Coronavirus Disease 2019 (COVID-19) Outbreak, Update # 11

On April 3, 2020, NH DHHS issued health alert COVID-19 update #11 regarding cloth masks and updated specimen collection guidance

NH DPHS Health AlertsKey Points and Recommendations:

  • COVID-19 can be transmitted when a person is asymptomatic or before symptoms develop [MMWR Mar 26;69(12):347-352; MMWR Apr 3;69(13):377-381; MMWR Apr 1;69(early release)]. In combination with an increasing number of healthcare provider infections and recognition of healthcare facility outbreaks, we recommend that (after usual screening for symptoms) all visitors and staff entering a healthcare facility should be given a washable (reusable) cloth mask to wear to reduce asymptomatic/presymptomatic transmission of COVID-19 while in the facility. 
    • A commercial, disposable face mask is likely more effective for this purpose, so if supplies are adequate, a surgical mask can be used instead. 
    • Clearly communicate that a cloth mask is NOT personal protective equipment (i.e., it does not protect the wearer, but can protect others in case the wearer is pre-symptomatically or asymptomatically shedding virus). 
    • A healthcare provider caring for a patient with suspect/confirmed COVID-19 should remove their cloth face mask, secure it in a plastic bag, conduct hand hygiene, and don usual COVID-19 PPE, which should include at a minimum a surgical face mask, eye protection, gown, and gloves. An N95 or higher level respirator should be used for patients undergoing aerosol-generating procedures. 
    • Anyone wearing a cloth mask must regularly perform hand hygiene and avoid touching their mask and face to avoid contaminating their hands and contaminating surfaces if they are pre- or asymptomatically shedding virus. 
    • Cloth masks should be collected from visitors and staff exiting the facility for washing and re-use. 
    • NH Division of Public Health Services (DPHS) is acquiring a supply of cloth masks for facilities to supplement the supply of community produced masks. 
  • CDC has updated their sample collection guidance for COVID-19 testing: https://www.cdc.gov/coronavirus/2019-nCoV/lab/guidelines-clinical-specim...
    • A nasopharyngeal (NP) swab is still the preferred specimen, but other acceptable alternatives now include patient-collected nasal mid-turbinate (NMT) or anterior nares swabs. This approach can conserve PPE and reduce risk to healthcare providers. We recommend obtaining a NMT rather than an anterior nares swab because of superior sensitivity (NMT swab sensitivity of 96% compared to NP swab; reference pending publication), unless the necessary flocked tapered swab is not available. 
    • For collection of the NMT swab, a provider should instruct the patient in the proper procedure facilitated by the attached Figure (below) and oversee collection of the swab from a safe distance:
      • For the preferred nasal mid-turbinate swab (flocked tapered swab) 
      1. Insert swab in the horizontal position into one nasal passage until gentle resistance is encountered 
      2. Rotate the swab in place for 10-15 seconds 
      3. Repeat the process in the other nostril using the same swab
      • For the anterior nares swab (foam swab): 
      1. Insert swab in the vertical position into one nasal passage until gentle resistance is encountered 
      2. Rotate the swab in place for 10-15 seconds 
      3. Repeat the process in the other nostril using the same swab 
      • Place the single swab in appropriate transport media and ensure tight closure. 
      • Refrigerate specimen at 2-8oC prior to transport to the testing laboratory 
  • Some long-term care facilities (LTCFs) are requiring negative COVID-19 testing in asymptomatic patients before accepting patient transfers from hospitals; this is because of guidance from the AHCA and NCAL. NH DPHS does not recommend testing of asymptomatic persons, in accordance with current Centers for Disease Control and Prevention (CDC) guidance, especially because the requirement for negative testing creates barriers to hospital discharge at a time when we need to be increasing hospital capacity. 
    • According to CMS guidance, LTCFs should admit any individuals they would normally admit to their facility, but admitted/re-admitted residents can be subject to 14-day quarantine. If possible, LTCFs should dedicate a unit/wing exclusively for any residents coming or returning from the hospital. This can serve as a stepdown unit where they remain for 14 days with no symptoms instead of integrating as usual. 
    • When available, we suggest all hospitals implement rapid COVID-19 testing capability (e.g., Abbott, Cepheid) to facilitate testing if required. If NP swabs are in shortage, alternate sample collection methods are also now options for COVID-19 testing (see above). 
  • In partnership with the New Hampshire Health Care Association, we will begin weekly standing calls starting on Wednesday April 8th from 12:00 – 1:00pm for LTCFs, assisted living facilities and other congregate settings with vulnerable patients. 
  • We will continue to host weekly calls to answer healthcare provider and local partner questions about COVID-19. The next discussion will be held on Thursday April 9th from 12:00 – 1:00 pm (noon hour), and calls will recur weekly. Call-in information for the Q&A session is: (833) 709-6685; this is an operator assisted call so no conference code is needed. 
  • All COVID-19 cases must be reported to NH DPHS by filling out and faxing the COVID-19 Case Report Form to our confidential fax at 603-271-0545. 
    • Please also use this form to report any confirmed COVID-19 cases who become hospitalized in your facility even if they were previously diagnosed and reported.

Full DHHS Alert