Missouri Department of Health & Senior Services Health A lert: Health Alert March 12, 2020 UPDATED Missouri FROM: RANDALL W. WILLIAMS, MD, FACOG COVID-19 PUI Definition DIRECTOR and Testing Algorithm SUBJECT: UPDATED Missouri COVID-19 PUI Definition and Testing Algorithm 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 March 12, 2020 areas of geographic risk are being identified and the criteria for considering testing are This document will be updated as new being updated to reflect this spread. In addition, with increasing access to testing, the information becomes available. The criteria for testing for COVID-19 have been expanded to include more symptomatic current version can always be viewed persons, even in the absence of travel history to affected areas or known exposure to at http://www.health.mo.gov. another case, to quickly detect and respond to community spread of the virus in the United The Missouri Department of Health & States Senior Services (DHSS) is now using four types of documents to provide Criteria to Guide Evaluation and Laboratory Testing for COVID-19 at the Missouri important information to medical and State Public Health Laboratory public health professionals, and to COVID-19 diagnostic testing is available through the Missouri State Public Health other interested persons: Laboratory for individuals meeting the criteria listed below. The areas with sustained Health Alerts convey information transmission have been updated since the March 9, 2020 Health Update. Clinicians should of the highest level of importance note that the geographic locations listed are likely to continue to change with the which warrants immediate action or epidemiologic picture of the outbreak. attention from Missouri health providers, emergency responders, In addition, the algorithm below is being used by our call center to determine if testing for public health agencies, and/or the public. COVID-19 by the State Public Health Laboratory will be approved. Health Advisories provide Please note that some of the initial decision points require that the patient be evaluated by important information for a specific a healthcare provider. In addition, requests for testing approval must come from a incident or situation, including that healthcare provider, not the patient or patient’s family member. To request testing for impacting neighboring states; may not patients that meet one of these criteria, please contact your local public health agency, or require immediate action. the Missouri Department of Health and Senior Services (DHSS) at 800-392-0272 (24/7). Health Guidances contain comprehensive information pertaining For individuals not meeting these DHSS criteria, providers may wish to pursue private to a particular disease or condition, laboratory testing. Testing through private laboratories does not require DHSS approval. and include recommendations, guidelines, etc. endorsed by DHSS. Health Updates provide new or updated information on an incident or situation; can also provide informa- tion to update a previously sent Health Alert, Health Advisory, or Health Guidance; unlikely to require immediate action. __________________________________ Office of the Director 912 Wildwood P.O. Box 570 Jefferson City, MO 65102 Telephone: 800-392-0272 Fax: 573-751-6041 Website: http://www.health.mo.gov 2 Interim Missouri COVID-19 Person Under Investigation (PUI) Definition - Interim Missouri COVID-19 Person Under Investigation (PUI) Definition Updated March 11, 2020 Clinical Features Epidemiologic Risk Fever1 or signs/symptoms of lower respiratory illness (e.g. cough or AND Any person, including healthcare workers', who has had close shortness of breath) contact3 with a laboratory-confirmed4 COVID-19 patient within 14 days of symptom onset Fever1 and signs/symptoms of a lower respiratory illness (e.g., cough or AND A history of travel from affected geographic areas5 (see below) within shortness of breath) requiring hospitalization 14 days of symptom onset Fever1 with severe acute lower respiratory illness (e.g., pneumonia, ARDS) AND No source of exposure has been identified requiring hospitalization and without alternative explanatory diagnosis (e.g., influenza)• Fever' and signs/symptoms of a lower respiratory illness (e.g., cough or AND A history of travel from affected geographic areas5 (see below) within shortness of breath) without alternative explanatory diagnosis (e.g., 14 days of symptom onset influenza), not hospitalized or considered severe Areas with Sustained (Ongoing) Transmission International (By WHO Region) us European Western Pacific Eastern Mediterranean King County/Seattle, Washington, USA Italy Japan Iran Westchester County, New York, USA Spain South Korea Santa Clara County, California, USA Germany China France Footnotes 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 sym~toms (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 Mana ement of Healthcare Personnel with Potential Ex osure in a Healthcare Settin to Patients with Coronav1rus Isease 3Close contact is defined as- a) being within approximately 6 feet (2 meters) of a COVID-19 case for a prolonged period of time; 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 or 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 ettings. Data to inform the definition of close contact are limited. Considerations when assessin11 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. 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. Relevant affected areas will be defined as a country with at least a CDC Level 2 Travel Health Notice. See all COVID-19 Travel Health Notices. •category includes single or clusters of patients with severe acute lower respiratory illness (e.g., pneumonia, ARDS) of unknown etiology in which COVID- 19 is being considered. Missouri Department of Health and Senior Services DHSS Health Alert March 12, 2020 3 Interim Missouri COVID-19 Testing Algorithm Does the patient have fever with severe acute respiratory distress or lower respiratory illness (e.g., pneumonia, ARDS) that requires hospitalization AND and have a negative influenza test? Does the patient have a fever OR symptoms Test approved. Provide of lower respiratory laboratory contact illness information to SPHL as soon as possible. Ensure isolation Has the patient had close Does not meet criteria, do while results pending and contact1 with a COVID-19 nottest atthistime. provide guidancefor home casewithin 14 days of care, ~------ ~aei~~:~:~:e:it:~:eif symptom onset? https://www.cdc.gov/corona physician would prefer to virus{2Q19- test ncov/hcp/guidance-prevent spread.html Has the patient traveled to Does the patient have Does the patient have an area with sustained a fever AND f------+I a positive influenza transmission within 14day.; symptoms of lower test? of symptom onset? respiratory illness 1Closecontact is defined as- Does not meet criteria, do a) being within approximately6 feet (2 meters) of a COVID-19 casef or a not test. Redirect to private prolonged period of time; closec ontact can occur while caring for, living laboratorytesting if with, visiting, or sharing a healthcarewaitingarea or room with a physician would prefer to COVID-19 case test 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 or PPE (e.g., gowns, gloves, NIOSH-certified disposable N95 respirator,eye protection), criteria for PUI consideration are met. Missouri Department of Health and Senior Services DHSS Health Alert March 12, 2020 Missouri Department of Health & Senior Services Health A lert: Health Alert May 24, 2020 Multisystem FROM: RANDALL W. WILLIAMS, MD, FACOG Inflammatory DIRECTOR Syndrome in Children SUBJECT: Multisystem Inflammatory Syndrome in Children (MIS-C) Case Report (MIS-C) Case Report Forms Forms May 24, 2020 On May 14, 2020 DHSS distributed a CDC-issued Health Advisory which detailed Multisystem Inflammatory Syndrome in Children (MIS-C) Associated with Coronavirus This document will be updated as new information becomes available. The Disease 2019 (COVID-19). current version can always be viewed at http://www.health.mo.gov. The advisory made reference to case report forms under development by CDC. Forms The Missouri Department of Health & were released Thursday, May 21. They include: Senior Services (DHSS) is now using - MIS-C CRF Instructions four types of documents to provide - MIS-C CRF Fillable important information to medical and public health professionals, and to o This is a PDF with fillable fields other interested persons: - MIS-C CRF Form Health Alerts convey information o Non-fillable form of the highest level of importance which warrants immediate action or Each form listed above can be found at attention from Missouri health providers, emergency responders, https://health.mo.gov/living/healthcondiseases/communicable/novel- public health agencies, and/or the coronavirus/professionals.php. public. Health Advisories provide Completed case report forms should be provided via email to your regional DHSS important information for a specific epidemiologist or via fax to the Bureau of Communicable Disease Control and Prevention incident or situation, including that at 573-526-0235. MIS-C as a reportable condition will be added to 19 CSR 20-20.020 at a impacting neighboring states; may not require immediate action. later date. Health Guidances contain comprehensive information pertaining Missouri healthcare providers and public health practitioners: Please contact your local to a particular disease or condition, public health agency or the Missouri Department of Health and Senior Services’ (DHSS’) and include recommendations, Bureau of Communicable Disease Control and Prevention at 573-751-6113 or 800-392- guidelines, etc. endorsed by DHSS. 0272 (24/7) with questions regarding this Alert. Health Updates provide new or updated information on an incident or situation; can also provide informa- tion to update a previously sent Health Alert, Health Advisory, or Health Guidance; unlikely to require immediate action. __________________________________ Office of the Director 912 Wildwood P.O. Box 570 Jefferson City, MO 65102 Telephone: 800-392-0272 Fax: 573-751-6041 Website: http://www.health.mo.gov U.S. DEPARTMENT OF Multisystem Inflammatory Syndrome Associated HEALTH AND HUMAN SERVICES CENTERS FOR DISEASE CONTROL with COVID-19 Case Report Form AND PREVENTION ATLANTA, GA 30329 MIS ID (REQUIRED): Health Department ID: NCOV ID (if available): NNDSS ID (local_record_id/case id): Tools for CRF data submission to supplement NNDSS case notification/data: 0 DCIPHER 0 RedCap Abstractor name: Date of abstraction: ____/____/______ SECTION 1 – INCLUSION CRITERIA 1.1 □ Age <21, AND 1.2 □ Fever >38.0°C for ≥24 hours, or report of subjective fever lasting ≥24 hours, AND 1.3 □ Laboratory markers of inflammation (including, but not limited to one or more; an elevated C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), fibrinogen, procalcitonin, d-dimer, ferritin, lactic acid dehydrogenase (LDH), or interleukin 6 (IL-6), elevated neutrophils, reduced lymphocytes and low albumin, AND 1.4 □ Evidence of clinically severe illness requiring hospitalization, with multisystem (≥2) organ involvement (check all applicable below): AND 1.4.1 □ Cardiac (e.g. shock, elevated troponin, BNP, abnormal echocardiogram, arrhythmia) 1.4.2 □ Renal (e.g. acute kidney injury or renal failure) 1.4.3 □ Respiratory (e.g. pneumonia, ARDS, pulmonary embolism) 1.4.4 □ Hematologic (e.g. elevated D-dimers, thrombophilia, or thrombocytopenia) 1.4.5 □ Gastrointestinal (e.g. elevated bilirubin, elevated liver enzymes, or diarrhea) 1.4.6 □ Dermatologic, (e.g. rash, mucocutaneous lesions) 1.4.7 □ Neurological, (e.g. CVA, aseptic meningitis, encephalopathy) 1.5 No alternative plausible diagnosis; AND □ 1.6 □ Positive for current or recent SARS-COV-2 infection by (check all applicable below): OR 1.6.1 □ RT-PCR 1.6.2 □ Serology 1.6.3 □ Antigen test 1.7 □ COVID-19 exposure within the 4 weeks prior to the onset of symptoms 1.7.1 If yes, date of first exposure within the 4 weeks prior : (MM/DD/YYYY): ____/____/______ □ Unknown SECTION 2 – PATIENT DEMOGRAPHICS 2.1 State of Residence: 2.2 Patient zip code/postal code (primary residence): 2.3 Date of birth (MM/DD/YYYY): ____/____/______ 2.4 Sex: 0 Male 0 Female 2.5 Ethnicity: 0 Hispanic or Latino 0 Not Hispanic or Latino 0 Refused or Unknown 2.6 Race (mark all that apply, selecting more than one option as necessary): 2.6.1 □ White 2.6.2 □ Black or African American 2.6.3 □ American Indian 2.6.4 □ Alaska Native or Aboriginal Canadian 2.6.5 □ Native Hawaiian 2.6.6 □ Other Pacific Islander 2.6.7 □ Asian 2.6.8 □ Other 2.6.9 □ Refused or Don’t know 2.7 Height: inches 2.8 Weight: lbs 2.9 BMI: Comorbidities: 2.10.1 Immunosuppressive 2.11 Hospital admission date disorder/malignancy 0 Yes 0 No 2.10.2 Obesity 0 Yes 0 No (MM/DD/YYYY): ____/____/______ 2. 10.3 Type 1 diabetes 0 Yes 0 No 2.11.1 Number of days in the hospital: 2. 10.4 Type 2 diabetes 0 Yes 0 No 2.12 If admitted to the ICU, admission date 2. 10.5 Seizures 0 Yes 0 No (MM/DD/YYYY): ____/____/______ 2. 10.6 Congenital heart disease 0 Yes 0 No 2. 10.7 Sickle cell disease 0 Yes 0 No 2.12.1 Number of days in the ICU: 2. 10.8 Chronic lung disease 0 Yes 0 No 2.13 Patient outcome: 0 Died 0 Discharged 0 Still admitted 2. 10.9 Other congenital malformations 0 Yes 0 No 2.13.2 Hospital discharge or death date 2. 10.10 Other (specify): (MM/DD/YYYY): ____/____/______ CS317086 May 2020 Page 1 of 3 SECTION 3 – CLINICAL SIGNS AND SYMPTOMS 3.1 Did the patient have preceding COVID-like illness? 0 Yes 0 No 3.1.1 Date of symptom onset (MM/DD/YYYY): ____/____/______ 3.2 Date of symptom onset of MIS (MM/DD/YYYY): ____/____/______ 3.3. Fever ≥ 38.0°C: 0 Yes 0 No 3.3.1 Date of fever onset (MM/DD/YYYY): ____/____/______ 3.3.2 Highest Temperature: OC 3.3.3 Number of days febrile: Signs and symptoms during present illness 3.4.1 Cardiac 3.4.5 Gastrointestinal 3.4.1.1 Shock 0 Yes 0 No 3.4.5.1 Abdominal pain 0 Yes 0 No 3.4.1.2 Elevated troponin 0 Yes 0 No 3.4.5.2 Vomiting 0 Yes 0 No 3.4.1.3 Elevated BNP or NT-proBNP 0 Yes 0 No 3.4.5.3 Diarrhea 0 Yes 0 No 3.4.5.4 Elevated bilirubin 0 Yes 0 No 3.4.2 Renal 3.4.5.5 Elevated liver enzymes 0 Yes 0 No 3.4.2.1 Acute kidney injury 0 Yes 0 No 3.4.2.2 Renal failure 0 Yes 0 No 3.4.6 Dermatologic 3.4.6.1 Rash 0 Yes 0 No 3.4.3 Respiratory 3.4.6.2 Mucocutaneous lesions 0 Yes 0 No 3.4.3.1 Cough 0 Yes 0 No 3.4.3.2 Shortness of breath 0 Yes 0 No 3.4.7 Neurological 3.4.3.3 Chest pain/tightness 0 Yes 0 No 3.4.7.1 Headache 0 Yes 0 No 3.4.3.4 Pneumonia 0 Yes 0 No 3.4.7.2 Altered mental state 0 Yes 0 No 3.4.3.5 ARDS 0 Yes 0 No 3.4.7.3 Syncope/near syncope 0 Yes 0 No 3.4.3.6 Pulmonary embolism 0 Yes 0 No 3.4.7.5 Meningitis 0 Yes 0 No 3.4.7.6 Encephalopathy 0 Yes 0 No 3.4.4 Hematologic 3.4.4.1 Elevated D-dimers 0 Yes 0 No 3.4.8 Other 3.4.4.2 Thrombophilia 0 Yes 0 No 3.4.8.1 Neck pain 0 Yes 0 No 3.4.4.3 Thrombocytopenia 0 Yes 0 No 3.4.8.2 Myalgia 0 Yes 0 No 3.4.8.3 Conjunctival injection 0 Yes 0 No 3.4.8.4 Periorbital edema 0 Yes 0 No 3.4.8.5 Cervical lymphadenopathy >1.5 cm diameter 0 Yes 0 No SECTION 4 – COMPLICATIONS 4.1 Arrhythmia 0 Yes 0 No 4.4 Pericarditis 0 Yes 0 No If yes: 4.5 Liver failure 0 Yes 0 No 4.1.1 Ventricular arrhythmia: 0 Yes 0 No 4.6 Deep vein thrombosis or PE 0 Yes 0 No 4.1.2 Supraventricular arrhythmia: 0 Yes 0 No 4.7 ARDS 0 Yes 0 No 4.1.3 Other arrhythmia (specify): 0 Yes 0 No 4.8 Pneumonia 0 Yes 0 No 4.9 CVA or stroke 0 Yes 0 No 4.10 Encephalitis or aseptic meningitis 0 Yes 0 No 4.2 Congestive heart failure 0 Yes 0 No 4.11 Shock 0 Yes 0 No 4.3 Myocarditis 0 Yes 0 No 4.12 Hypotension 0 Yes 0 No SECTION 5 – TREATMENTS 5.1 Low flow nasal cannula 0 Yes 0 No 5.10 Antiplatelets 5.2 High flow nasal cannula 0 Yes 0 No (e.g. aspirin, clopidogrel) 0 Yes 0 No 5.3 Non-invasive ventilation 0 Yes 0 No (specify): 5.4 Intubation 0 Yes 0 No 5.5 Mechanical ventilation 0 Yes 0 No 5.11 Anticoagulation (e.g. heparin, 5.6 ECMO 0 Yes 0 No enoxaparin, warfarin) 0 Yes 0 No 5.7 Vasoactive medications (specify): (e.g. epinephrine, milrinone, norepinephrine, or vasopressin) 0 Yes 0 No (specify): 5.12 Dialysis 0 Yes 0 No 5.13 First IVIG 0 Yes 0 No 5.8 Steroids 0 Yes 0 No 5.14 Second IVIG 0 Yes 0 No 5.9 Immune modulators (e.g. anakinra, tocilizumab) 0 Yes 0 No (specify): CS317086 May 2020 Page 2 of 3 SECTION 6 – STUDIES 6.1 Blood Test Results 6.1.1 Fibrinogen Highest value: units: 0 Low 0 Normal 0 High 6.1.2 CRP Highest value: units: 0 Low 0 Normal 0 High 6.1.3 Ferritin Highest value: units: 0 Low 0 Normal 0 High 6.1.4 Troponin Highest value: units: 0 Low 0 Normal 0 High 6.1.5 BNP Highest value: units: 0 Low 0 Normal 0 High 6.1.6 NT-proBNP Highest value: units: 0 Low 0 Normal 0 High 6.1.7 D-dimer Highest value: units: 0 Low 0 Normal 0 High 6.1.8 IL-6 Highest value: units: 0 Low 0 Normal 0 High 6.1.9 Serum White blood count Highest value: Lowest value : units: 6.1.10 Platelets Highest value : __________ Lowest value : __________ units: 6.1.11 Neutrophils Highest value: Lowest value : units: 6.1.12 Lymphocytes Highest value: Lowest value : units: 6.1.13 Bands Highest value: Lowest value : units: 6.2 CSF Studies 6.2.1 White blood count Highest value : Lowest value : units: 6.2.2 Protein Highest value : Lowest value : units: 6.2.3 Glucose Highest value : Lowest value : units: 6.3 Urinalysis 6.3.1 Urine White blood count Highest value : Lowest value : units: 6.4 Echocardiogram (check if seen on ANY echocardiogram) 6.4.1 □ Not done 6.4.2 □ Normal results 6.4.3 □ Coronary artery aneurysms 6.4.3.1 Max coronary artery Z-score: 6.4.4 □ Coronary artery dilatation 6.4.5 □ Cardiac dysfunction (decreased function), specify type: 6.4.5.1 □ left ventricular dysfunction 6.4.5.2 □ right ventricular dysfunction 6.4.6 □ Pericardial effusion 6.4.7 □ Pleural effusion 6.4.8 □ Mitral regurgitation, specify type: 0 mild 0 moderate 0 severe 6.4.9 □ Other (specify): 6.5 Date of first test showing coronary artery aneurysm or dilatation (MM/DD/YYYY): ____/____/______ 6.6 Abdominal imaging □ Ultrasound □ CT 0 Not done 6.6.1 □ Normal 6.6.2 □ Mesenteric lymphadenopathy 6.6.3 □ Free fluid 6.6.4 □ Other (specify): 6.7 Chest imaging □ Chest x-ray □ CT 0 Not done 6.7.1 □ Normal 6.7.2 □ Pneumonia 6.7.3 □ Atelectasis 6.7.4 □ Pleural effusion 6.7.5 □ Other (specify): SARS-COV-2 testing 6.8 RT-PCR: 0 Positive 0 Negative 0 Not done 6.8.1 If performed, date (MM/DD/YYYY): ____/____/______ 6.9 Antigen: 0 Positive 0 Negative 0 Not done 6.9.1 If performed, date (MM/DD/YYYY): ____/____/______ 6.10 IgG: 0 Positive 0 Negative 0 Not done 6.10.1 If performed, date (MM/DD/YYYY): ____/____/______ 6.11 IgM: 0 Positive 0 Negative 0 Not done 6.11.1 If performed, date (MM/DD/YYYY): ____/____/______ 6.12 IgA: 0 Positive 0 Negative 0 Not done 6.12.1 If performed, date (MM/DD/YYYY): ____/____/______ CS317086 May 2020 Page 3 of 3