LAC DPH Health Advisory: COVID-19 Revised Isolation Period and Clinical Symptoms May 1, 2020 Public Health, Coronavirus, COVID-19, LA County 1279 Key Messages The Centers for Disease Control and Prevention (CDC) have recently extended the time-period for isolation of persons with COVID-19 and have expanded the list of symptoms to consider testing for SARS-CoV-2. The Los Angeles County Department of Public Health (LAC DPH) has released a new interactive COVID-19 surveillance dashboard. Health care providers are reminded that results from serologic tests cannot not be used as the sole basis to diagnose or exclude SARS-CoV-2 infection. Serologic test results may not be used to release a person from isolation or quarantine nor to clear a person to return to work. See Discussion of Molecular and Serologic Tests for more information. Discontinuing Isolation for Persons with COVID-19 Based on evidence suggesting a longer duration of culture-positive viral shedding, the CDC has extended the duration of isolation of persons with COVID-19 to at least 10 days from the onset of symptoms (or initial positive test for those without symptoms). Symptom-based strategy Symptomatic patients with presumed or confirmed COVID-19 can be released from isolation when the following criteria have been met: 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. Asymptomatic persons with laboratory confirmed COVID-19 may be released from isolation, barring the development of symptoms, 10 days after the initial positive PCR test. The CDC has named this the time-based strategy. The same criteria as above are used for the return to work for healthcare personnel, see CDC, Criteria for Return to Work for Healthcare Personnel with Confirmed or Suspected COVID-19. Note: the CDC’s test-based strategy for discontinuing isolation/return to work is unchanged and still requires a combination of resolution of fever, AND improvement of symptoms, AND at least two negative consecutive results from nasopharyngeal swab specimens collected ≥24 hours apart using an FDA Emergency Use Authorized COVID-19 molecular assay for detection of SARS-CoV-2 RNA. This strategy is not encouraged by LAC DPH due to limited testing capacity as well as reports of prolonged detection of RNA without direct correlation to viral culture. COVID-19 Clinical Presentation Full characterization of the spectrum of COVID-19 disease is ongoing. The signs and symptoms present at illness onset vary, but over the course of the disease, most patients with confirmed COVID-19 have developed an influenza-like illness with fever and lower respiratory tract symptoms. Atypical presentations have been described and older adults and persons with medical co-morbidities may have delayed presentation of fever and respiratory symptoms. Asymptomatic infection also occurs but the prevalence is not well understood. See CDC Interim Clinical Guidance for Management of Patients with Confirmed Coronavirus Disease for a more detailed discussion of COVID-19 presentations and asymptomatic infection. CDC Inclusion of Additional Symptoms The CDC has updated their evaluation and testing guidance to encourage clinicians to consider testing patients presenting with an expanded list of symptoms: fever, cough, shortness of breath, chills, muscle pain, new loss of taste or smell, vomiting or diarrhea, and/or sore throat. LAC DPH Recommendations There are no changes to the current criteria for presumptive diagnosis of COVID-19 in LA County. In LA County, patients with symptoms of a viral respiratory illness (i.e., fever, cough, shortness of breath) should be presumed to have COVID-19. Per the Health Officer isolation order, individuals must self-isolate immediately if they have one of the following: Laboratory-confirmed COVID-19, Signs or symptoms that are consistent with COVID-19 (i.e., fever, cough, shortness of breath/trouble breathing), Physician has informed them that they are likely to have COVID-19 These patients must follow the home isolation instructions and must provide all their close contacts with home quarantine instructions. If molecular (PCR) testing resources are available, clinicians are encouraged to test symptomatic patients, particularly those in highest priority groups or those at higher risk for severe disease, see LAC DPH testing priorities. Clinicians should use their clinical judgement to determine if patients presenting with other less common symptoms may have COVID-19.