Updated Guidance on Evaluating and Testing Persons for Coronavirus Disease 2019 (COVID-19)

Distributed via the CDC Health Alert Network
March 08, 2020, 8:20 PM ET
CDCHAN-00429

Summary
The Centers for Disease Control and Prevention (CDC) continues to closely monitor and respond to the COVID-19 outbreak caused by the novel coronavirus, SARS-CoV-2.

This CDC Health Alert Network (HAN) Update highlights guidance and recommendations for evaluating and identifying patients who should be tested for COVID-19 that were shared on March 4, 2020, on the CDC COVID-19 website at https://www.cdc.gov/coronavirus/2019-nCoV/hcp/clinical-criteria.html. It supersedes the guidance and recommendations provided in CDC’s HAN 428 distributed on February 28, 2020.

The outbreak that began in Wuhan, Hubei Province, has now spread throughout China and to 101 other countries and territories, including the United States. As of March 8, 2020, there were more than 105,000 cases reported globally. In addition to sustained transmission in China, there is now community spread in several additional countries. CDC has updated travel guidance to reflect this information (https://www.cdc.gov/coronavirus/2019-ncov/travelers/index.html).

As of March 7, 2020, there were a total of 213 cases within the United States, of which, 49 were among repatriated persons from high-risk settings. Among the other 164 cases that were diagnosed in the United States, 36 were among persons with a history of recent travel in China or other affected areas, and 18 were persons in close contact with another confirmed COVID-19 patient (i.e., person-to-person spread); 110 cases are currently under investigation. During the week of February 23, community spread of the virus that causes COVID-19 was reported in California in two places, Oregon, and Washington. Community spread in Washington resulted in the first reported case of COVID-19 in a healthcare worker, and the first outbreak in a long-term care facility. The first death due to COVID-19 was also reported from Washington; there have now been 11 reported deaths in the U.S. from COVID-19. As of March 7, 2020, COVID-19 cases had been reported by 19 states. CDC will continue to work with state and local health departments, clinicians, and laboratorians to identify and respond to other cases of COVID-19, especially those with an unknown source of infection, to limit further community spread. The most recent update describing COVID-19 in the United States can be found at https://www.cdc.gov/coronavirus/2019-ncov/cases-in-us.html.

Recognizing persons who are at risk for COVID-19 is a critical component of identifying cases and preventing further transmission. With expanding spread of COVID-19, additional areas of geographic risk are being identified and the criteria for considering testing are being updated to reflect this spread. In addition, with increasing access to testing, the criteria for testing for COVID-19 have been expanded to include more symptomatic persons, even in the absence of travel history to affected areas or known exposure to another case, to quickly detect and respond to community spread of the virus in the United States.

Criteria to Guide Evaluation and Laboratory Testing for COVID-19
Clinicians should work with their local and state health departments to coordinate testing through public health laboratories. In addition, COVID-19 diagnostic testing, authorized by the Food and Drug Administration under an Emergency Use Authorization (EUA), is becoming available in clinical laboratories. This additional testing capacity will allow clinicians to consider COVID-19 testing for a wider group of symptomatic patients.

Clinicians should use their judgment to determine if a patient has signs and symptoms compatible with COVID-19 and whether the patient should be tested. Most patients with confirmed COVID-19 have developed fever¹ and/or symptoms of acute respiratory illness (e.g., cough, difficulty breathing). Priorities for testing may include:

1. Hospitalized patients who have signs and symptoms compatible with COVID-19 in order to inform decisions related to infection control.
2. Other symptomatic individuals such as, older adults (age ≥ 65 years) and individuals with chronic medical conditions and/or an immunocompromised state that may put them at higher risk for poor outcomes (e.g., diabetes, heart disease, receiving immunosuppressive medications, chronic lung disease, chronic kidney disease).
3. Any persons including healthcare personnel², who within 14 days of symptom onset had close contact³ with a suspect or laboratory-confirmed⁴ COVID-19 patient, or who have a history of travel from affected geographic areas⁵ (see below) within 14 days of their symptom onset.

There are epidemiologic factors that may also help guide decisions about COVID-19 testing. Documented COVID-19 infections in a jurisdiction and known community transmission may contribute to an epidemiologic risk assessment to inform testing decisions. Clinicians are strongly encouraged to test for other causes of respiratory illness (e.g., influenza).

Mildly ill patients should be encouraged to stay home and contact their healthcare provider by phone for guidance about clinical management. Patients who have severe symptoms, such as difficulty breathing, should seek care immediately. Older patients and individuals who have underlying medical conditions or are immunocompromised should contact their physician early in the course of even mild illness.

International Areas with Sustained (Ongoing) Transmission
Last updated March 8, 2020
(https://www.cdc.gov/coronavirus/2019-ncov/travelers/index.html)

• China: Level 3 Travel Health Notice (https://wwwnc.cdc.gov/travel/notices/warning/novel-coronavirus-china)
• Iran: Level 3 Travel Health Notice (https://wwwnc.cdc.gov/travel/notices/warning/coronavirus-iran)
• Italy: Level 3 Travel Health Notice (https://wwwnc.cdc.gov/travel/notices/warning/coronavirus-italy)
• Japan: Level 2 Travel Health Notice (https://wwwnc.cdc.gov/travel/notices/alert/coronavirus-japan)
• South Korea: Level 3 Travel Health Notice  (https://wwwnc.cdc.gov/travel/notices/warning/coronavirus-south-korea)

Recommendations for Reporting, Laboratory Testing, and Specimen Collection
Clinicians should immediately implement recommended infection prevention and control practices (https://www.cdc.gov/coronavirus/2019-ncov/infection-control/control-recommendations.html) if a patient is suspected of having COVID-19. They should also notify infection control personnel at their healthcare facility and their state or local health department if it is suspected that a patient may have COVID-19. State health departments that have identified a person suspected of having COVID-19 or a laboratory-confirmed case should complete a PUI and Case Report form through the processes identified on CDC’s Coronavirus Disease 2019 website (https://www.cdc.gov/coronavirus/2019-ncov/php/reporting-pui.html). If specimens are sent to CDC for laboratory testing, state and local health departments can contact CDC’s Emergency Operations Center (EOC) at 770-488-7100 for assistance with obtaining, storing, and shipping, including after hours, on weekends, and holidays.

Guidance for the identification and management of potentially exposed contacts of a confirmed case of COVID-19 can be found in Interim US Guidance for Risk Assessment and Public Health Management of Persons with Potential Coronavirus Disease 2019 (COVID-19) Exposures: Geographic Risk and Contacts of Laboratory-confirmed Cases (https://www.cdc.gov/coronavirus/2019-ncov/php/risk-assessment.html).

Separate guidance for the management of potentially exposed contacts of a COVID-19 case who are healthcare personnel is provided in Interim U.S. Guidance for Risk Assessment and Public Health Management of Healthcare Personnel with Potential Exposure in a Healthcare Setting to Patients with Coronavirus Disease (COVID-19) (https://www.cdc.gov/coronavirus/2019-ncov/hcp/guidance-risk-assesment-hcp.html).

For initial diagnostic testing for COVID-19, CDC recommends collecting and testing upper respiratory tract specimens (nasopharyngeal AND oropharyngeal swabs). CDC also recommends testing lower respiratory tract specimens, if available. For patients who develop a productive cough, sputum should be collected and tested for SARS-CoV-2. The induction of sputum is not recommended. For patients for whom it is clinically indicated (e.g., those receiving invasive mechanical ventilation), a lower respiratory tract aspirate or bronchoalveolar lavage sample should be collected and tested as a lower respiratory tract specimen. Specimens should be collected as soon as possible once a person has been identified for testing, regardless of the time of symptom onset. See Interim Guidelines for Collecting, Handling, and Testing Clinical Specimens from Patients Under Investigation (PUIs) for COVID-19 (https://www.cdc.gov/coronavirus/2019-nCoV/lab/guidelines-clinical-specimens.html) and Biosafety FAQs for handling and processing specimens from suspected cases and PUIs (https://www.cdc.gov/coronavirus/2019-ncov/lab/biosafety-faqs.html).

¹Fever may be subjective or confirmed

²For healthcare personnel, testing may be considered if there has been exposure to a person with suspected COVID-19 without laboratory confirmation. Because of their often extensive and close contact with vulnerable patients in healthcare settings, even mild signs and symptoms (e.g., sore throat) of COVID-19 should be evaluated among potentially exposed healthcare personnel. Additional information is available in CDC’s Interim U.S. Guidance for Risk Assessment and Public Health Management of Healthcare Personnel with Potential Exposure in a Healthcare Setting to Patients with Coronavirus Disease 2019 (COVID-19) (https://www.cdc.gov/coronavirus/2019-ncov/hcp/guidance-risk-assesment-hcp.html).

³Close contact is defined as—

• a) being within approximately 6 feet (2 meters) of a COVID-19 case for a prolonged period; close contact can occur while caring for, living with, visiting, or sharing a healthcare waiting area or room with a COVID-19 case
• – or –
• b) having direct contact with infectious secretions of a COVID-19 case (e.g., being coughed on)
  If such contact occurs while not wearing recommended personal protective equipment (PPE) (e.g., gowns, gloves, NIOSH-certified disposable N95 respirator, eye protection), criteria for PUI consideration are met.
• Additional information is available in CDC’s updated Interim Infection Prevention and Control Recommendations for Patients with Confirmed COVID-19 or Persons Under Investigation for COVID-19 in Healthcare Settings  (https://www.cdc.gov/coronavirus/2019-ncov/infection-control/control-recommendations.html).

• Data to inform the definition of close contact are limited. Considerations when assessing close contact include the duration of exposure (e.g., longer exposure time likely increases exposure risk) and the clinical symptoms of the person with COVID-19 (e.g., coughing likely increases exposure risk as does exposure to a severely ill patient). Special consideration should be given to healthcare personnel exposed in healthcare settings as described in CDC’s Interim U.S. Guidance for Risk Assessment and Public Health Management of Healthcare Personnel with Potential Exposure in a Healthcare Setting to Patients with COVID-19 (https://www.cdc.gov/coronavirus/2019-ncov/hcp/guidance-risk-assesment-hcp.html).

⁴Documentation of laboratory-confirmation of COVID-19 may not be possible for travelers or persons caring for COVID-19 patients in other countries.

⁵Affected areas are defined as geographic regions where sustained community transmission has been identified. For a list of relevant affected areas, see Coronavirus Disease 2019 Information for Travel (https://www.cdc.gov/coronavirus/2019-ncov/travelers/index.html).

For More Information

More information is available at the COVID-19 website: https://www.cdc.gov/coronavirus/2019-ncov/index.html.