performed. Do not use rapid influenza diagnostic tests that are not RT-PCR based. At this time, positive results for another respiratory pathogen do not preclude testing for 2019-nCoV.

Infection Control Guidance for 2019-nCoV Infection

Although the transmission dynamics have yet to be determined, CDPH currently recommends a cautious approach to patients under investigation for 2019-nCoV. Such patients should be given a surgical mask to wear as soon as they are identified and should optimally be evaluated in an airborne infection isolation room (AIIR). If an AIIR is not available, and it is not possible to transfer the patient to a facility with an AIIR, the patient should be evaluated in a private room with the door closed, and healthcare personnel entering the room should use Standard, Contact, and Airborne precautions, plus eye protection; this means that healthcare personnel should don gloves, gown, goggles or a face shield, and a fit tested N95 or higher level respirator upon room entry.

Healthcare facilities should additionally implement procedures to minimize the number of healthcare personnel that interact with a PUI and ensure that potentially exposed healthcare personnel and patients can be identified if the PUI is confirmed to be infected with 2019-nCoV.

As healthcare employers, facilities are required to follow recommendations under the California Occupational Safety Health Administration's (Cal/OSHA) Aerosol Transmissible Diseases (ATD) Standard, Title 8 of the California Code of Regulations (CCR) Section 5199. Because 2019-nCoV meets the criteria for a novel aerosol transmissible pathogen (ATP) under the ATD Standard, employers must provide a powered air purifying respirator (PAPR) with a High Efficiency Particulate Air (HEPA) filter(s), or a respirator providing equivalent or greater protection, to employees who perform high hazard procedures on 2019-nCoV PUIs or confirmed cases.

Laboratory Biosafety for 2019-nCoV Infection

Laboratory workers should wear appropriate personal protective equipment (PPE), which includes disposable gloves, laboratory coat/gown, and eye protection when handling potentially infectious specimens.

Any procedure with the potential to generate fine-particulate aerosols (e.g., vortexing or sonication of specimens in an open tube) should be performed in a Class II Biological Safety Cabinet (BSC). Appropriate physical containment devices (e.g., centrifuge safety buckets; sealed rotors) should be used for centrifugation. Ideally, rotors and buckets should be loaded and unloaded in a BSC. Perform any procedures outside a BSC in a manner that minimizes the risk of exposure to an inadvertent sample release.

After specimens are processed, decontaminate work surfaces and equipment with appropriate disinfectants. Use any EPA-registered hospital disinfectant. Follow manufacturer's recommendations for use-dilution (i.e., concentration), contact time, and care in handling. All disposable waste should be autoclaved.

Virus isolation in cell culture and initial characterization of viral agents recovered in cultures of 2019-nCoV specimens are NOT recommended at this time.

Laboratories are also required to follow recommendations under the laboratory section of Cal/OSHA ATD Standard, Title 8 CCR Section 5199, found under subsection (f).

2019-nCoV Update Teleconference

CDPH is holding a teleconference with providers to discuss 2019-nCoV to discuss the status of this outbreak. Healthcare facilities and providers are encouraged to attend. The teleconference will be held:

Date: Thursday, January 23, 2020
Time: 12:00 P.M.
Dial-in: 1-844-867-6167
Access Code: 2633697

CDC Resources

Please refer to the following guidance for further information:

Criteria to Guide Evaluation of Patients Under Investigation (PUI) for 2019-nCoV
Interim Healthcare Infection Prevention and Control Recommendations for Patients Under Investigation for 2019 Novel Coronavirus
Interim Laboratory Biosafety Guidelines for Handling and Processing Specimens Associated with 2019 Novel Coronavirus (2019-nCoV)

If you have any questions regarding the infection prevention and control of 2019-nCoV, please contact the CDPH Healthcare-Associated Infections (HAI) Program at novelvirus@cdph.ca.gov.

Sincerely,

Original signed by Sonia Y. Angell

Sonia Y. Angell MD MPH

State Public Health Officer and Director

California Department of Public Health

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​All Fac​ilities Letter (AFL) Summary