1 Missouri Department of Health & Senior Services Health Health Update March 9, 2020 Update: FROM: RANDALL W. WILLIAMS, MD, FACOG Updated Guidance on DIRECTOR Evaluating and Testing Persons for Coronavirus SUBJECT: Updated Guidance on Evaluating and Testing Persons for Disease 2019 (COVID-19) Coronavirus Disease 2019 (COVID-19) Distributed via the CDC Health Alert Network March 08, 2020, 8:20 PM ET CDCHAN-00429 Summary March 9, 2020 This document will be updated as new The Centers for Disease Control and Prevention (CDC) continues to closely monitor and information becomes available. The respond to the COVID-19 outbreak caused by the novel coronavirus, SARS-CoV-2. current version can always be viewed at http://www.health.mo.gov. This CDC Health Alert Network (HAN) Update highlights guidance and recommendations for The Missouri Department of Health & evaluating and identifying patients who should be tested for COVID-19 that were shared on Senior Services (DHSS) is now using March 4, 2020, on the CDC COVID-19 website at https://www.cdc.gov/coronavirus/2019- four types of documents to provide nCoV/hcp/clinical-criteria.html. It supersedes the guidance and recommendations provided important information to medical and in CDC’s HAN 428 distributed on February 28, 2020. public health professionals, and to other interested persons: The outbreak that began in Wuhan, Hubei Province, has now spread throughout China and Health Alerts convey information to 101 other countries and territories, including the United States. As of March 8, 2020, of the highest level of importance there were more than 105,000 cases reported globally. In addition to sustained transmission which warrants immediate action or in China, there is now community spread in several additional countries. CDC has updated attention from Missouri health providers, emergency responders, travel guidance to reflect this information (https://www.cdc.gov/coronavirus/2019- public health agencies or the public. ncov/travelers/index.html). Health Advisories provide As of March 7, 2020, there were a total of 213 cases within the United States, of which, 49 important information for a specific incident or situation, including that were among repatriated persons from high-risk settings. Among the other 164 cases that impacting neighboring states; may not were diagnosed in the United States, 36 were among persons with a history of recent travel require immediate action. 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 Health Guidances contain investigation. During the week of February 23, community spread of the virus that causes comprehensive information pertaining to a particular disease or condition, COVID-19 was reported in California in two places, Oregon, and Washington. Community and include recommendations, spread in Washington resulted in the first reported case of COVID-19 in a healthcare guidelines, etc. endorsed by DHSS. 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. Health Updates provide new or updated information on an incident or from COVID-19. As of March 7, 2020, COVID-19 cases had been reported by 19 states. situation; can also provide informa- CDC will continue to work with state and local health departments, clinicians, and tion to update a previously sent laboratorians to identify and respond to other cases of COVID-19, especially those with an Health Alert, Health Advisory, or unknown source of infection, to limit further community spread. The most recent update Health Guidance; unlikely to require describing COVID-19 in the United States can be found at immediate action. https://www.cdc.gov/coronavirus/2019ncov/cases-in-us.html. __________________________________ Office of the Director Recognizing persons who are at risk for COVID-19 is a critical component of identifying 912 Wildwood cases and preventing further transmission. With expanding spread of COVID-19, additional P.O. Box 570 areas of geographic risk are being identified and the criteria for considering testing are Jefferson City, MO 65102 being updated to reflect this spread. In addition, with increasing access to testing, the Telephone: 800-392-0272 criteria for testing for COVID-19 have been expanded to include more symptomatic persons, Fax: 573-751-6041 even in the absence of travel history to affected areas or known exposure to another case, Website: http://www.health.mo.gov to quickly detect and respond to community spread of the virus in the United States. 2 Criteria to Guide Evaluation and Laboratory Testing for COVID-19 at the Missouri State Public Health Laboratory COVID-19 diagnostic testing is available through the Missouri State Public Health Laboratory for individuals meeting the criteria listed below. Clinicians should note that the geographic locations listed are likely to change with the epidemiologic picture of the outbreak. To request testing for patients that meet one of these criteria, please contact your local public health agency, or the Missouri Department of Health and Senior Services (DHSS) at 800-392-0272 (24/7). - Interim Missouri COVI0-19 Person Under Investigation (PUI) Definition Updated Morch 9, 2020 Clinical Features Epidemiologic Risk Fever' or signs/symptoms of lower respiratory illness (e.g. oough or AND Any person, including healthcare workers', who has had close shortness of breath) contact' with a laboratory-confirmed' COVID-19 patient within 14 days of symptom onset Fever' and signs/symptoms of a lower respiratory illness (e.g., oough or AND A history of travel from affected geographic areas• (see below) within shortness of breath) requiring hospitalization 14 days of symptom onset Fever' 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., oough or AND A history of travel from affected geographic areas• (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 us China Japan King County/Seattle, Washington, USA Iran South Korea Italy 'Fever may be subjective or confirmed 'For 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 extemive and close contact with vulnerable patients in healthcare settings, even mild signs and symptoms (e.g., sore throat) of C9VID-19 should be evalu_ated amon potentially ex osed healthcare perso_nnel. Addi_tional infoffi)ation is available in_C DC's • · . · • Disease 2019 (CQVIP:J9l. 'close 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 COVI0-19 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 Pceventjpn and Control Berommendations for patients wjth Confirmed roYIP-19 or Persoos under lmrest;eatioo for CQYIP:J9 io Healthcare settings. Data to inform the definition of close contact are limited. Considerations when a.s.sessing dose contact include the duration of exposure (e.g., longer eKposure time likely increases ex_pQsure risk) and the clinical SVJ'!1ptoms of the J!e_rson with COVID-19 (e.g.;, coughing likely increases exposure risk as does eWKpao\6sfuer%e t\o'~ a~ sJefvJe£r'e:jly4 ~ilrl patient). Special consideration shoulil be given to ohfe althcare personnel exposeo in healthcare settiinng as a s describedS eintt iCnDgC t'os Risk Assessment and Pwrhlic Health Manaeemeot Healthcare Pe£Soonel with Potential Fxoos11re Heattbrare 'Documentation of laboratory-confirmation of COVID-19 may not be possible for travelers or persom caring for COVID-19 patients in other countries. 'Affected areas are defined as geographic regions where sustained community transmission has been identified. Relevant affected areas will be defined as a country with aUell.s1 a coc Level 2 Travel Health Notice. See all coyrp.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. National priorities for COVID-19 Testing at Commercial Laboratories 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 than can be tested through the Missouri State Public Health Laboratory. 3 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. 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/novelcoronavirus-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/coronavirusjapan) • 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 4 Coronavirus Disease (COVID-19) (https://www.cdc.gov/coronavirus/2019-ncov/hcp/guidance-riskassesment- 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/2019ncov/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/controlrecommendations.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-riskassesment-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). 5 For More Information More information is available at the COVID-19 website: https://www.cdc.gov/coronavirus/2019ncov/index.html. The Centers for Disease Control and Prevention (CDC) protects people's health and safety by preventing and controlling diseases and injuries; enhances health decisions by providing credible information on critical health issues; and promotes healthy living through strong partnerships with local, national, and international organizations. _________________________________________________________________ Categories of Health Alert Network messages: Health Alert Requires immediate action or attention; highest level of importance Health Advisory May not require immediate action; provides important information for a specific incident or situation Health Update Unlikely to require immediate action; provides updated information regarding an incident or situation HAN Info Service Does not require immediate action; provides general public health information ##This message was distributed to state and local health officers, state and local epidemiologists, state and local laboratory directors, public information officers, epidemiologists, HAN coordinators, and clinician organizations## 1 Missouri Department of Health & Senior Services Health Health Update March 24, 2020 Update: FROM: RANDALL W. WILLIAMS, MD, FACOG DIRECTOR Criteria to Guide Evaluation and SUBJECT: Update: Criteria to Guide Evaluation and Laboratory Laboratory Testing for Testing for COVID-19 (updates underlined) COVID-19 Issued March 22, 2020 Summary Testing for COVID-19 is available through the Missouri State Public Health Laboratory March 24, 2020 (SPHL) as well as commercial clinical laboratories. Clinicians who wish to submit This document will be updated as new specimens to the SPHL must submit a Missouri Patient Under Investigation (PUI) and information becomes available. The Case Report Form and a Virology Test Request for each approved patient. For more current version can always be viewed at http://www.health.mo.gov. information and to access the forms, please visit the SPHL Novel Coronavirus webpage at https://health.mo.gov/lab/ncov.php. COVID-19 testing for asymptomatic individuals The Missouri Department of Health & Senior Services (DHSS) is now using through any laboratory is not recommended. To request testing through the SPHL, four types of documents to provide providers should call the Department of Health and Senior Services Hotline at 877- important information to medical and 435-8411. public health professionals, and to other interested persons: Health Alerts convey information Clinicians should use their judgment to determine if a patient has signs and symptoms of the highest level of importance compatible with COVID-19 and whether the patient should be tested. Most patients which warrants immediate action or with confirmed COVID-19 have developed fever1 and/or symptoms of acute respiratory attention from Missouri health providers, emergency responders, illness (e.g., cough, difficulty breathing). Priorities for testing may include: public health agencies or the public. Health Advisories provide 1. Hospitalized patients who have signs and symptoms compatible with important information for a specific COVID-19 in order to inform decisions related to infection control. incident or situation, including that 2. Symptomatic residents of congregate living facilities that house adults impacting neighboring states; may not require immediate action. ages 65 or older and individuals with chronic medical conditions and/or an immunocompromised state that may put them at higher risk for poor Health Guidances contain comprehensive information pertaining outcomes (e.g., diabetes, chronic heart disease, such as heart failure, to a particular disease or condition, receiving immunosuppressive medications, chronic lung disease, chronic and include recommendations, kidney disease). guidelines, etc. endorsed by DHSS. 3. Any persons including healthcare personnel2, who within 14 days of Health Updates provide new or symptom onset had close contact3 with a suspect COVID-19 patient with updated information on an incident or situation; can also provide informa- pending laboratory testing or laboratory-confirmed4 COVID-19 patient. tion to update a previously sent Health Alert, Health Advisory, or Health Guidance; unlikely to require There are epidemiologic factors that may also help guide decisions about COVID-19 immediate action. testing. Documented COVID-19 infections in a jurisdiction and known community __________________________________ transmission may contribute to an epidemiologic risk assessment to inform testing Office of the Director decisions. Clinicians are strongly encouraged to test for other causes of respiratory 912 Wildwood illness (e.g., influenza). P.O. Box 570 Jefferson City, MO 65102 Telephone: 800-392-0272 Fax: 573-751-6041 Website: http://www.health.mo.gov 2 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. FOR PERSONS with COVID-19 UNDER HOME ISOLATION: The decision to discontinue home isolation should be made in the context of local circumstances. Options now include both 1) a time-since-illness-onset and time-since-recovery (non-test-based) strategy, and 2) a test-based strategy. Time-since-illness-onset and time-since-recovery strategy (non-test-based strategy) - Persons with COVID-19 who have symptoms and were directed to care for themselves at home may discontinue home isolation under the following conditions:  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 7 days have passed since symptoms first appeared. This recommendation will prevent most, but may not prevent all instances of secondary spread. The risk of transmission after recovery, is likely very substantially less than that during illness. Previous recommendations for a test-based strategy remain applicable; however, a test-based strategy is contingent on the availability of ample testing supplies and laboratory capacity as well as convenient access to testing. Individuals with laboratory-confirmed COVID-19 who have not had any symptoms may discontinue home isolation when at least 7 days have passed since the date of their first positive COVID-19 diagnostic test and have had no subsequent illness. Return to Work Criteria for HCP with Confirmed or Suspected COVID-19 Two recommended options are listed below for healthcare facilities that have employees returning to work after COVID-19 illness. 1. Non-test-based strategy. Exclude from work until: a. 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, b. At least 7 days have passed since symptoms first appeared. 2. Test-based strategy. Exclude from work until: a. Resolution of fever without the use of fever-reducing medications and b. Improvement in respiratory symptoms (e.g., cough, shortness of breath), and c. Negative results of an FDA Emergency Use Authorized molecular assay for COVID-19 from at least two consecutive nasopharyngeal swab specimens collected ≥24 hours apart (total of two negative specimens)[1]. See Interim Guidelines for Collecting, Handling, and Testing Clinical Specimens for 2019 Novel Coronavirus (2019-nCoV). If HCP were never tested for COVID-19 but have an alternative diagnosis (e.g., tested positive for influenza), criteria for return to work should be based on that diagnosis. 3 Return to Work Practices and Work Restrictions After returning to work, HCP should:  Wear a facemask at all times while in the healthcare facility until all symptoms are completely resolved or until 14 days after illness onset, whichever is longer  Be restricted from contact with severely immunocompromised patients (e.g., transplant, hematology-oncology) until 14 days after illness onset  Adhere to hand hygiene, respiratory hygiene, and cough etiquette in CDC’s interim infection control guidance (e.g., cover nose and mouth when coughing or sneezing, dispose of tissues in waste receptacles)  Self-monitor for symptoms, and seek re-evaluation from occupational health if respiratory symptoms recur or worsen 1 Fever may be subjective or confirmed. 2 For 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). 3 Close 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 Settings. 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. 4 Documentation of laboratory-confirmation of COVID-19 may not be possible for travelers or persons caring for COVID-19 patients in other countries. 1 Missouri Department of Health & Senior Services Healt h Health Update April 6, 2020 Update: FROM: RANDALL W. WILLIAMS, MD, FACOG DIRECTOR Update: Reporting SUBJECT: Update: Reporting COVID-19 Cases COVID-19 Cases Background The Missouri Department of Health and Senior Services (DHSS) has been working with partners across the state to respond to the COVID-19 pandemic. As of today’s report, 2,722 cases of COVID-19 have been reported in Missouri. Several waivers have been granted to statute and rule alike in order to better serve Missourians during this April 6, 2020 unprecedented event. The purpose of this update is to provide healthcare providers a This document will be updated as new resource that pulls together multiple waivers that are intended to ensure a robust information becomes available. The surveillance system for COVID-19. The rule changes and waivers include the reporting current version can always be viewed of COVID-19 to DHSS, duplicate reporting of negative results by hospitals, and the at http://www.health.mo.gov. reporting of COVID-19 deaths to DHSS. The Missouri Department of Health & Senior Services (DHSS) is now using Reporting Rules Changes and Waivers four types of documents to provide important information to medical and public health professionals, and to Disease Reporting other interested persons: Health Alerts convey information The State of Missouri has waived certain aspects of communicable disease reporting of the highest level of importance rules as they apply to COVID-19. 19 CSR 20-20.020 (1), (6), and (8) have been be which warrants immediate action or waived to the extent necessary to have all positive and negative test results for COVID- attention from Missouri health 19 sent only to DHSS. This waiver removes the option for the reporter to send such providers, emergency responders, public health agencies or the public. results to either the local health authority or DHSS. This will remain in place throughout the State of Emergency. This waiver does not limit communication between Health Advisories provide important information for a specific healthcare providers and local public health agencies (LPHAs) that are investigating incident or situation, including that COVID-19 cases. This waiver does not prohibit reporting to LPHAs. However, it does impacting neighboring states; may not mandate that providers must report to DHSS. require immediate action. Health Guidances contain Negative Result Reporting by Laboratories Only comprehensive information pertaining to a particular disease or condition, and include recommendations, Missouri 19 CSR 20-20.020(6) has been waived to the extent that it requires duplicative guidelines, etc. endorsed by DHSS. reporting to DHSS of negative test results for 2019 Novel Coronavirus (2019-nCoV) by a hospital and the separate laboratory that conducted the testing. Under this waiver, Health Updates provide new or updated information on an incident or when the testing is conducted outside the hospital by a separate laboratory that must situation; can also provide informa- also report the result to the Department, only the laboratory must make the report. This tion to update a previously sent waiver does not apply to the reporting of cases of COVID-19. Health Alert, Health Advisory, or Health Guidance; unlikely to require immediate action. Reporting Death Associated with SARS CoV-2 or Clinically Diagnosed COVID-19 __________________________________ Office of the Director Deaths of individuals with positive laboratory tests for SARS CoV-2 or clinically 912 Wildwood diagnosed COVID-19 are reportable to DHSS within twenty-four (24) hours. In the P.O. Box 570 event that an individual dies while awaiting COVID-19 test results and a positive result is Jefferson City, MO 65102 later confirmed, the death shall be reported to the Department within twenty-four (24) Telephone: 800-392-0272 hours of receipt of the positive confirmation. COVID-19 death reporting is required of Fax: 573-751-6041 the physician in charge of the decedent’s care, or by the physician in attendance either at Website: http://www.health.mo.gov 2 the time of death or immediately before or after, or when appropriate by the local medical examiner, to ensure that such death is reported at once, without delay, and with a sense of urgency by means of rapid communication to the Department regardless of the day or hour. Death notification can be amended at any time should additional information become available. Reporting Methods Healthcare providers in Missouri are asked to complete a standard Disease Case Report (CD-1 Form) for the reporting of confirmed and presumptive COVID-19 cases. A fully completed and timely submitted CD-1 will help allow for a prompt public health follow-up, and help minimize follow-up requests for additional information. The reporting of death in any patient with a positive laboratory test for SARS CoV-2 or clinically diagnosed COVID-19 should also be reported using a CD-1. If the COVID-19 death is the first report for the case, then only one CD-1 Form is needed to report the COVID-19 case and death; insert “COVID-19 Death” as the disease/condition name and check the corresponding box on the CD-1 Form regarding the death and fill in the date of death. If the case had previously been reported, update and resubmit the original CD-1 with the disease/condition name amended to “COVID-19 Death”, check the corresponding box noting death, and include the date of death. Please consider the following options for the timely submission of completed CD-1 reports for confirmed cases, suspected cases, and deaths of COVID-19: Fax submissions: As noted on the CD-1, these can be submitted via fax to 573-751-6417. Please note that this fax line experiences high volume during normal business hours. SFTP: For providers that would like to submit reports via Secure File Transfer Protocol (SFTP), please call 573-526-5271. The SFTP option functions as a secure online folder where files may be submitted with no wait. In order to use this option, at least one contact e-mail address for the submitting organization must be provided. Further instructions will be sent to the indicated e-mail address(es) once an account is set up for the organization. Phone: For single COVID-19 death reports, providers have the option to call the Missouri COVID-19 Hotline at 877-435-8411 and convey information verbally to an operator who will complete the CD- 1 for the provider. When utilizing this method of reporting, please choose option 2 at the prompt. General questions about COVID-19 reporting should be directed to DHSS’ Bureau of Reportable Disease Informatics at 573-526-5271. References: Dual Reporting of Negative COVID-19 Lab Results: https://health.mo.gov/living/healthcondiseases/communicable/novel-coronavirus/pdf/waiver-dual-reporting-of- negative-results.pdf Reporting Death Associated with SARS CoV-2 or Clinically Diagnosed COVID-19: https://health.mo.gov/living/healthcondiseases/communicable/novel-coronavirus/pdf/report-of-covid-19- death.pdf Reporting of COVID-19 Lab Results: https://health.mo.gov/living/healthcondiseases/communicable/novel-coronavirus/pdf/waiver-reporting-of- covid-19-lab-results.pdf