February 28, 2020
Kentucky Department for Public Health
COVID-19 HEALTH ADVISORY UPDATE
The 2019 novel coronavirus (COVID-19), first identified in China, is known to have infected thousands and has spread to many countries. At the time of this writing, the World Health Organization reports 82,294 confirmed cases worldwide, and 2,804 deaths (3.4% mortality rate). The bulk of cases (95.5%) and deaths (98.0%) have occurred in China, but the situation is rapidly changing, with rising case counts in countries like South Korea (1,766), Italy (400), and Japan (186). While the risk of exposure to COVID-19 remains low in countries outside of China, it is a strong possibility that we will see cases and possibly widespread transmission in the United States in the near future. As a witness of that possibility, the first U.S. case with no outside travel or known contact with a confirmed case was reported with COVID-19 infection in California yesterday. So far, the United States has avoided widespread introduction of COVID-19 through aggressive travel restrictions and public health actions to identify and monitor those at risk for exposure. To date, we have only 15 confirmed cases in the U.S., along with 42 other cases from the Diamond Princess cruise ship who were repatriated and are isolated at an Air Force base.
Clinicians in Kentucky have done an outstanding job of identifying people who might be at risk for COVID-19 based on symptoms and exposure history. The Kentucky Department for Public Health
(KDPH) has fielded over 50 calls about possible cases since February 12. To date, only one of these has qualified for actual COVID-19 testing, and that traveler from China tested negative. KDPH has monitored around 120 people for symptoms for 14 days after their last possible exposure, either through travel or exposure to a known COVID-19 case, and none of these people met the existing
“Person Under Investigation” (PUI) criteria for being tested (though we did test the one mentioned above out of an abundance of caution).
Due to rapidly changing situation worldwide, however, CDC yesterday broadened the PUI designation to include:
1) any person, including healthcare workers, with symptoms (fever or lower respiratory symptoms) who have had close contact with a lab-confirmed COVID-19 patient within 14 days of symptom onset;
2) those with symptoms (fever and lower respiratory symptoms) and travel from affected geographic areas (this will be updated as the situation evolves, but currently China, Iran, Japan, Italy, and South Korea) within 14 days of symptom onset; or
3) those with fever with severe acute lower respiratory illness (e.g., pneumonia, acute respiratory distress syndrome (ARDS)) requiring hospitalization, without an alternative explanatory diagnosis (e.g., influenza) where no source of exposure has been identified.
Criteria 2 and 3 have changed the implications for how we address this situation in Kentucky (Criteria 1 was included in the previous PUI criteria). Regarding Criteria 2, CDC is now officially considering exposure in an expanding number of countries as a possibility when considering COVID-19 testing. It must be emphasized that the risk of contracting COVID-19 in these other countries is extremely low for travelers and that China is still the major focal point of this outbreak. Additionally, international travel alone does not constitute a known risk factor for COVID-19 infection. Criteria 3, however, adds a new layer of testing in that anyone hospitalized with unexplained, severe respiratory symptoms may be eligible for testing if all other possible known etiologies are ruled out.
All patients should be assessed for international travel and contact with a known COVID-19 case. Patients with fever or lower respiratory illness who have had close contact with someone who is lab-confirmed with COVID-19, those with fever, lower respiratory illness and travel to any of the implicated countries, or patients experiencing fever with severe acute lower respiratory illness (e.g., pneumonia, ARDS) requiring hospitalization, without an alternative explanatory diagnosis (e.g., influenza) where no source of exposure has been identified, are considered a
“Patient Under Investigation” (PUI) (Please see for updates on these criteria).
NOTE: Due to regular circulation of various coronavirus strains in Kentucky, meeting one of the above criteria are required to be designated a COVID-19 PUI. Please do not report cases of coronavirus identified through hospital or commercial laboratory PCR testing – COVID-19 will not test positive on these multiplex PCR assays.
For all COVID-19 PUI you should follow the below guidelines immediately:
1) Ask the patient to wear a surgical mask as soon as they are identified (Recognize, Identify, Isolate);
2) Evaluate the patient in a private room with the door closed, ideally an airborne infection isolation room;
3) Healthcare personnel entering the room should use standard precautions, contact precautions, airborne precautions, and eye protection (e.g., goggles or a face shield);
4) Obtain a detailed travel and exposure history;
5) Notify your healthcare facility’s infection control personnel;
6) Notify the Kentucky Department for Public Health (KDPH): 502-564-3261
- During regular business hours (8:00 am – 4:30 pm, M-F), call 502-564-3261 and ask for the Novel Coronavirus Response Team
- After hours or on weekends: Call 888-9-REPORT (888-973-7678)
7) Assist with/facilitate completion of Kentucky’s “Updated CDC COVID-19 PUI Case Investigation Form Fillable.pdf” (attached) as needed. Please replace the earlier version with this form.
8) If a patient suspected to have COVID-19 refuses medical assistance or leaves the hospital against medical advice (AMA), please refer to the attached short guidance about next steps
(“COVID-19 AMA Protocol 2.0 Final.pdf”)
Testing, and Specimen Collection:
1) Note that FDA-approved respiratory panel assays will not detect COVID-19;
2) Conduct routine testing for respiratory pathogens;
3) Coordinate with KDPH to collect and ship specimens to CDC for COVID-19 testing;
a. All specimen submission must be approved by KDPH before shipping. Please call the KDPH Reportable Disease Section at 502-564-3261 and ask for the Novel Coronavirus Response Team. After hours or on weekends, call 888-9-REPORT (888-973-7678);
b. For initial diagnostic testing, CDC recommends collecting and testing both upper and lower respiratory clinical specimens;
c. For biosafety reasons, DO NOT perform virus isolation in cell culture or initial characterization of viral agents recovered in cultures of specimens from a PUI for COVID-19;
d. For additional guidance or coordination of specimen submission, contact Rachel Zinner or Teresa Fields at the KDPH Division of Laboratory Services at 502-564-4446;
4) Additional specimen types (e.g., serum, stool, urine, whole blood) may be collected and stored to increase the likelihood of detecting COVID-19 infection;
5) Specimens should be collected as soon as possible once a PUI is identified regardless of time of symptom onset;
6) Additional guidance for collection, handling, and testing of clinical specimens is attached and is available at this link:
Persons under investigation who test positive for another respiratory pathogen should be clinically evaluated in consultation with public health authorities. As a result of this process, they may no longer be considered a PUI; however, this may evolve further as more information becomes available on possible COVID-19 co-infections.
Infection Prevention and Control Guidelines:
CDC has provided infection prevention and control recommendations for patients who who meet the PUI criteria in a healthcare setting. These include: minimize chance for exposures; adherence to standard, contact and airborne precautions, including the use of eye protection; managing visitor access in the facility; engineering controls; environmental measures; and several other items. The importance of strict hand hygiene compliance can ever be overemphasized. Please find these guidelines at this link.
Frequently asked questions for healthcare providers regarding COVID-19, respirator use, and strategies for optimizing N95 supplies can be found at:
Frequently Asked Questions About Respirators and Their Use: https://www.cdc.gov/coronavirus/2019-ncov/hcp/respirator-use-faq.html
As this international situation evolves, the possibility of widespread transmission in the United States exists. If this happens, the availability of needed personal protective equipment may become more limited. We urge healthcare facilities to work at PPE conservation strategies in order to have needed supplies on hand should the need arise. We have prepared an additional document on conservation of PPE which is included with this guidance (“Guide to Respiratory Protection Resource Conservation and ReUse Final.pdf”).
Please feel free to contact us with any questions. We continue to value what you do on the front lines of healthcare and public health. Your astute efforts in identifying and reporting cases of COVID-19 will be vital to effective prevention and control of this pathogen.
Doug Thoroughman, PhD, MS
State Epidemiologist (Acting)
CDC Career Epidemiology Field Officer Kentucky Department for Public Health Phone: 502-564-3418 x4315