COVID-19 Case

CASE

Zahra is a 46-year-old married mother of 2 children who works as a teacher at a primary school. She enjoys good health and frequently visits her friends, one of whom recently travelled abroad. She developed a cough with congestion one week ago and has had an intermittent low-grade fever with myalgia and fatigue for the last 3-4 days. She has heard a rumour that a case of COVID-19 was diagnosed in the school where she works. She is concerned and presents to the local clinic for evaluation. Her past medical history is significant for diabetes mellitus and high blood pressure. She takes metformin and lisinopril. She is HIV negative. On presentation her T is 38.1°C, RR 24, breathing is shallow with minimal added sounds. Her pulse is 118bpm and her BP is 95/66 mmHg. Physical exam is otherwise unremarkable.

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What are the clinical characteristics of COVID-19 infection as well as risk factors for acquisition, including among people with HIV (PWH),

KEY
POINTS

The recent COVID-19 outbreak (which appeared first in China and has now spread globally) is caused by the SARS-CoV-2 virus. Much of the data available about the typical presentation of COVID-19 is from initial studies performed in China. 

Source: Chen N, Zhou M, Dong X, et al. Epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in Wuhan, China: a descriptive study. Lancet Jan 2020. Available at: https://www.cdc.gov/coronavirus/2019-ncov/downloads/characterstics-of-nCoV-patients-Wuhan-Lancet-1-29-2020.pdf

This case series involves only hospitalized patients and thus findings may not be as frequent in all infected patients.

From the case series, the most typical presentation of COVID-19 in hospitalized patients are:
1. Fever
2. Cough
3. Shortness of breath
4. Muscle aches

Time-to-Event Distributions

Source: Li Q, Guan X, Wu P, et al. Early Transmission Dynamics in Wuhan, China, of Novel Coronavirus–Infected Pneumonia. N Engl J Med 2020; 1–9.

The Time-to-Event Distributions figure, characterizes the time between initial infection and onset of symptoms during the initial outbreak in China.

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Why is this time period, often referred to as the ‘incubation period,’ important to understand why this disease has spread so widely? What is the importance of the delay between initial infection and symptom development?

KEY
POINTS

People may acquire infection from someone without any idea they have been exposed. They may not present with any symptoms for sometime after infection. The incubation period for COVID-19 is thought to be within 14 days following exposure, with most cases occurring approximately four to five days after exposure.

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What are the recommendations for screening? What are the key screening questions you might ask? What other infections should you consider in a patient presenting with these symptoms?

What are the diagnostic algorithms?
Given the concern about COVID-19, how would you evaluate Zahra.

KEY
POINTS

Step1: Screening & Triage: It is important to isolate all patients suspected with COVID-19 at the first point of contact with the health care system (such as the emergency department or outpatient department/clinic).

Step 2: Ask key screening questions, per WHO and country guidelines, including the following:

• Cough
• Rhinorrhea
• Sore Throat
• Diarrhea
• Fever
• Shortness of breath
• Myalgia
• Ask about potential of confirmed contact with individuals with COVID-19. * Consider asking about travel to COVID-19 hotspots. For the current outbreak status, visit: https://coronavirus.jhu.edu/map.html

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What constitutes a contact with an individual with COVID-19? 

KEY
POINTS

WHO defines as close proximity for greater than 10 minutes or direct contact with infectious secretions from a patient with COVID-19.

The CDC defines close proximity as within 6 feet (about 2m).

Step 3: Consider other infections as possible differentials, such as TB, influenza, bacterial pneumonia and other respiratory viral infections. 

Note that patients over 65 years of age and those with co-morbidities, such as cardiovascular disease, chronic respiratory disease, and diabetes mellitus, have increased risk of severe disease and mortality.  They may present with mild symptoms but have a high risk of deterioration and should be admitted to a designated unit for close monitoring.

Step 4:  Ask about symptoms that will put individuals at higher risk for worse outcomes. This includes anyone who has any of the following:

  • Age >65 years
  • Medical co-morbidities, e.g. heart failure, chronic lung disease, Immunosuppression, e.g. HIV, diabetes mellitus, end stage kidney disease, malignancy

Figure: Proposed COVID-19 triage algorithm for low income settings without established local transmission

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After reviewing these steps, would Zahra meet the criteria for COVID-19 testing?

KEY
POINTS

Zahra has a high risk of COVID-19 and should be tested

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What is the importance of infection prevention and control (IPC) for health care workers, including the role of different infection control strategies to minimize nosocomial transmission?

KEY
POINTS

Immediate implementation of appropriate IPC is critical and integral in the clinical management of patients.

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In each of the sections below identify the statements that are true for any patient who is suspected of having COVID-19. There is one incorrect statement per section, place a check mark next to the correct statements.

1. Instruction for patients (persons under investigation):

  • Give patient a medical mask and place the patient in an isolation room if available.
  • Give the patient an N95 and place them in the HIV clinic waiting room .
  • Instruct the patient to cover nose and mouth or sneeze with tissue or flexed elbow.
  • Keep at least 2m distance between suspected patients and other patients.

2. Apply droplet precautions:

  • Droplet precautions prevent large droplet transmission of respiratory viruses.
  • Use a medical mask if working within 1 m of the patient.
  • Ensure that health care workers use sterile gloves when touching patients.
  • Place patient in single rooms or group together those with the same etiologic diagnosis.
  • Use eye protection (face mask or goggles) because sprays of secretions may occur

3. Apply contact precautions:

  • Contact precautions prevent airborne transmission.
  • Use personal protective equipment (PPE, i.e. medical mask, eye protection, gloves, gown) when entering room and remove PPE when leaving.
  • Practice hand hygiene after PPE removal. If possible, use either disposable or dedicated equipment (stethoscopes, blood pressure cuffs, etc).  If equipment needs to be shared among patients, clean and disinfect between each patient.

4. Apply airborne precautions when performing an aerosol-generating procedure:

  • Aerosol generating procedures include intubation, cardiopulmonary resuscitation, suctioning of airway, and nebulizer administration.
  • To do these procedures, health care workers should wear surgical masks and glasses.
  • A fit-tested respirator (N95 or equivalent) should be worn in addition to gloves, eye protection, and long-sleeved gowns.
  • When possible, perform such procedures in adequately ventilated single rooms.

Visit the WHO’s website for COVID-19 infection prevention and control to determine the correct answers: https://www.who.int/emergencies/diseases/novelcoronavirus-2019/technical-guidance/infectionprevention-and-control

KEY
POINTS

1. Instruction for patients (persons under investigation):

  • Give patient a medical mask and place the patient in an isolation room if available.
  • *Give the patient an N95 and place them in the HIV clinic waiting room [incorrect]
  • Instruct the patient to cover nose and mouth or sneeze with tissue or flexed elbow
  • Keep at least 2m distance between suspected patients and other patients

 2. Apply droplet precautions:

  •  
  • Droplet precautions prevent large droplet transmission of respiratory viruses
  • Use a medical mask if working within 1 m of the patient
  • *Ensure that health care workers use sterile gloves when touching patients [incorrect]
  • Place patient in single rooms or group together those with the same etiologic diagnosis
  • Use eye protection (face mask or goggles) because sprays of secretions may occur

3. Apply contact precautions:

  • *Contact precautions prevent airborne transmission [incorrect]
  • Use personal protective equipment (PPE, i.e. medical mask, eye protection, gloves, gown) when entering room and remove PPE when leaving
  • Practice hand hygiene after PPE removal
  • If possible, use either disposable or dedicated equipment (stethoscopes, blood pressure cuffs, etc). If equipment needs to be shared among patients, clean and disinfect between each patient.

4. Apply airborne precautions when performing an aerosol-generating procedure:

  • Aerosol generating procedures include intubation, cardiopulmonary resuscitation, suctioning of airway, and nebulizer administration.
  • *To do these procedures, health care workers should wear surgical masks and glasses [incorrect]
  • A fit-tested respirator (N95 or equivalent) should be worn in addition to gloves, eye protection, and long-sleeved gowns.
  • When possible, perform such procedures in adequately ventilated single rooms.

It is important to note that these IPC strategies are for ideal situations. Many countries are experiencing a shortage of N95 masks and PPE. If this is true or becomes true in your country, to adhere to prioritization guidance in your setting.

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What is the appropriate infection control strategy for the various health care professionals in the health care team caring for a person confirmed or suspected of having COVID-19)?

Provider role & patient contact Infection prevention & control
Doctor examining a patient suspected of having COVID-19
Medical mask, gown, gloves and eye protection (goggles or face shield)
Nurse collecting an upper respiratory tract sample from a patient (i.e. placing a Dacron/rayon swab in oropharynx or nasopharynx)
Medical mask, gown, gloves and eye protection (goggles or face shield)
Laboratorian processing swab in the lab
Medical mask, gown, gloves and eye protection (goggles or face shield)
Pharmacy dispensing paracetamol to a relative of patient suspected of having COVID-19 in outpatient pharmacy
No PPE required
Community health care worker escorting a patient with confirmed COVID-19 from outpatient clinic to the hospital emergency department
Mask, ideally maintaining >2 m spatial distance from the patient
Hospital administrator walking between offices near to where patients are being managed
No PPE required
A patient with HIV, diagnosed with confirmed Gene Xpert TB (sputum AFB++) and COVID-19
Medical mask as tolerated if presenting with respiratory symptoms
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Even though Zahra meets criteria for COVID-19 testing, depending on where you are working you may or may not have the capacity to test her for COVID-19.  

What infection prevention controls would you implement.

How long do you anticipate you might need them? What would help determine if a person with confirmed COVID-19 could be managed at home?

There may be 3 possible scenarios with Zahra

Scenario #1: You decide she is sufficiently sick and she needs to be admitted but you do not have access to COVID-19 testing.

Scenario #2: You think she may be able to go home; you can test her now before she goes home (but the test result will not be available until tomorrow).

Scenario #3: You decide she is well enough to go home but you do not have access to COVID-19 testing.

What are the principles of clinical management of COVID-19?

What is the importance of supportive care and possible experimental agents?

What would you do under each scenario? 

KEY
POINTS

Scenario # 1: A decision to be admitted should be based on the patient’s clinical status as well their premorbid status (i.e. whether they have any pre-existing health issues) and if they are immunocompromised.  Anyone presenting with severe pneumonia (RR >30 breaths/min), severe respiratory distress or Oxygen sats <93% on room air should be considered for prompt admission if capacity allows. Those with more severe acute respiratory distress should be prioritized for admission.

Scenario # 2: The WHO defines mild illness as uncomplicated upper respiratory viral infection with non-specific symptoms, cough, etc.  The elderly and immunocompromised (including HIV with low CD4 and/or viral load >200 copies/mL;) may present with atypical symptoms.  Due to physiologic adaptations of pregnancy or adverse pregnancy events, such as dyspnea, fever, GI symptoms, may overlap with COVID-19 symptoms.

For those with mild illness, hospitalization may not be indicated unless there is concern about rapid deterioration or an inability to return to hospital, but isolation to contain/mitigate virus transmission should be prioritized.  All patients cared for outside the hospital (i.e. at home or non-traditional setting) should be instructed to manage themselves appropriately according to local/regional protocols for home isolation and return to designated COVID-19 hospital if they get worse.

Scenario # 3: Manage as if a presumed case, even in the absence of COVID-19 testing, while excluding other diagnoses including TB and pneumonia if possible (performing CXR and HIV testing if possible).  Ideally, from an infection control prevention perspective this means: 

  • Have the patient wear a surgical mask. To help preserve the supply of N95 masks, health care workers and patient attendants should generally where surgical masks.  N95 respirators should be used only if high risk for aerosolizing (ventilation, high-flow cannula, 1 hour after nebulizers, and while collecting swabs) or if TB is suspected.
  • Isolate the patient in an examination room with the door closed. If an examination room is not readily available ensure the patient is not allowed to wait among other patients seeking care.
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If a decision is made to discharge Zahra home, what are the key recommendations that you will want to communicate to her (and her caregiver)?

KEY
POINTS

Patient and household member should be educated about personal hygiene, basic IPC measures and how to care for the family member suspected of having COVID-19 disease as safely as possible to prevent infection spreading to household contacts. The patient and family should be provided with ongoing support and education.  

Recommendations should include:

  • Place the patient in a well-ventilated single room (i.e. with open windows, adequate light, and an open door only if it leads to outside and not to another part of the house where there are other people).
  • Limit movement of the patient in the house and minimize shared space.
  • Ensure shared spaces are well ventilated (keep windows open).
  • Household members should stay in a different room or, if not possible, maintain a distance of at least 2m from the ill person.
  • Limit the number of care givers. Ideally assign one person who is in good health and has no underlying chronic conditions.
  • Perform hand hygiene after any type of contact with the patient or their immediate environment.
  • To contain respiratory secretions, a medical mask should be provided to the patient when around other household members.
  • Caregivers should wear a tightly fitted medical mask that covers their mouth and nose when in the same room as the patient.
  • Clean common surfaces with alcohol-based disinfectant or soap and water.

 Refer to the resource document entitled: Home care for patients with suspected COVID-19 infection presenting with mild symptoms, and management of their contacts.  

After establishing that Zahra has mild disease and doesn’t need admission, but needs to be in isolation to contain virus transmission, you intend to counsel her and her family about treatments at home. 

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What are the treatment options for COVID-19? What are the principles of clinical management of COVID-19, including the importance of supportive care and possible experimental agents?

KEY
POINTS

  • Treatment is primarily supportive with symptom management and continued monitoring of temperature, respiratory status/comfort, and for other emerging symptoms. Paracetamol can be used for low grade fever and myalgia, elevated fever (T>39 c) or worsening respiratory symptoms should trigger contacting the medical care provider (by phone is preferable).
  • Encourage fluid intake, rest and good nutrition.
  • While there is ongoing research exploring experimental treatments (Remdesivir, chloroquine, hydroxychloroquine, tociluzimab, and Lopinavir/ritonavir) there is currently no clear evidence demonstrating their proven efficacy and they are not currently recommended. Patients with HIV should not be switched from current regimens to Lopinavir/ritonavir simply because of potential activity at this point.

Your clinic supervisor informs your team there have been 3 confirmed cases of COVID-19 in your district. In addition, a colleague tells you there have been another 7 cases very similar to Zahra.  None of them have travelled outside of the local community. You wonder what public health interventions can be introduced to slow the spread. 

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 What is the importance of public health strategies, including containment and mitigation, in curtailing COVID-19 spread?

KEY
POINTS

Refer to the CDC’s guide on the Implementation of Mitigation Strategies for Communities with Local COVID-19 Transmission.

There are 2 strategies: 

  • A containment strategy limits the spread of a contagious infection by isolating all infected persons and identifying all persons potentially exposed to the source patient (contact tracing) for follow-up evaluation and quarantine; if screening is available, a RT-PCR test can be done for those who develop symptoms.
  • Containment is most effective and practical when the number of identified cases is not large, or does not exceed the capabilities of the health care system to pursue contact tracing.
  • Infectious diseases when there is spread from asymptomatic individuals are the most difficult to contain, as these persons are unlikely to ever be tested; early data suggest that transmission of COVID-19 from asymptomatic patients is possible but not nearly as common as from symptomatic patients.
  • Mitigation strategies are used in communities to slow the transmission of an infectious disease, in particular to protect individuals at risk for severe illness (including older adults and persons of any age with underlying conditions), and the health care and critical infrastructure workforces.
    • Implementation is based on:
      – Emphasizing individual responsibility for following recommended person-level actions.
      – Minimizing disruptions to daily life to the extent possible.
      – Empowering businesses, schools, and community organizations to implement recommended actions, particularly in ways that protect persons at increased risk of severe illness.
      – Focusing on settings that provide critical services to individuals at increased risk of severe illness

Public Health Strategies in Emerging Epidemics

Containment – minimize expansion Identification of infected persons with testing Quarantine of exposed persons and confirmed cases for period of infectiousness Contact tracing of potentially exposed persons Algorithms for screening based on dynamics of local epidemic and populations at risk Implementation of personal protection equipment (PPE) Training of health care personnel – case recognition and reporting, PPE/infection control measures, accurate risk communication to public
Mitigation – minimize impact of spread Accurate and timely information to the public about the disease and how to protect themselves, including personal hygiene/handwashing Social distancing - for airborne diseases, limit large social gatherings, maintain personal space (1-2 metres) Identify and take measures to protect populations at higher risk Optimize capacities of health care system to respond – safely manage mild cases outpatient Alternative work environments- where feasible, offer option to work by electronic means

Local Factors to Consider for Determining Mitigation Strategies

Source: Centers for Disease Control and Prevention. Implementation of Mitigation Strategies for Communities with Local COVID-19 Transmission. Available at https://www.cdc.gov/coronavirus/2019-ncov/downloads/community-mitigation-strategy.pdf

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What are the strategies to improve interprofessional care of patients and support each other as team members during the COVID-19 pandemic?

What are the roles of the different health professions?  Why is each profession so important to an effective public health response?

KEY
POINTS

  • The biggest burden of care will be on doctors and nurses and other frontline clinical staff, but risks of exposure will also exist for laboratorians, community health teams and other clinical professionals.
  • Public health and infectious disease specialists will be an indispensable resource to clinical teams and for consults.
  • Team members can support each other to practice proper infection prevention and control (for themselves and for patients).

The added workload and risk of being infected with COVID-19 will present considerable stress for health care workers. It is important for health care workers to adopt strategies that will enable them cope with stress including taking small breaks, being aware of their feelings and discussing them, and connecting with friends and family by phone, text, or email.

Conclusion

It is important to refer to national country guidelines, as well as the CDC and WHO websites for up-to-date guidance.

https://ucsf.co1.qualtrics.com/jfe/form/SV_1zUhoWvLTGarrnv  

Appendix A: Clinicians Corner – Understanding Transmission

Understanding of the transmission risk is incomplete. Epidemiologic investigation in China at the beginning of the outbreak identified an initial association with a seafood market that sold live animals, where most patients had worked or visited and which was subsequently closed for disinfection.15 However, as the outbreak progressed, person-to-person spread became the main mode of transmission. 

Person-to-person spread of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is thought to occur mainly via respiratory droplets and contact with contaminated surfaces. With droplet transmission, virus released in the respiratory secretions when a person with infection coughs, sneezes, or talks can infect another person if it makes direct contact with the mucous membranes. Infection can also occur if a person touches an infected surface and then touches their eyes, nose, or mouth. Droplets typically do not travel more than six feet (about two meters) and do not linger in the air. Viable virus has been detected up to 2-3 days on plastic and stainless steel and in aerosols up to 3 hours post aerolsolization.11  Airborne precautions are recommended routinely in some countries and in the setting of certain high-risk procedures in others.

Viral RNA levels appear to be higher soon after symptom onset compared with later in the illness.3  This raises the possibility that transmission might be more likely in the earlier stage of infection, but additional data are needed to confirm this hypothesis.

The reported rates of transmission from an individual with symptomatic infection vary by location and infection control interventions. According to a joint WHO-China report, the rate of secondary COVID-19 ranged from 1 to 5 percent among tens of thousands of close contacts of confirmed patients in China.10 In the United States, the symptomatic secondary attack rate was 0.45 percent among 445 close contacts of 10 confirmed patients.2

Transmission of SARS-CoV-2 from asymptomatic individuals (or individuals within the incubation period) has also been described. However, the extent to which this occurs remains unknown. Large-scale serologic screening may be able to provide a better sense of the scope of asymptomatic infections and inform epidemiologic analysis; several serologic tests for SARS-CoV-2 are under development.8

SARS-CoV-2 RNA has been detected in blood and stool specimens. 4 Live virus has been cultured from stool in some cases, but according to a joint WHO China report, fecal-oral transmission did not appear to be a significant factor in the spread of infection.10,12

REFERENCES

1. Ayebare RR, Flick R, Okware S, Bodo B, Lamorde M. Adoption of COVID-19 triage strategies for lowincome settings. Lancet Respir Med DOI:10.1016/S2213-2600(20)30114-4.

2. Burke RM, Midgley CM, Dratch A, Fenstersheib, M, Haupt T, Holshue M, Ghinai I, Jarashow MC, Lo J, McPherson TD, Rudman S, Scott S, Hall AJ, Fry AM, Rolfes MA. Active Monitoring of Persons Exposed to Patients with Confirmed COVID-19 – United States, January – February 2020. Morb Moral Wkly Rep. 2020 March 6; 69(9): 245-6.

3. Centers for Disease Control and Prevention. Coronavirus Disease 2019 (COVID-19): Cases in U.S. 2020. Accessed March 21, 2020 at https://www.cdc.gov/coronavirus/2019-ncov/casesin-us.html

4. Centers for Disease Control and Prevention. Coronavirus Disease 2019 (COVID-19): Clinical Care. Accessed March 21, 2020 at https://www.cdc.gov/coronavirus/2019ncov/hcp/clinical-guidance-managementpatients.html  

5. Centers for Disease Control and Prevention. Implementation of Mitigation Strategies for Communities with Local COVID-19 Transmission. Accessed March 21, 2020 at https://www.cdc.gov/coronavirus/2019ncov/downloads/community-mitigation-strategy.pdf

6. Chen N, Zhou M, Dong X, et al. Epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in Wuhan, China: a descriptive study. Lancet DOI:10.1016/S0140-6736(20)30211-7

7. Li Q, Guan X, Wu P, et al. Early Transmission Dynamics in Wuhan, China, of Novel Coronavirus– Infected Pneumonia. N Engl J Med 2020; 1–9.

8. Li X, Zai J, Wang X, Li Y. Potential of large “first generation” human-to-human transmission of 2019-nCov. J Med Virol 2020;92(4):448-454.

9. Sheahan TP, Sims AC, Leist SR, et al. Comparative therapeutic efficacy of remdesivir and combination lopinavir, ritonavir, and interferon beta against MERS-CoV. Nat Commun 2020; 11. DOI:10.1038/s41467-019-13940-6.

10. The Joint Mission. Report of the WHO-China Join Mission on Coronavirus Disease 2019 (COVID-19). 2020. Accessed March 21, 2020 at http://www.who.int/docs/defaultsource/coronaviruse/who-china-joint-mission-oncovid-19-final-report.pdf  

11. van Doremalen N, Bushmaker T, Morris DH, et al. Aerosol and Surface Stability of SARS-CoV-2 as Compared with SARS-CoV-1. N Engl J Med 2020; : 0–2.

12. Wang D, Hu B, Hu C, et al. Clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus-infected pneumonia in Wuhan, China.  

13. World Health Organization. Coronavirus disease (COVID-19) technical guidance: Infection prevention and control / WASH. Accessed March 21, 2020 at https://www.who.int/emergencies/diseases/novelcoronavirus-2019/technical-guidance/infectionprevention-and-control

14. World Health Organization. Home care for patients with COVID-19 presenting with mild symptoms and management of their contacts. Accessed March 21, 2020 at https://www.who.int/publicationsdetail/home-care-for-patients-with-suspectednovel-coronavirus-(ncov)-infection-presenting-withmild-symptoms-and-management-of-contacts

15.World Health Organization. Novel Coronavirus (2019-nCoV) Situation Report – 2: 22 January 2020. 2020. Accessed March 21, 2020 at https://www.who.int/docs/defaultsource/coronaviruse/situation-reports/20200122sitrep-2-2019-ncov.pd

Additional resources:

 Learner Materials

  • WHO advice for “Home care for patients with suspected COVID-19 infection presenting with mild symptoms, and management of their contacts”
  • CDC Guide on the “Implementation of

Mitigation Strategies for communities with local COVID-19 Transmission.”