What if my patient is requesting to be seen in my clinic for respiratory symptoms?
As standard practice, sick patients should be isolated from others and roomed as quickly as possible. Healthcare personnel should also utilize appropriate personal protective equipment (PPE). Patients should preferably be placed in a negative pressure room, but a standard room where they will be isolated from other patients can be used. Please consult the CDC's information about Infection Control when seeing patients with suspected COVID-19.
If you do not have appropriate equipment to keep you and your staff safe, consider referral to a local telehealth virtual care if available. It is not necessary to refer patients to emergency departments or urgent cares simply to get tested. They should only be referred if you believe they require an urgent medical evaluation. Advise patients to isolate while they are symptomatic.
When should I test for COVID-19?
DHEC will continue to update and communicate testing guidance through the South Carolina Health Alert Network (SCHAN). In general, patients who are being considered for PCR or antigen testing should be symptomatic with respiratory illness and alternative diagnoses should have been considered. Antibody testing is not recommended to diagnose an acute illness.
It is recommended that close contacts to those contagious with COVID-19 be tested immediately if symptomatic. They may also be tested again 5-7 days after last contact with the person who has COVID-19 (this is usually about 5-7 days into the quarantine period). If they do not get tested they must remain in quarantine for at least 14 days. Options to shorten quarantine can be found here.
Should I use antibody testing?
DHEC provided guidance for antibody testing through the South Carolina Health Alert Network (SCHAN). DHEC does NOT recommend using this testing to diagnose an acute infection. PCR testing is the preferred method for identifying new cases. Until more is known about this testing, patients should NOT assume immunity to COVID-19 on the basis of this testing. Use the CDC guidance when considering implementing antibody testing.
What specimen do I collect for PCR testing and where do I send it?
CDC identifies five acceptable specimen types as nasopharyngeal (NP), oropharyngeal (OP), nasal mid-turbinate, or anterior nares (nasal) swabs; or nasopharyngeal wash/aspirate or nasal wash/aspirate specimens. Only one specimen needs to be collected.
The DHEC Public Health Laboratory (PHL) can run samples collected by providers. Directions for completion of paperwork and for specimen transport to the DHEC PHL can be found on the SC DHEC website. A variety of private labs can be utilized for testing. Please fill out the lab requisition form with the patient’s appropriate contact information. The initiation of contact investigations can be delayed if follow up is needed to obtain case information from ordering facilities.
How long will it take to get test results?
The time to receive results from private laboratories varies depending on which laboratory is utilized. Please speak with your lab representative in order to give accurate expectations to your patients. Results from the PHL usually take 24-48 hours to report and are available via OpenElis, the secure laboratory web portal. A customer ID is needed to access results electronically. That timeframe may change based on testing volume or demand. Whichever laboratory is used, patients should be advised to isolate while their results are pending. Also, their home/close contacts should minimize their activities outside the home as well. Please report the results to your patient as soon as you receive them. Due to the necessity to urgently start public health investigations and provide isolation guidance, DHEC staff will contact all patients and will not be able to confirm they have been contacted by their provider.
My patient has a COVID-19 infection after being fully vaccinated against COVID-19—can I send their PCR sample to the Public Health Lab for Whole Genome Sequencing (WGS)?
At this time, the Public Health Lab (PHL) is only performing WGS on samples from patients if they are/were hospitalized or are deceased provided that at least 14 days have passed since they completed their primary series of an FDA-authorized COVID-19 vaccine and they have not had another positive PCR test in the previous 45 days.
Additional information and instructions for submission can be found here and here. Please note that WGS through DHEC is currently to monitor for the occurrence of variants for surveillance purposes. Sequencing performed by PHL is not CLIA approved for clinical use and results are not to be communicated back to individual healthcare providers or patients at this time. If you are interested in individualized results for clinical decision making, then you may wish to pursue WGS through a private laboratory.
Also, providers may wish to contact private and/or health system laboratories about their routine or provider-requested WGS testing.
My patient has COVID-19 infection but does not need to be hospitalized. What other treatment should I consider?
Monoclonal antibodies are a treatment for COVID-19 approved under an FDA Emergency Use Authorization (EUA) and have been shown to be highly effective in preventing progression of disease and hospitalization. Guidelines for eligibility criteria can be found here.
My patient has a second COVID-19 infection and/or is not responding to therapies for their COVID-19 infection—can I send their PCR sample to the PHL for Whole Genome Sequencing (WGS)?
Not for the purposes of clinical decision making at this time. WGS performed at the PHL is for surveillance purposes to provide understanding of population level incidence of SARS-CoV-2 strains. For more information about surveillance for variants see: Science Brief: Emerging SARS-CoV-2 Variants. The testing performed by PHL is not CLIA approved for clinical use and results are not to be communicated back to individual healthcare providers or patients at this time. If you are interested in individualized results for clinical decision making, then you may wish to pursue WGS through a private laboratory.
If pursuing WGS for antibody therapy decisions, please note that given the sustained increase in SARS-CoV-2 viral variants in the United States that are resistant to bamlanivimab administered alone, and the availability of other authorized monoclonal antibody therapies that are expected to retain activity to these variants, the U.S. Government, in coordination with Eli Lilly and Company, stopped the distribution of bamlanivimab alone. For additional information see: FDA authorizes revisions to address SARS-CoV2 variants and monoclonal antibody products.
A patient tested positive. What do I do?
Please notify DHEC of positive results. COVID-19 cases and deaths are urgently reportable per the South Carolina List of Reportable Conditions. They must be reported by phone within 24 hours to the appropriate regional health department. When reporting, please alert DHEC if your patient is 65 years old or greater, 5 years old or younger, pregnant, hospitalized, or someone who resides in or attends a congregate setting (e.g. nursing home, long-term care facility, behavioral health facility, or child care).
Please notify the patient of their results and if able to remain or care for themselves at home, advise them to remain in isolation until they meet all of the following conditions:
- No fever for at least 24 hours without the use of fever reducing medication – and -
- It has been least ten (10) days* from the start of their initial symptoms – and -
- Their symptoms have improved.
* - Some patient with severe illness or immunocompromised states are recommended to extend this time period from ten (10) to twenty (20) days. See the SCHAN notice for guidance on this.
Note that the CDC no longer recommends using the test-based strategy for ending isolation except in rare cases of severely immunocompromised patients in which there is concern for extended shedding of virus. The symptom-based strategy described above is sufficient for almost all cases of COVID-19, including as criteria for allowing healthcare workers to return to work.
For those who live in the same house as someone recovering from COVID-19 infection, this 14-day quarantine period begins when they are able to separate from sick household member or when the sick person is told they are no longer contagious (when they complete their 10-day isolation period). The household contacts may quarantine for either 14 days or apply to 7-day or 10-day criteria to shorten the quarantine at that point. Resources are available for cases and contacts on the DHEC website and can be provided prior to being contacted by DHEC.
I think my patient has "long-COVID". What can I tell them?
Post-COVID conditions, informally known as “long COVID,” describe a wide range of physical and mental health conditions that some people may experience four or more weeks after a COVID-19 infection. New, ongoing, or returning symptoms have been reported among people who previously had a COVID-19 infection, even for people who had no symptoms or a mild COVID-19 illness. Symptoms of post-COVID conditions are often difficult to distinguish from symptoms that occur for other health reasons.
For CDC interim guidance for diagnosing and treating long-COVID visit https://www.cdc.gov/coronavirus/2019-ncov/hcp/clinical-care/post-covid-index.html.
My patient is now recovered and meets criteria to end isolation. Will they need to quarantine if they have close contact to another case?
It is not known at this point, to what extent recovery from a confirmed infection offers protection against reinfection, but there is evidence of short-term immunity against reinfection. Cases confirmed by PCR testing who meet criteria to end their isolation period may do so even if there are other COVID-19 cases still in isolation in the same household. They do not need to quarantine for any contacts occurring within three (3) months after the start of their symptoms (or the date their test sample was collected if they have no symptoms). Any close contact with a case that occurs outside that three (3) month window will require quarantine based on the current recommendations. Antibody testing should not be used to make this determination of immunity until more is known about these tests and the significance of the antibodies they detect.
Do I need to notify patients who were in the clinic they were exposed to someone with COVID-19?
Since most exposures between patients in a physician’s office are brief and patients are not in close contact for a prolonged period, a notification of other patients in the clinic is likely unnecessary. Measures should be in place to ensure proper social distancing between patients waiting for appointments and mask use should be encouraged.
Do I and my staff need to quarantine?
If the patient was wearing a surgical mask and you and your personnel caring for the patient were wearing appropriate PPE, the risk of transmission is low. Health care staff may continue to work while monitoring for symptoms and checking their temperature daily and prior to starting their shifts. You and your staff who cared for the patient should wear face masks in the office at all times while you monitor for symptoms. Any staff who had a high risk exposure where PPE was not utilized should be excluded from work if possible, but if they must continue to work as essential workers, they should quarantine when outside of work to avoid exposing others. If you or your staff develop fever or respiratory illness, you should isolate and seek medical evaluation. Please see the CDC website for risk stratification in your decision-making process.