From: Davis, Charles (Todd) (CDC/DDID/NCIRD/ID) [mailto:eou8@cdc.gov]
Sent: 3 May, 2020 22:33
To: Geleishvili, Marika (CDC/DDPHSIS/CGH/DGHP) ; McCarron, Margaret (Meg) (CDC/DDID/NCIRD/ID) ; Mirza, Sara (CDC/DDID/NCIRD/DBD) ; Pathmanathan, Ishani (CDC/DDPHSIS/CGH/DGHT) ; Igboh, Ledor (CDC/DDID/NCIRD/ID) ; Wilson, Katie (CDC/DDID/NCEZID/DHQP) ; Hedges, Sarah (CDC/DDPHSIS/CGH/DGHP) ; Luvsansharav, Ulzii Orshikh (CDC/DDID/NCEZID/DHQP) ; Weiss, Jamine (CDC/DDID/NCEZID/DHQP) ; Zhou, Weigong (CDC/DDID/NCIRD/ID)
Cc: Anaya, Gabriel (CDC/DDPHSIS/CGH/GID) ; Bolkvadze, Tamar (CDC/DDPHSIS/CGH/DGHP) ; Tamar Gabunia ; Saganelidze, Nino (CDC/DDPHSIS/CGH/DGHP) ; Killam, William P. (CDC/DDPHSIS/CGH/DGHT) ; Soeters, Heidi (CDC/DDPHSIS/CGH/GID) ; Shah, Minesh Pradyuman (CDC/DDPHSIS/CGH/DGHT) ; Balish, Amanda (CDC/DDPHSIS/CGH/DGHP) ; Hurlston, Mackenzie (CDC/DDPHSIS/CGH/DGHT) ; Gianetti, Brittany (CDC/DDPHSIS/CGH/DGHT) ; Alexander, Heather (CDC/DDPHSIS/CGH/DGHT)
Subject: RE: Georgia questions

From: Geleishvili, Marika (CDC/DDPHSIS/CGH/DGHP) <ivu9@cdc.gov>
Sent: Saturday, May 2, 2020 3:37 PM
To: Davis, Charles (Todd) (CDC/DDID/NCIRD/ID) <eou8@cdc.gov>; McCarron, Margaret (Meg) (CDC/DDID/NCIRD/ID) <dme8@cdc.gov>; Mirza, Sara (CDC/DDID/NCIRD/DBD) <zjk4@cdc.gov>; Pathmanathan, Ishani (CDC/DDPHSIS/CGH/DGHT) <ydi6@cdc.gov>; Igboh, Ledor (CDC/DDID/NCIRD/ID) <ymq4@cdc.gov>; Wilson, Katie (CDC/DDID/NCEZID/DHQP) <vvd6@cdc.gov>; Hedges, Sarah (CDC/DDPHSIS/CGH/DGHP) <vow7@cdc.gov>; Luvsansharav, Ulzii Orshikh (CDC/DDID/NCEZID/DHQP) <xde7@cdc.gov>; Weiss, Jamine (CDC/DDID/NCEZID/DHQP) <yuu6@cdc.gov>; Zhou, Weigong (CDC/DDID/NCIRD/ID) <waz6@cdc.gov>
Cc: Anaya, Gabriel (CDC/DDPHSIS/CGH/GID) <gda1@cdc.gov>; Bolkvadze, Tamar (CDC/DDPHSIS/CGH/DGHP) <irl6@cdc.gov>; Tamar Gabunia <tgabunia@moh.gov.ge>; Saganelidze, Nino (CDC/DDPHSIS/CGH/DGHP) <kpq4@cdc.gov>; Killam, William P. (CDC/DDPHSIS/CGH/DGHT) <imi5@cdc.gov>
Subject: RE: Georgia questions

From: Davis, Charles (Todd) (CDC/DDID/NCIRD/ID) <eou8@cdc.gov>
Sent: Saturday, May 2, 2020 5:31 PM
To: McCarron, Margaret (Meg) (CDC/DDID/NCIRD/ID) <dme8@cdc.gov>; Geleishvili, Marika (CDC/DDPHSIS/CGH/DGHP) <ivu9@cdc.gov>; Mirza, Sara (CDC/DDID/NCIRD/DBD) <zjk4@cdc.gov>; Pathmanathan, Ishani (CDC/DDPHSIS/CGH/DGHT) <ydi6@cdc.gov>; Igboh, Ledor (CDC/DDID/NCIRD/ID) <ymq4@cdc.gov>; Wilson, Katie (CDC/DDID/NCEZID/DHQP) <vvd6@cdc.gov>; Hedges, Sarah (CDC/DDPHSIS/CGH/DGHP) <vow7@cdc.gov>; Luvsansharav, Ulzii Orshikh (CDC/DDID/NCEZID/DHQP) <xde7@cdc.gov>; Weiss, Jamine (CDC/DDID/NCEZID/DHQP) <yuu6@cdc.gov>; Zhou, Weigong (CDC/DDID/NCIRD/ID) <waz6@cdc.gov>
Cc: Anaya, Gabriel (CDC/DDPHSIS/CGH/GID) <gda1@cdc.gov>; Bolkvadze, Tamar (CDC/DDPHSIS/CGH/DGHP) <irl6@cdc.gov>; Tamar Gabunia <tgabunia@moh.gov.ge>; Saganelidze, Nino (CDC/DDPHSIS/CGH/DGHP) <kpq4@cdc.gov>; Killam, William P. (CDC/DDPHSIS/CGH/DGHT) <imi5@cdc.gov>
Subject: Re: Georgia questions

Get Outlook for iOS

Dear Marika,

WHO has published a nice document with laboratory testing strategy recommendations for COVID-19, attached. They include strategies for countries at different phases of their epidemics, from first introductions to widespread community transmission or large clusters as well as prioritized testing strategies based on resource allocation, such as quantity of kits available.  Unfortunately these are questions with no concrete answers and national testing strategies differ based on lots of different variables.

I have copied Todd Davis, the Laboratory team lead on the international task force. Todd might be able to answer some of your questions regarding how often you might want to re-test if you were to adopt a strategy for routine testing of asymptomatic persons.

Todd, see below, where I have copied Marika’s questions.

Best,

Meg

“We would like to ask for your advice and suggestions regarding the testing strategy for screening in the high risk groups.

Current testing strategy:  

Diagnostic: PCR test for all patients, who meet the covid-19 case definition and with fever and pneumonia.

Screening: IgM and IgG tests for all healthcare workers biweekly; if the test is positive – PCR.  

High risk groups are : healthcare workers, residents of long-term facilities, army and may be few more.  

We would like to have your suggestions and answers on the following questions:

·         Should we test asymptomatic individuals from the high risk groups?

·         If yes, please, let us know which ones should be prioritized?

·         What method should be used for screening of  asymptomatic  individuals (PCR or serology)?

·         How often should we perform screening of asymptomatic  individuals in the high risk groups?

·         Would you suggest to use PCR tests for HCW screening instead of serology (IgM& IgG). If yes – how often.

·         When the restrictions are lifted, should we start screening in other groups as well (e.g. media workers, supermarket staff, etc.)?”

Thank you Sara and Ledor, for your support and collaboration and wish you all the best.

Dear  Weigong and Meg, welcome to the team.

Can you, please, response to our questions below?

Best regards,

Marika  

Hi Marika,

Ledor and I have rotated off the ITF Epi Team. I’m including Weigong Zhou and Meg McCarron here for future reference.

Thanks,

Sara

Dear Team,

Hope you all are healthy and doing well.

Just to update you on Georgia COVID situation: we have 566 cases, 7 death. Country is planning to lift restrictions soon, among cases >30 are healthcare workers.

We would like to ask for your advice and suggestions regarding the testing strategy for screening in the high risk groups.

Current testing strategy:  

Diagnostic: PCR test for all patients, who meet the covid-19 case definition and with fever and pneumonia.

Screening: IgM and IgG tests for all healthcare workers biweekly; if the test is positive – PCR.  

High risk groups are : healthcare workers, residents of long-term facilities, army and may be few more.  

We would like to have your suggestions and answers on the following questions:

·         Should we test asymptomatic individuals from the high risk groups?

·         If yes, please, let us know which ones should be prioritized?

·         What method should be used for screening of  asymptomatic  individuals (PCR or serology)?

·         How often should we perform screening of asymptomatic  individuals in the high risk groups?

·         Would you suggest to use PCR tests for HCW screening instead of serology (IgM& IgG). If yes – how often.

·         When the restrictions are lifted, should we start screening in other groups as well (e.g. media workers, supermarket staff, etc.)?   

Looking forward to hearing from you,

And have a happy Friday,

Marika

Hi Marika- this is the right ream! (I have rotated off but Perry is cc’ed here)

Dear Team,

Thank you for your support. We are still working with the modeling team for the Rt-Ro calculation and modeling.

Current practices and guidance on isolation and for the organized groups are attached.  Your comments and suggestions are most welcome.

Dear Ishani,

I think this is the right team to address with these epi questions. In case key SMEs are missed, please, help me to communicate with them and ask to review the action plan.

Best regards,

Marika

Dear Ledor,

Thank you for your prompt response. All the provided information and links are very helpful.

a.       The RT – Ro study is the highest priority for the country and we’d appreciate if you can send the study design and protocol. We can start creating the instrument for data collection as soon as you send the list of required information. Please, let me know if IRB approval is needed – usually for the outbreak-related studies IRB is not required, but in case we need it – I’ll submit the proper documents and get approval within 10 days from the National CDC. 

b.       MoH has guidance on activities  for the local authorities (when the outbreak is registered in regions). The documents look  well structured and cover most of the activities for outbreak response. Let me send the translated document on Monday. Your comments and suggestions are much valuable. 

Thanks again,

Looking forward to hearing from you,

Marika        

Hello Marika,

1.       Epi questions:

a.       MoH-Ge needs SME support to conduct real -time monitoring of transmission of COVID-19 in Georgia. She has provided article describing the same study in Singapore. https://www.medrxiv.org/content/10.1101/2020.02.21.20026435v7 . The result of the study will assess effectiveness of the epidemiological measures that country has taken in response to the COVID-19 outbreak. For this project we’ll need to have a PI at HQ and we can provide the PI all the required information from the central and NCDC level. According to Dr. Gabunia, MoH will provide evidence based recommendations to the National Coordination Counsel on recovery and lifting restrictions.

Response:

·         This is noted. Thank you for sharing this information with us.

·         Please let the Epi team know how we can support you as you deliberate further.

b.       With the community spread of the disease, different geographical areas (region / district / villages ) are showing increased number of cases and clusters. Each district is responding to the increase in different way. Dr. Gabunia asked for a structured plan for actions at local level (e.g. is quarantine required, what additional restrictions should be in place, how long should the quarantine last – one incubation period, 2 incubation period, or based no number of cases; is population-wide thermo-screening helpful, what are the target population for lab tests, etc..). This guidance will help country to save resources and lift restrictions tamely. 

Response:

·         The recommendation is for all suspected cased of COVID-19 to be tested according to the WHO case definitions

·         Testing can be expanded as resources allow when the clusters become larger as you’ve stated. In this scenario, its crucial that testing of suspected cases continues so that cases can be isolated and quarantined.

·         For areas with community-wide transmission, the focus should be on early detection and prioritization of  vulnerable patients and health care workers.

·         Testing for specific populations can give a rough estimate of transmission in the area and these data can be used to monitor trends.

·         Depending on resources available, those who are at highest risk should be prioritized and tested. More information on evaluating and testing for COVID-19 (this can be adjusted to suit your context): https://www.cdc.gov/coronavirus/2019-ncov/hcp/clinical-criteria.html.

·         There is no one size fits all approach but based on your risk assessment, the recommendation is to rapidly implement necessary measures for testing. The WHO guidance for laboratory testing strategy recommendations here. outlines some adaptable strategies.

·         Duration of quarantine: 14 days, if symptomatic, assume COVID-19 and extend quarantine.

o    For recovering patients who have tested negative twice, discharge after an additional 14 days in self-isolation.

Thanks,

Ledor

Hi Marika,

For #3 (managing healthcare workforce during COVID-19), there are a few key messages and resources that can help. I’ve also looped in Jami, who can follow up with you.

·         Make sure there is a system for monitoring/screening healthcare workers

o    There are a number of options to do this (self-assessment before shifts, active check-ins before shifts)

o    More detailed information here (look at #5): https://www.cdc.gov/coronavirus/2019-ncov/hcp/non-us-settings/guidance-identify-hcw-patients.html

·         Plan for alternative human resources at facilities

o    Identify inactive HCW that can surge in the event of an HCW shortage (e.g. retired, private or military HCWs, HCW not working in clinical settings, volunteers).

o    Identify active HCWs that can be repurpose/redeploy to COVID-19 wards from other areas of the hospital where patient volume is low due to pandemic (e.g. staff in outpatient departments)

o    Develop a database of alternate/on-call HCWs.

o    Provide training opportunities and resources for incoming HCWs.

·         Ensure there are plans for managing exposed healthcare workers (risk assessment and monitoring)

o    A number of operational considerations are here (including how to do when there are staff shortages): https://www.cdc.gov/coronavirus/2019-ncov/hcp/non-us-settings/public-health-management-hcw-exposed.html

·         Plan systems for triage and isolation of patients presenting with respiratory symptoms

o    Set up triage system (to help protect HCWs) using this SOP as example: https://www.cdc.gov/coronavirus/2019-ncov/hcp/non-us-settings/sop-triage-prevent-transmission.html

o    Also reference this WHO guidance for maintaining health services (start at page 7): https://www.who.int/publications-detail/covid-19-operational-guidance-for-maintaining-essential-health-services-during-an-outbreak

Best,

Katie

Katie Wilson, MPH

Infection Prevention and Control Team

International Task Force

CDC COVID-19 Response

Office: +1 404.639.4333 | Mobile: +1 470.755.5720

+ Perry

Hi Marika- adding my Epi, Mitigation and IPC colleagues for their input on 1a, 1b and 3, respectively!

Dear Team,

I have met with the Deputy Minister Dr. Gabunia to discuss questions for CDC. Please, see summary here:

1.       Epi questions:

a.       MoH-Ge needs SME support to conduct real -time monitoring of transmission of COVID-19 in Georgia. She has provided article describing the same study in Singapore. https://www.medrxiv.org/content/10.1101/2020.02.21.20026435v7 . The result of the study will assess effectiveness of the epidemiological measures that country has taken in response to the covid outbreak. For this project we’ll need to have a PI at HQ and we can provide the PI all the required information from the central and NCDC level. According to Dr. Gabunia, MoH will provide evidence based recommendations to the National Coordination Counsel on recovery and lifting restrictions.

b.       With the community spread of the disease, different geographical areas (region / district / villages ) are showing increased number of cases and clusters. Each district is responding to the increase in different way. Dr. Gabunia asked for a structured plan for actions at local level (e.g. is quarantine required, what additional restrictions should be in place, how long should the quarantine last – one incubation period, 2 incubation period, or based no number of cases; is population-wide thermo-screening helpful, what are the target population for lab tests, etc). This guidance will help country to save resources and lift restrictions tamely. 

These two projects are extremely important for recovery phase at central and local levels.

2.       Lab questions: Dr. Gabuni will have consultations with the Lab and Clinical teams and get back with coordinated request on lab side. 

3.       IPC questions:  As healthcare workers are heavily affected during the pandemics globally, and Georgia is experiencing the same trends (about 20% of cases are healthcare workers), several hospitals have been shutdown due to infected staff, it is important to provide HCFs with guidance how to manage human resources:  back-up teams, additional trainings , reduce number of staff per shift and keep them “clean” in case infection spreads among the frontline HCW. So, guidance in managing HCW during the covid response is much desirable.

Please, let me know if further clarification is needed.

Looking forward to hearing from you,

Marika        

Thank you so much Ishani.  We are still waiting on the Ministry too so delays on both sides.

Thanks for following up,

Sarah

Sorry for delay on this Sarah- I didn’t hear back after email Friday and have re-pinged them

Ok thanks Sarah – let me follow up with our SMEs here

Hi Ishani,

Definitely English.  Language won’t be an issue.  We really appreciate the support.  Dr. Geleishvili, CDC’s senior med epi, will work with the Ministry next week to gather more specific information around what questions they have and better sense of when they would like have the call.

Marika, please feel free to add additional information here as you have it.

Thank you again,

Sarah

Hi Sarah,

Do you know if language will be an issue, and when they hope to do this call? We have gotten many requests like this and have typically deferred to the in-country CDC staff to liaise directly with Ministries (while our ITF SMEs work ahead of time to prepare our CDC country teams) partly because of language/time restrictions and partly because of our SME’s bandwidth supporting all countries. That said, given your circumstances and if English is ok (especially if a formal presentation is not needed), I can definitely check with our IPC and epi teams here to see if they can do this! I think would especially be great to get their questions in advance as much as possible to maximize efficiency!

Let me know thoughts and I can pitch it to our SME teams tomorrow

Ishani

Hi Ishani,

Thanks so much for reaching out.  As you may know, the CDC Georgia office does not currently have any USDHs at post.  I serve as the deputy director at large and, for the past year, the acting country director as we wait for US staff to relocate to post later this calendar year.  We are lucky to have a very talented group of locally employed staff, several of whom are copied here. 

We have received a request from the Deputy Minister for Health to consult with COVID-19 experts by phone or video conference (request details are being finalized) in the areas of lab, surveillance, and IPC.  I’ve attached a cable highlighting the request and other COVID-19 related updates.

As we wait for details on how the ministry would like to proceed, I wanted to give your team a heads up that this request is coming in case you need additional information from us.

Thank you again for hosting these calls.  We really appreciate the information sharing opportunities.

Best,

Sarah  

SO sorry we ran out of time! How can we help you?

Ishani Pathmanathan, MD/MPH

Regional Technical Lead - Latin American/Caribbean, Eastern Europe/Central Asia, Middle East

Country Support Team - International Task Force

2019 Novel Coronavirus Response

U.S. Centers for Disease Control and Prevention (CDC)

Office: (404) 718-8387 | Cell: (404) 200-4965