Clinician Update
COVID-19 Guidance
February 12, 2021
COVID-19 Situation Report
Requested Actions
- Maintain awareness of the level and trajectory of COVID-19 transmission in the community.
- Be able to direct patients and colleagues to guidance on Washington State’s Roadmap to Recovery as well as to prevention and safety guidance for schools, businesses and workplaces.
Summary
- Through February 6, the reported number of COVID-19 cases per 100,000 residents over the preceding 14-day period has declined 60% off its peak in late December. Hospitalizations, long term care cases, outbreaks, and deaths are also declining in a roughly parallel fashion.
- Based upon sustained improvements in all four of the state’s Roadmap to Recovery metrics (R2R--reported case rate, test positivity, hospital admissions, and intensive care capacity) the Puget Sound region (Snohomish, King and Pierce Counties) recently advanced to Phase 2 of the R2R. As a region, we must maintain stable or improving results in 3-of-4 metrics to remain in Phase 2. No Phase 3 has been defined by Governor Inslee at this time, so no further advance is anticipated in the imminent future.
- These phases of the R2R are separate and distinct from the phases defined for prioritization of vaccine candidates. We are NOT in phase 2 of the vaccination prioritization framework but rather are in phase 1b1 (see COVID-19 Vaccination item below).
COVID-19 Data Resources
SARS-CoV-2 Variants of Concern (VOC)
Requested action:
Maintain awareness of strain variants and their implications for COVID-19 prevention and control.
Summary
Currently recognized VOCs arise from mutations in the SARS-CoV-2 gene coding the spike protein, with implications for any of the following: transmission, severity, detection, response to treatment, or immunity. Concern for the moment is primarily focused on the B.1.1.7 VOC with respect to its apparent capacity for increased transmissibility (30-50%), severity (extent not specified), and health care surge. Not thought to be at stake with respect to B.1.1.7 is the clinical effectiveness of vaccine- and naturally acquired immunity. Through convenience sampling and analysis of a small proportion of specimens, the current prevalence of B.1.1.7 in Washington State was roughly 0.2% of COVID-19 cases (range 0.1-0.5%) several weeks ago when two such cases were detected in Snohomish County residents who had no travel history. CDC predicts that this strain will largely replace other circulating strains in the United States within several months. The current response at the local level to this challenge includes emphasizing ongoing personal prevention measures and rolling out vaccine as quickly as possible. No change in B.1.1.7 case or contact management is recommended at this time. Furthermore, surveillance testing results for VOCs are not available to the managing clinician or the patient because this is not a CLIA-approved test. At the state and national level, efforts are underway to enhance laboratory capacity for variant strain surveillance and to adjust clinical diagnostic and vaccine technology when appropriate.
Additional Resources
Vaccine Roll-Out
Requested action
- Be aware of and direct patients to resources for determining eligibility and accessing vaccine.
- Urge your patients to adhere to the prioritization phases and to accept that limited vaccine supply means accessing an appointment may take time and repeated efforts.
Summary
Above are county-wide totals on vaccine allocation and administration through February 6, exclusive of the federalpharmacy partnership addressing nursing homes and assisted living facilities. Capacity to administer up to 20,000 doses weekly is currently in place through county-operated mass vaccination sites. Plans are ongoing for further expansion up to approximately 50,000 doses weekly in addition to throughput in the healthcare system and other venues. However, scarcity of vaccine supply at the federal and state level are the current bottleneck in making progress toward vaccinating the county’s approximately 650,000 eligible adults. The vaccine prioritization framework (currently in phase 1b1) and allocations are established by the Washington State Department of Health (DOH). Current DOH allocations of the limited supply are emphasizing mass vaccination and equity-oriented venues. County-operated mass vaccination sites operate on an appointment basis with pre-registration via internet. New appointment slots are posted weekly when vaccine supply comes in. Given the limited vaccine supply and the large number of 1b1 eligibles still seeking vaccination, repeated efforts to get a slot across the course of wees may be necessary. As time passes, the vaccine supply improves, and competition for slots decreases, chances of success will also improve with each passing week. In the meantime, longer-term scheduling beyond the current week will become available when vaccine supply forecasts permit. Individuals without internet access, especially elders, as well as those needing language assistance may contact the call center for help in scheduling an appointment (425-339-5278; 8:30AM – 4:30PM Monday-Friday).
Vaccination Resources
SARS-CoV-2 Vaccine Adverse Effects
Requested action
- Be aware of the clinical presentation of acute and delayed adverse reactions to SARS-CoV-2 mRNA vaccines.
- Report adverse reactions requiring medical attention to CDC’s Vaccine Adverse Event Reporting System.
Summary
- Typical reactions occurring in a substantial proportion of patients include local and systemic inflammatory reactions not uncommon to influenza, shingles, and other live viral vaccines. These are more common after the second dose.
- Acute reactions appear to be more common than with other adult immunizations and can include the full spectrum of allergy from pruritus-with-rash up through rare cases of angioedema or anaphylaxis. All settings conducting vaccination should have epinephrine pens immediately available and contingency plans for on-site emergency management and referral to 911. Regional lymphadenopathy, cross reactions to dermal filler, and selflimited hyperdynamic hypertensive episodes have also been reported.
- Delayed reactions have included erythema, tenderness and swelling at the injection site several days to a week later, with or without rash. These typically can be managed with antihistamines, topical potent corticosteroids, and analgesics.
Additional Resources
Quarantine Exemption for Fully Vaccinated Individuals
Action Requested
Be familiar with the liberty afforded to asymptomatic individuals who are exposed to COVID-19 more than 14 days after their second dose of vaccine.
Summary
CDC posted on February 11 that vaccinated persons with an exposure to someone with suspected or confirmed COVID19 are not required to quarantine if they meet the following criteria:
- are fully vaccinated (i.e., ≥2 weeks following receipt of the second dose in a 2-dose series, or ≥2 weeks following receipt of one dose of a single-dose vaccine); AND
- are within 3 months following receipt of the last dose in the series; AND
- have remained asymptomatic since the current COVID-19 exposure
Individuals who do not meet all three of the above criteria should continue to follow current quarantine guidance after exposure to someone with suspected or confirmed COVID-19.
The Health District is pleased to note that CDC’s confidence in the vaccine’s efficacy is translating into greater flexibility for public health and infection prevention management of exposed individuals who are fully vaccinated. The Health District defers to health care facilities on how they choose to implement this guidance with respect to their staff and visitors.
Additional Resources
Mask Fit and Layering Updates from CDC
Requested actions
- With respect to use of face coverings in the community, be aware of the importance of a good fit minimizing leakage and the use of multilayer tightly woven cloth.
- Be aware that a second layer of cloth improves filtration and may benefit both source control and the wearer.
Summary
After reporting on February 10 results from filtration experiments assessing different methods for layering or improving fit, CDC offered updated masking recommendations on February 11. These recommendations include adding layers of material in one of the two following ways:
- Use a cloth mask that has multiple layers of fabric.
- Wear one disposable mask underneath a cloth mask
CDC recommends against doubling up on disposable masks or combining K95 masks with any other mask.
While the marginal clinical effectiveness of double-masking in healthcare or community settings has not been delineated in these communications and the branching consequences for personal protective equipment supplies could be a concern in healthcare settings, the Health District endorses efforts to ensure that all people (1) wear a multilayer mask of tightly woven cloth when it is appropriate to do so, (2) ensure that it fits snugly, and (3) consider double-masking or additional layers as they may provide better source control additional protection to the wearer. The Health District discourages use of medical grade masks in community settings and defers to health care facilities on how they choose to implement CDC’s guidance with respect to their staff and visitors.
Additional Resources
Face Coverings for Children in School Settings
Requested actions
- Scrutinize requests for exclusions from face covering requirements in the school setting.
- Limit issuance of such exclusions to students who meet generally accepted criteria established in prevailing guidelines
Background
Schools in Snohomish County and throughout Washington State continue a process started last autumn of the serial introduction of students back toward in-person learning, beginning with the youngest and special needs students. The preponderance of evidence supports the relatively low risk of in person learning in cohorted hybrids of students with proper prevention measures in place (e.g., face coverings, distancing, hand hygiene, sanitation of frequently touched surfaces). Face coverings are an essential component of this evidence-based strategy and a key part of a successful return to in-person learning for Snohomish County children and adolescents. This approach is unequivocally supported by the American Academy of Pediatrics and the CDC. With proper implementation of these measures, our experience locally, statewide, and nationally has been that transmission in the school setting is unusual and limited.
Coincident with this gradual return to in-person learning, the Health District’s school outreach and outbreak investigation team has noted increased reports from schools of children presenting with clinician notes affording medical exclusions to wearing face coverings in the school setting. These exclusions may have been issued in good faith based on reasonable clinical judgment. The Health District defers to that judgment but also wants to take this opportunity to remind clinicians that the indications for such an exclusion are relatively rare (see links below) and CDC does not consider face shields an effective alternative to face coverings for source control.
Additional Resources on Face Coverings in School
Gloves Not a Required Element of PPE for Vaccine Administration
Requested Actions
- Consider the impacts of routine glove use for COVID-19 vaccination on your and the health care system’s supply chain.
- Consider implementing state guidance addressing gloves and other personal protective equipment (PPE) for COVID-19 vaccination
Summary
Gloves have been a recent bottleneck in the supply chain of PPE. The Washington State Department of Health advises that gloves are not recommended for most vaccination administration and are not required for the COVID-19 vaccine under most situations. Please see the Glove and Other PPE Guidance for COVID-19 Vaccine Administration from WA DOH for more information. Additionally, updated guidance is now available in Prioritization Guidelines for Allocation of Personal Protective Equipment when Supplies are Severely Limited.