Under Title 17, Section 2500, California Code of Regulations all suspected outbreaks are reportable.
Definition of Outbreak:
1. Two or more laboratory confirmed cases (symptomatic or asymptomatic) of COVID-19 in a patient 7 or more days after admission for a non-COVID condition, with epi-linkage. (Epi-linkage among patients is defined as overlap on the same unit or ward for any duration or having the potential to have been cared for by common Health Care Personnel (HCP) within a 14-day time period of each other).
2. Three or more laboratory confirmed cases (symptomatic or asymptomatic) of COVID-19 in HCP with epi-linkage who do not share a household and are not listed as a close contact of each other outside of the workplace during standard case investigation or contact tracing. Epi-linkage among HCP is defined as having the potential to have been within 6 feet for 15 minutes or longer while working in the facility during the 14 days prior to the onset of symptoms or positive test (e.g., worked on the same unit during the same shift).
Isolate suspected or confirmed case of COVID-19
Immediately isolate and initiate standard, contact, droplet precautions, plus N95 respiratory use and eye protection for all suspect or confirmed patients with fever and/or symptoms of COVID-19.
HCP should be excluded from work if symptomatic. For facilities experiencing staffing shortages, consult with Area Medical Director (AMD) or designee if HCP in quarantine area is permitted to return to work during an outbreak in the facility. See Infection Prevention and Guidance for Healthcare Personnel
A close contact is a person with exposure to a confirmed or suspected case of COVID-19 during the period from 2 days before symptom onset until the case meets criteria for discontinuing isolation (see detailed instructions below for staff and patients). For asymptomatic cases, the date of collection of the specimen positive SARS-CoV-2 can be used in place of symptom onset date to determine period of isolation.
Exposures are defined as follows:
*A patient with COVID-19 is considered to be infectious from 2 days before their symptoms started until their isolation period ends. Asymptomatic patients with a positive SARS-CoV-2 diagnostic (viral) test are considered to be infectious from 2 days before their test was taken until 10 days after their test was taken.
Note: A person is still considered a close contact even if they and/or the case were wearing a facemask at the time of exposure. Exceptions to this are HCP wearing appropriate PPE and employees who were wearing a respirator as per Cal/OSHA regulations.
Identify any close contacts or exposures to the COVID-19 positive case and place them in quarantine for 14 days, regardless of vaccination status. Continue to monitor patients for fever and respiratory symptoms (i.e., cough, sore throat, shortness of breath). Patients who are considered exposed due to being in the same unit/wing as a case do not need to be moved.
Healthcare Personnel (HCP):
Identify all close contact HCP (includes clinical and ancillary staff), and determine risk status using the guide outlined in Infection Prevention Guidance for Healthcare Personnel and a companion guidance, CDC Criteria for Return to Work for Healthcare Personnel with Confirmed or Suspected COVID-19. Monitor HCP for fever, cough, and shortness of breath. HCP who are not fully vaccinated must quarantine and be excluded from work for 10 days after a work exposure. Exceptions for critical staffing shortages is determined by public health officials during an outbreak. Work restrictions may be implemented for HCP who are asymptomatic and fully vaccinated (i.e., staff refusing COVID-19 testing) when directed by public health authorities during an outbreak. See: CDC Interim U.S. Guidance for Risk Assessment and Work Restrictions for Healthcare Personnel with Potential Exposure to SARS-CoV-2.
Contact any visitors that may have been exposed to a suspected or confirmed case and instruct them to self-quarantine for 10 days after last exposure unless they are exempt (see COVID-19 Quarantine and Other Instructions for Close Contacts). Visitors should call their primary care provider to discuss testing options.
Note: CDC does not recommend testing, symptom monitoring or special management for people exposed to asymptomatic people with potential exposures to SARS-CoV-2 (i.e., “contacts of contacts;” these people are not considered exposed to SARS-CoV-2).
All healthcare providers should be able to provide staff and patients with timely access to SARS-CoV-2 diagnostic testing when indicated (see LAC DPH Health Officer Order: Access to Diagnostic Testing Through Healthcare Facilities)
As shown in the LAC DPH SARS-CoV-2 Testing Guidelines, diagnostic testing is indicated when infection is suspected, such as when the person:
Increase environmental cleaning throughout the facility with emphasis on high touch surfaces particularly in the unit where the case(s) was located. Ensure that approved cleaning agent is being used. See EPA About List N: Disinfectants for Coronavirus (COVID-19).
Discontinue indoor and outdoor visitation until the outbreak has been closed (see DHHS Visitation at Psychiatric Residential Treatment Facilities and CDPH Visitation Guidance AFL 20-38.7) Visitation may be restricted during an outbreak as directed by public health officials.
Discontinue indoor and outdoor communal activities and dining until the outbreak has been closed. Eating needs to remain supervised due to potential for self-harm with eating utensils and because commonly used psychiatric medications may cause side effects (e.g., tardive dyskinesia, dysphagia, hypo- and hypersalivation) that increase choking risk for patients. Some options are to position staff in patient’s rooms to monitor their dining or have patients sit in appropriately spaced chairs in the hallway outside their rooms so they can be monitored while they eat.
Follow COVID-19 interfacility transfer guidelines including:
Instruct the facility to immediately notify District Public Health Nurse (DPHN), assigned to the facility, if any patient or staff report fever or respiratory symptoms and any COVID-19 positive test results. Comply with reporting requirements regarding COVID-19 or SARS-CoV-2 virus testing results. DPHN must be notified of a death and the facility will need to complete and submit a death report to ACDC (see Reporting COVID-19 Associated Deaths).
Healthcare worker vaccination requirement mandates employers of health care and home care workers who work in or routinely visit high-risk or residential care settings to document their fully vaccinated status; for those with approved medical or religious exemptions, document weekly or twice weekly regular testing for COVID-19. This mandate reflects the State Health Officer Order and LAC DPH Health Officer Order requiring health care worker vaccination and testing.
The outbreak can be closed once closure criteria is met:
1. Two consecutive weeks of response testing in a staff and patients have been negative;
2. Upon the discretion of the AMD or MD designee.
Prior to closure, all of the following documents must be completed:
View LAC DPH infection prevention guidance and assuring PPE supplies and CDC recommendations for healthcare personnel during the COVID-19 pandemic for additional information.
Due to security and behavioral concerns in behavioral health settings, some infection control guidance may need to be tailored for the safety of the patients (see CDC Clinical Questions about COVID-19: Questions and Answers for further guidance).
View CDC recommendations for universal source control.
Recommend COVID-19 PCR testing upon admission for unvaccinated patients, patients whose vaccination status is unknown, patients who are symptomatic, and patients with known exposure as these results can inform the type of infection control precautions used (e.g., room assignment/cohorting, or personal protective equipment used). Recommend antigen or COVID-19 PCR testing upon admission for fully vaccinated patients who are asymptomatic and without known exposure. Continue to monitor all patients for the development of COVID-19 symptoms, and promptly test any newly symptomatic patients and patients who are exposed to a suspected or confirmed case during their hospital stay, regardless of their vaccination status.
View CDC recommendations for universal use of PPE for patient care.
For additional information on PPE for patients with suspected or confirmed COVID-19 view CDC recommendations and NIOSH Considerations for Covering N95s to Extend Use.
NOTE: Local public health guidance with respect to outbreak control and management is understood to take precedence of both state and federal guidance.