Algorithm for the Management of Suspected COVID-19 Cases in CARPHA Member States

Triage: recognize and sort all patients with Severe Acute Respiratory Infection (SARI) or Influenza-like Illness (ILI) at first point of contact with health care system (such as the emergency department). Consider COVID-19 as a possible etiology of SARI1 under certain
conditions.
Triage patients and start emergency treatments based on disease severity.
Fever or Respiratory Illness

Recent close contact with persons suspected to have COVID-192 or recent exposure to locations with Hospitalized with radiographic Treat as clinically
suspected or documented COVID-19 cases3,4 No evidence of pneumonia No indicated

1Clinical description of SARI: An Acute Respiratory Infection (ARI) with history of fever or measured temperature ≥38 °C and cough;

Yes Yes onset within the last 10 days; and requiring hospitalization. Influenza-like Illness (ILI) shows the same symptoms but does not require
hospitalization. The absence of fever does NOT exclude viral infection.
2Contact Follow-up: The National Public Health Authority should be advised of any suspected cases in order to carryout follow-up of

Begin COVID-19 isolation precautions, initiate preliminary workup5, treat as clinically indicated, and Consider alternative diagnosis any close contacts.
notify health department and treat as clinically indicated6 3 Surveillance case definitions for COVID-19* Suspect case A. Patients with severe acute respiratory illness (fever, and at least one

sign/symptom of respiratory disease (e.g. cough, shortness of breath), AND with no other etiology that fully explains the clinical
presentation AND a history of travel to or residence in a country/area or territory reporting local transmission of COVID-19 during the
last 14 days prior to symptom onset OR B. A patient with any acute respiratory illness AND having been in contact with a confirmed or
probable COVID-19 case (see definition of contact) in the last 14 days prior to the onset of symptoms OR C. A patient with severe
Perform laboratory COVID-19 testing Symptoms improve acute respiratory infection (fever and at least one sign/symptom of respiratory disease, e.g. cough, shortness of breath) AND requiring
(qPCR) 7 or resolve hospitalization AND with no other aetiology that fully explains the clinical presentation. Probable case: A suspect case for whom
testing for COVID-19 is inconclusive. Confirmed case: A person with laboratory confirmation of COVID-19 infection, irrespective of
Laboratory Alternative clinical signs and symptoms.
4See CARPHA Situation Reports at [Link]
confirmation of diagnosis 5Clinical work-up: Clinicians should work up patients as clinically indicated. Depending on symptoms and exposure history, initial
COVID-19 confirmed6 management for patients with suspected COVID-19 may include: Complete blood count (CBC) with differential, chest radiograph,
pulse oximetry, blood culture, sputum Gram’s stain and culture, testing for viral respiratory pathogens, notably influenza A and B and
respiratory syncytial virus, or Legionella and pneumococcal urinary antigen testing if radiographic evidence of pneumonia (adults
only). Acute clinical specimens (nasopharyngeal and oropharyngeal swabs in ambulatory and hospitalized patients and sputum (if
produced) and/or endotracheal aspirate or bronchoalveolar lavage in patients with more severe respiratory disease; should be taken
Continue SARI Consider Perform COVID-19 testing6 for testing. COVID-19 testing may be considered as part of the initial work-up if there is a high level of suspicion for it based on
isolation discontinuing Continue SARI isolation exposure/ travel history. For additional details see WHO Interim Guidance Laboratory testing for 2019 novel coronavirus disease
Radiographic (2019-nCoV) in suspected human cases [Link]
precautions until 14 SARI isolation precautions until laboratory
evidence of suspected-human-cases-20200117 and CDC’s Coronavirus Disease 2019 (COVID-19) website [Link]
days following precautions8 diagnosis confirms or not ncov/about/[Link] for specialized laboratory testing options available through the Laboratory Response Network (LRN).
pneumonia9
resolution of fever COVID-19 6Alternative diagnosis: In some settings, Polymerase Chain Reaction (PCR) testing for other bacterial and viral pathogens can also

given respiratory be used to help establish alternative diagnoses. The presence of an alternative diagnosis does not necessarily rule out co-infection.
7qPCR: A real-time polymerase chain reaction (real-time PCR), also known as quantitative polymerase chain reaction (qPCR), is a
symptoms are
absent or resolving laboratory technique of molecular biology based on the polymerase chain reaction (PCR). It monitors the amplification of a
targeted DNA molecule during the PCR (i.e., in real time), therefore, to amplify COVID-19 genome only acute samples (where the
virus is present) are needed. To date, serology or rapid tests have no reliable positive predictive value, sensitivity and specificity.
8 Discontinuation of COVID-19 isolation precautions: COVID-19 isolation precautions should be discontinued only after

Consider consultation with the local public health authorities and the evaluating clinician. Factors that might be considered include the
discontinuing strength of the epidemiologic exposure to COVID-19, the nature of contact with others in the residential or work setting, the
strength of evidence for an alternative diagnosis, or the confirmation of an alternative disease, and evidence for clustering of
Laboratory confirmation of COVID-19 pneumonia among close contacts. Isolation precautions should be discontinued on the basis of an alternative diagnosis only when
COVID-197 isolation the following criteria are met: (1) Absence of strong epidemiologic link to known cases of COVID-19 (2) Alternative diagnosis
precautions8 confirmed (3) Clinical manifestations entirely explained by the alternative diagnosis (4) No evidence of clustering of pneumonia
cases among close contacts (unless >1 case in the cluster is confirmed to have the same alternative diagnosis) (5) All cases of
presumed COVID-19 identified in the surrounding community can be epidemiologically linked to known cases or locations in which
transmission is known to have curbed.
9Radiographic testing: Chest CT and chest radiograph (CXR) may show evidence of an infiltrate and can be useful for the diagnosis

and management of pneumonia. Therefore, either or both methods should be considered, if available, in confirmed patients for
COVID-19 or in those with a strong epidemiologic link to a known case of COVID-19 to evaluate the evolution of pneumonia and
pulmonary recovery.
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CARPHA: Algorithm for the Management of Coronavirus Disease (COVID-19) Cases. Version 2 03 March 2020