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That's the press conference. In summary: - A Washington County resident has tested positive for #covid19usa - The CDC has not yet confirmed the positive test result - The person was hospitalized at Kaiser Permanente in Hillsboro (1/2) 1 Mark Miller @markdmiller2 · 5m - The #COVID19USA patient recently spent time at Forest Hills Elementary School in Lake Oswego - The person is not known to have travel to a country experiencing widespread #coronavirus outbreak - Oregon officials are treating this as a case of "community spread" (2/2)

https://www.facebook.com/sccpublichealth/videos/215371799853074/?eid=ARCt7xffolv-xe8gnlE7OAk_KG9_18ILUoupH81kHhfDnbZHZZFoX-jYbLH-fOhqppkWv6qHNL-3r8av

FOR IMMEDIATE RELEASE February 28, 2020   For more information contact:   County of Santa Clara Public Health Communications   Media Line: (408) 794-0707        County of Santa Clara Public Health Department Reports Third Case of COVID-19      News highlights · The third case of COVID-19 in Santa Clara County and is not related to other cases. · The third case had no known exposure to the virus through travel or close contact with a known infected individual. · Now is the time to prepare for the possibility of widespread community transmission. SANTA CLARA COUNTY-The County of Santa Clara Public Health Department confirms the third case of COVID-19. This is the third case to be identified in our County, but is different from the other two cases since this person does not have a travel history nor any known contact with a traveler or infected person.  The individual is an older adult woman with chronic health conditions who was hospitalized for a respiratory illness. Her infectious disease physician contacted the Public Health Department to discuss the case and request testing for the novel coronavirus. The County of Santa Clara Public Health Laboratory received the specimens yesterday and performed the testing. Since receiving the results last night, the department has been working to identify contacts and understand the extent of exposures. Due to medical privacy requirements and to protect her identity, further information about this case will not be released. “This new case indicates that there is evidence of community transmission but the extent is still not clear,” said Dr. Sara Cody, Health Officer for Santa Clara County and Director of the County of Santa Clara Public Health Department. “I understand this may be concerning to hear, but this is what we have been preparing for. Now we need to start taking additional actions to slow down the spread of the disease.” This case is important because it signals that now is the time to change course.  The public health measures taken so far – isolation, quarantine, contract tracing, and travel restrictions – have helped to slow the spread of the disease. The department will continue to implement these measures and continue to trace close contacts of our cases to protect the health of individuals and our community. Since the disease is here, an important priority for the department will be to conduct community surveillance to determine the extent of local transmission. Since the County Public Health Laboratory has the ability to run the test, the department can quickly evaluate what is happening in our community. For individuals, the recommendations are very simple, but very important: · Keep your hands clean. It is one of the most important steps you can take to avoid getting sick and spreading germs to others. And always need to cover your cough and stay home when you are sick.   · Today, start working on not touching your face because one way viruses spread is when you touch your own mouth, nose or eyes.   · Since we know the disease is here, we all need to stay away from people who are sick.  · Start thinking about family preparedness, how to take care of sick family while not getting infected. Think about a room to isolate a sick person. There are practical measures that can help limit spread by reducing exposure in community settings: · Schools: should plan for absenteeism and explore options for tele-learning and enhance surface cleaning. · Businesses: whenever possible, can replace in-person meetings with video or telephone conferences and increase teleworking options and modify absenteeism policies and also enhance surface cleaning. The County of Santa Clara Public Health Department is working closely with the U.S. Centers for Disease Control and Prevention (CDC), the State of California Department of Public Health, and other partners as the new coronavirus situation continues to change. Information will be updated as soon as possible on our website: http://sccphd.org/coronavirus    The news conference will be streamed live at on the department’s Facebook page https://www.facebook.com/sccpublichealth/ ###   About the County of Santa Clara Public Health Department The County of Santa Clara Public Health Department focuses on protecting and improving the health of communities through education, promotion of healthy lifestyles, disease and injury prevention, and the promotion of sound health policy. To learn more about how the Public Health Department serves the people who live, work, study, and play in the County of Santa Clara, please visit our website, sccphd.org, and follow us on Facebook, facebook.com/sccpublichealth. Public Health Department County of Santa Clara, Public Health Department 976 Lenzen Avenue, San Jose CA 95126 www.sccphd.org

Coronavirus: Latest patient was first to be infected in UK 1 hour ago Share this with Facebook Share this with Messenger Share this with Twitter Share this with Email Share Image captionHaslemere Health Centre has been closed since Friday morning The latest patient diagnosed with the coronavirus in England is the first to catch it in the UK. It is unclear whether this was directly or indirectly from someone who recently returned from abroad, England's chief medical officer said. The man is a resident of Surrey who had not been abroad recently himself. It takes the total number of UK cases to 20 and comes after a British man in his 70s became the first UK citizen to die from the virus. That man, who lived abroad, had been taken to hospital in Japan after catching coronavirus on the Diamond Princess cruise ship, which was quarantined off the port of Yokohama earlier this month. Confirming the latest UK case, England's chief medical officer Prof Chris Whitty said the man had been transferred to a specialist NHS infection centre at Guy's and St Thomas' Hospital in central London. He was a patient at Haslemere Health Centre in Surrey which has been closed for "deep cleaning" since Friday morning. Image captionThe surgery was closed to patients while cleaning took place Image captionSigns informed patients that the centre was closed Prof Whitty said the case was being investigated and contact tracing has begun. ADVERTISEMENT Ads by Teads The Department of Health and Social Care said the virus was passed on in the UK but the original source was "unclear" and there was no "immediately identifiable link" to overseas travel. Coronavirus: 'Self-isolating will cost me £600' Can coronavirus harm breastfed babies, and other questions EasyJet and British Airways warn over virus impact How is the UK getting ready for coronavirus? Public Health England said it was working with Surrey County Council to contact people who had "close contact" with the latest coronavirus case. Prof Jonathan Ball, from the University of Nottingham, said the latest case marks a "new chapter for the UK" and that it is "crucial" to understand the infection's origin. "This was always a concern - this is a virus that frequently causes symptoms very similar to mild flu or a common cold, and it's easily transmitted from person to person. This means it can easily go under the radar," the virology expert added. Prime Minister Boris Johnson, who is due to chair an emergency Cobra committee meeting on Monday, said preparing for an outbreak in the UK was now the government's "top priority". Who did this man catch the virus from? This is the urgent question that needs answering about the 20th case in the UK. So far, no connection with anyone who has travelled to an affected country has been discovered. Until we know the answer it is difficult to know how big a development this is. This could be an "outbreak of two" - with just one other, still to be identified, person that caught coronavirus abroad. Or is this the first case to be detected from a much larger outbreak? We know this can happen, Italian scientists believe the virus was circulating there unnoticed for weeks. For now, we simply do not know, but this is a scenario officials have been preparing for. When asked if the government should have acted sooner for Britons on the cruise ship, he said it had been following the "best medical advice" about not repatriating people unless it was certain there would not be a spread to the UK. Mr Johnson has also faced criticism from Labour for waiting until Monday to hold the government Cobra meeting. What do I need to know about the coronavirus? WHAT ARE THE SYMPTOMS? A simple guide WAYS TO PREVENT CATCHING IT: How to wash your hands WHERE ARE WE WITH A VACCINE? Progress so far A VISUAL GUIDE TO THE OUTBREAK: Virus maps and charts WHAT DOES IT MEAN FOR MY HOLIDAY? Your rights as a traveller But he said he had been working behind the scenes, meeting with the health secretary and chief medical officers to discuss the NHS's preparations. Hundreds of guests have been confined to the H10 Costa Adeje Palace in Tenerife after at least four tourists were diagnosed with coronavirus. Six Britons were among those told by Spanish authorities that they could leave on Friday because they had arrived at the hotel on Monday - after those who tested positive had been taken to hospital. Earlier three more cases of the virus were confirmed in the UK, including the first one in Wales. Two new patients in England contracted the virus while in Iran, the Department of Health and Social Care said. Can we answer your question on the coronavirus? Here's what others have been asking Once you've had coronavirus, will you be immune? Is the coronavirus worse than flu or Sars? Who is worst affected by the virus? Public Health Wales said it was working to identify close contacts of the Welsh patient, who is believed to be from the Swansea area and was infected in northern Italy before returning to the UK. Northern Ireland also confirmed its first case on Thursday. Authorities said they had contacted passengers who sat near the woman on a flight from northern Italy to Dublin. The World Health Organization has raised its global risk assessment of the virus to "very high" because of the continued emergence of cases and new countries being affected. But Dr Michael Ryan, executive director of the World Health Organization Health Emergencies Programme, reiterated that the outbreak was not a pandemic. He told a press conference: "If we say there is a pandemic of coronavirus we are essentially accepting every human on the planet will be exposed to that virus and the data does not support that as yet."

Press release CMO for England announces a new case of novel coronavirus: 28 February 2020 Chief Medical Officer Professor Chris Whitty statement on a new case of COVID-19 passed on in the UK. Published 28 February 2020 From: Department of Health and Social Care One further patient in England has tested positive for COVID-19. The virus was passed on in the UK. It is not yet clear whether they contracted it directly or indirectly from an individual who had recently returned from abroad. This is being investigated and contact tracing has begun. The patient has been transferred to a specialist NHS infection centre at Guy’s and St Thomas’. The total number of cases in England is now 18. Following confirmed cases in Northern Ireland and Wales, the total number of UK cases is 20. https://www.gov.uk/government/news/cmo-for-england-announces-a-new-case-of-novel-coronavirus-28-february-2020

The man is a resident of Surrey who had not been abroad recently himself. https://www.bbc.com/news/uk-51683428

Transcript for the CDC Telebriefing Update on COVID-19 playstopskip-backwardskip-forwardvolume Volume Range Slider Scrub Range Slider Press Briefing Transcript Friday, February 28, 2020 Please Note: This transcript is not edited and may contain errors. Benjamin Haynes: Thank you all joining us for this briefing. We’re joined today by the director of CDC’s National Center for Immunization and Respiratory Disease, Dr. Nancy Messonnier. At this time Ii will turn the call over. Dr. Nancy Messonnier: Good afternoon, thank you for joining us today. Since I last briefed you, there has been one new case of COVID-19 detected through the U.S. public health system. As has been widely reported, at this time we don’t know how or where this person became infected. This brings the number of confirmed cases of person-to-person spread in the United States to 3. We also have confirmed 2 more people who have tested positive for the virus that causes COVID-19 among U.S. citizens repatriated from the Diamond Princess cruise ship. That brings the total number of people with COVID-19 to 44 among this group of people. I’d like to share with you some additional information about the U.S. case CDC confirmed on Wednesday. CDC officials first heard from public health colleagues in California about this patient last Sunday, February 23rd. California reported a severely ill person who had not recently traveled abroad or had contact with a known case of COVID-19. CDC recommended testing for COVID-19 that day. We received samples on February 25th and confirmed the results with public health officials in California the day they were finalized, on February 26th. As I said, the patient’s exposure is unknown. It’s possible this could be the first instance of community spread – meaning the illness was acquired through an unknown exposure in the community. It’s also possible, however, that a thorough investigation may show that the patient had exposure through contact to a returned traveler who was infected. CDC has sent a team to support the California Department of Health and the local health departments in investigating this case. We are working hard to find and identify how the patient was exposed as well as tracing back people who were exposed or might have been exposed to this patient. Like you, we are thinking about the wellbeing of this patient, this family, and this community. People who were exposed to this person during their infection are at some level of risk depending on their exposure. Based on what we know about how this virus behaves, we expect that we will find additional people who have had contact with this patient, especially those who have had close, prolonged contact. This of course includes family members and potentially among healthcare workers who cared for the patient. There has been some confusion about whether this person met CDC’s criteria for testing of COVID-19. Let me comment briefly on how we have set our PUI criteria, which has been evolving as all of our guidance has to meet the needs of this rapidly evolving situation. You can look for these updates online at www.cdc.gov/covid19. CDC’s definition of a person under investigation, or PUI, from the beginning has been broad, for travelers especially, because this was a disease that was being introduced from another part of the world. We have been looking for people with fever, cough, or trouble breathing. Fever and cough are pretty broad parameters, especially during flu season, and we’ve had to rule out many people who had other respiratory illnesses. At this point in our investigation, we are most focused on symptomatic people who are closely linked to confirmed cases or had travel history. But our criteria also allows for clinical discretion. As public health professionals, we know that there is no substitute for the astute clinician on the frontlines of patient care. Our clinical team working with state and local health departments to assess PUIs has not said no to any request for testing. So, on the topic of PUIs, I want to say that as we’ve been watching the increased spread of this virus across the world, we have been working with our partners on an updated PUI definition. That was posted online yesterday. The updated PUI definition takes into account the new geographic spread of the virus and includes a list of affected areas with widespread or sustained community spread. This list is dynamic and will change as our travel guidance is revised. I would now like to share an update on our progress to get all state and local public health labs the capacity to test for this virus. That is CDC’s role in testing for this illness. As I’ve said before, this has not gone as smoothly as we would have liked. We have been working simultaneously on a couple of possible solutions and I’m happy to say today that both have delivered. Right now, labs can start testing with existing CDC test kits. States that were able to validate their kits should continue to test in this manner. States that were able to validate only the two components specific to novel coronavirus can test using only these two using revised instructions developed at CDC. We have established that the third component, which was the cause of the inconclusive results, can be excluded from testing without affecting accuracy. We have been working with FDA and they agree with our approach. While we’re working to amend the existing EUA, we have discretionary authority from FDA to proceed in this manner. This will increase testing capacity at state and local health departments. All positive test results will continue to be confirmed by CDC for some time. Additionally, CDC has manufactured brand new test kits that will only include the two components that are specific to novel coronavirus. Those test kits are at the International Reagent Resource, where orders can be placed. We are working as quickly as we can to get CDC test kits to state and local public health authorities. However, during any infectious disease response there is a great need for test manufacturers to rapidly make testing available in clinics, in hospitals, and at the bedside. This is part of a huge effort within the US government led by HHS. States will now start testing for this virus. You may start hearing from states directly. As always, their case counts will be the most up-to-date. CDC will continue to report case counts on Mondays, Wednesdays and Fridays. Our priority continues to be getting accurate diagnostic capacity—and doing so quickly—because we know public health surveillance is critical to our fight against this novel coronavirus. To date, our strategies have been largely successful. As a result, we have very few cases in the United States. And while we may be confronting the first instance of community spread, we are working very hard with our state and local public health partners to find out more. I want to recognize that people are concerned about this situation. We appreciate that Americans are taking this threat seriously and continuing to seek information about how to be prepared. As always, President Trump’s and our number one priority is the health and safety of the American people. Our mission includes providing you with clear information that allows you to make decisions about how best to protect yourself and your family. While the immediate risk to the general American public remains low, and the U.S. government is doing everything we can to keep it low. CDC is constantly monitoring what is happening abroad. Our guidelines and advice are likely to be interim and subject to change as we learn more. We will continue to keep you updated. I would be happy to take questions now. Haynes: We’re ready to open up for questions. Operator: If you would like to ask a question please press star 1. Record your name, if you would like to withdraw your question, press star 2. Please wait a moment while we way for questions to queue. Our first question comes from Helen Branswell, your line is now open. Helen Branswell: Now that test kits — state and local labs can test more broadly, how soon will you be able to get the surveillance project that you were talking about earlier with the six cities up and running? Dr. Messonnier: Thank you for that question. It is increasingly important to be able to do not just surveillance focused on the PUIs, but broader community level surveillance. And we’re moving rapidly to go from those six sights to national surveillance. We expect the first site to do testing by next week and we hope to be able to rapidly move from six to all 50 states. This is part of a layered approach with that first component that you’re talking about but multiple other systems that we’re modifying. we can modify them to be able to also test for this coronavirus. Haynes: Next question, please. Operator: Our next question comes from Rob Stein at NPR. Rob Stein: Could you be a little more specific on the testing? How many states are testing now? How many states do you think will be testing let’s say next week, and sort of what is the timeline that you’re projecting for that? Dr. Messonnier: I’m not going to give a specific number because throughout the day today we expect additional states to stand up and we expect that to be happening for the next week. Our goal is to have every state and local health department online doing their own testing by the end of next weekend and doing everything we can to continue that. Haynes: Next question, please? Operator: Our next question comes from Elizabeth Cohen at CNN, your line is open. Elizabeth Cohen: Thank you for taking my question. When the CDC and the local state departments have been doing contact tracing, are they tracing contacts while they were symptomatic, or only while they were asymptomatic but presumably infected? And has that been the system the entire time or is that a new policy or was that the old policy? Dr. Messonnier: Because there have been such a small number of cases in the United States, CDC has been able to supplement the activities of the state and local health departments, to be very aggressive in our contact tracing, that is true from the first case and it remains true now. We have been broad in terms of our evaluations of the potential contacts of cases, and I remind you that so far before this most recent case all but two of our cases were travelers, and the two cases we had that were person to person spread were quite close contacts of cases, they were spouses. While we have been aggressive and broad where we have found those cases were actually in very close contacts. Reporter Issam Ahmed at AFP: Hi, thank you for this. About what you were saying about the California patient, it seems to be at odds with what Representative Berra (?) said in Congress yesterday, he said the patient was brought in on the 19th of February, and it wasn’t until five days – and doctors immediately asked for a test, and it wasn’t until Sunday the 23rd that federal authorities agreed to do that test. I was wondering if you could speak to that? And another question is that given the US situation with its public health system with 27.5 million people uninsured, do you think that this could be a problem if it takes root in this community and spread and people will be reluctant to approach their health care providers because of the cost involved? Thank you. Dr. Messonnier: According to CDC records, the first call we got about this patient was on Sunday, February 23rd. The second question is we need to remember that right now the case count in the United States is really low and that is a reflection of the aggressive containment efforts of the US government. There is certainly the possibility of additional cases. We will continue to work aggressively to try to keep that number low. The spread we hope will be limited, and any disease in the U.S. will be mild, our focus on public health is on those issues. Haynes: Next question, please? Operator: Our next question comes from Craig at KNX CBS. Your line is now open. Reporter: You talk about the case count being low, how do we reconcile that with the fact that here in California the most populous state, the governor yesterday said only a couple hundred testing kits. The case count will be low because it sounds like there is not enough tests that could reflect it. It seems like the issue the math on that seems to be a low count. Dr. Messonnier: Yes, thank you for the opportunity to talk about that. We need to remember that this situation is taken place rapidly. By far the majority of cases have been in California. A few weeks ago we found an increase in cases around the world. And again this week we have seen an increase in cases globally. Because of the aggressive U.S. efforts at our border strategy the number of cases have been low. And we have been able to focus our efforts on travelers and their close contact based on our evaluation of who is at highest risk. We will continue to modify our approach. In terms of diagnostic testing, additional labs are coming on-line and additional test kits are on their way now. Operator: Our next question comes from Michelle Cortez, at Bloomberg News, your line is now open. Michelle Cortez: I think what a lot of us are grappling with a little bit is the idea that China has been able to do tens of thousands of tests. Korea has been able to do thousands of tests. And here in the US, in our local we have done about 500 in our local patients and then plus another 2,000 patients or so that have been repatriated — we just don’t have the numbers they do. Can you explain that to us how others aer able to do thousands and thousands of tests, that we have not been able to do that yet? Dr. Messonnier: I think there are two answers to that question. One is that the epidemiological situation in China and other countries is really different from the U.S. We acted incredibly quickly before most other countries. Aggressively controlled our borders and we were able to slow the spread into the United States. That was an intentional US strategy with the goal of allowing us to control our efforts, so we have focused surveillance for those at highest risk. And again, that is why the number of patients that were identified as PUIs in the US has been smaller. I guess i would also direct you back, the CDC role was in rapidly developing a diagnostic and focusing on the front line on getting that out to the public. But our solution, a larger part of the any such infectious disease is getting the test kit out more broadly to the hospitals, and to the HHS and to the front lines, and that is part of a U.S. government strategy that is a huge priority with HHS leadership right now. CDC has always had the capacity to test from the time rapidly when the sequence was available and that is two labs at the CDC doing the testing, and we have been testing aggressively the patients that state health departments have referred to us. Reporter Mike Stobbe, AP: Hi, thank you for taking my call. You mentioned is there are two new cases from the Diamond Princess, can you tell us about them and where they are and can you tell us more about the testing, why was three needed in the first place and was there problems with one of the other two? I heard reports that might have been the case. And finally in the change of the testing criteria, are there potential downsides to that? Thank you. Dr. Messonnier: First question, those are two additional cases among the U.S. are repatriated, that can be available on our website. In terms of three to two, please remember that our laboratories developed this test kit before there were US cases. We developed it based on the posted genetic sequencing, and it was this test kit that allowed us, to identify the first cases in the United States. As more cases have been identified and more cases have been available it is clear that two of the three reactions, we actually are appropriately sensitive and specific in identifying cases. That is why after being able to share that data with FDA, they agreed and there is a new protocol, and that’s what we’re talking about when we’re talking about the change from three to two. In terms of we signed that that is what we’re talking about. In terms of test criteria, I think you’re referring to the PUI definition. What I would say about that is that the situation has evolved and it continues to evolve very quickly and therefore we need to continue to evolve our PUI definition. This is not something that we take lightly. We take ramifications from this. That is why any such decision involves not just CDC, but all of our local and state health departments and partners who have a stake in this, and we’ll see the impact of it. It was certainly not a decision we made without a lot of consultation. Our goal is and remains to do everything we can to help the American people. Haynes: We have time for two more questions, please. Operator: Okay, next we have a question from Laura Johnson at CBN News. Laura Johnson: I was wondering what is your reaction to the fact that the new cases in China have been lower if many days in a row and the death rate outside of China is lower than inside of China, and what is your opinion of the anti-viral medication remdesivir as a possible treatment and also the possibility of immune-therapy drugs as possible treatments. Thank you. Dr. Messonnier: Thank you, I think it is really good news that the case counts in China are decreasing. We’re watching that closely and we hope that is a trend that continues both for the good of the citizens in China who have been through quite an outbreak, and also in the hopes that it will help us learn what we can better do in the United States to continue to control it right here. In terms of the case fatality ratio, I think there is a whole bunch of data from China and from other countries around the world on the ratios, and there is a variety of mathematical models that are looking at that data, and hoping that it will — and working together to better understand it and use it to better analyze what we might expect elsewhere including in the United States. What I can say is that in the U.S. our cases have been doing very well. We will continue to do everything we can. They have a product that has been used in some of these cases. It is something that NIH has been going for and those questions are better answered by NIH. Haynes: Last question, please. Operator: Our last question comes from Roni Rabin from New York Times. Roni Rabin: If states are able to do these testing, they still need to have a confirmatory test by the CDC, does that mean there is a 48-hour delay for the patient getting that information? And can you comment on the whistleblower report and tell us what kind of precautions were taken and was CDC involved in the visits to Travis Air Force Base. I also want to know how often you’ll hold these briefings, Can you give us a regular schedule? Dr. Messonnier: Thank you for actually allowing me to sort of speak specifically about this issue. Which is that there are procedures that we’re working through with the states and FDA in terms of confirmatory testing. More important than the confirmatory language, is what is actionable from a public health perspective at a state and local health department. So it is possible, for example, that there might be presumptive positives that are waiting confirmation, but others which state and local health departments will be able to take action and that is what is most important and we’re working through those labels now and we’ll have more information as we figure out that piece. In terms of the whistle-blower investigation, let me say that CDC takes the health and safety of our employees very seriously. We’re aware of the HHS whistle-blower complaint, but I defer any other questions on this matter to HHS. And in terms of the telebriefings, we will continue to routinely provide information when we can. Haynes: Thank you all for joining us from today’s briefing, please check the CDC.gov/COVID19 website. If you have more questions please call the media line 404-639-3286 or e-mail media @cdc.gov. Thank you.

AUDIO https://www.cdc.gov/media/releases/2020/t0228-COVID-19-update.mp3

Recommendations for Reporting, Testing, and Specimen Collection Clinicians should immediately implement recommended infection prevention and control practices (https://www.cdc.gov/coronavirus/2019-ncov/infection-control/control-recommendations.html) if a patient is suspected of having COVID-19. They should also notify infection control personnel at their healthcare facility and their state or local health department if a patient is classified as a PUI for COVID-19. State health departments that have identified a PUI or a laboratory-confirmed case should complete a PUI and Case Report form through the processes identified on CDC’s Coronavirus Disease 2019 website (https://www.cdc.gov/coronavirus/2019-ncov/php/reporting-pui.html). State and local health departments can contact CDC’s Emergency Operations Center (EOC) at 770-488-7100for assistance with obtaining, storing, and shipping appropriate specimens to CDC for testing, including after hours or on weekends or holidays. Currently, diagnostic testing for COVID-19 is being performed at state public health laboratories and CDC.Testing for other respiratory pathogens should not delay specimen testing for COVID-19. For initial diagnostic testing for SARS-CoV-2, CDC recommends collecting and testing upper respiratory tract specimens (nasopharyngeal AND oropharyngeal swabs). CDC also recommends testing lower respiratory tract specimens, if available. For patients who develop a productive cough, sputum should be collected and tested for SARS-CoV-2. The induction of sputum is not recommended. For patients for whom it is clinically indicated (e.g., those receiving invasive mechanical ventilation), a lower respiratory tract aspirate or bronchoalveolar lavage sample should be collected and tested as a lower respiratory tract specimen. Specimens should be collected as soon as possible once a PUI is identified, regardless of the time of symptom onset. See Interim Guidelines for Collecting, Handling, and Testing Clinical Specimens from Patients Under Investigation (PUIs) for COVID-19 (https://www.cdc.gov/coronavirus/2019-nCoV/lab/guidelines-clinical-specimens.html) and Biosafety FAQs for handling and processing specimens from suspected cases and PUIs (https://www.cdc.gov/coronavirus/2019-ncov/lab/biosafety-faqs.html). For More Information More information is available at the COVID-19 website: https://www.cdc.gov/coronavirus/2019-ncov/index.html.

Criteria to Guide Evaluation and Testing of Patients Under Investigation (PUI) for COVID-19 Local or state health departments, in consultation with clinicians, should determine whether a patient is a PUI for COVID-19. The CDC clinical criteria for COVID-19 PUIs have been developed based on available information about this novel virus, as well as what is known about Severe Acute Respiratory Syndrome (SARS) (https://www.cdc.gov/sars/clinical/guidance.html) and Middle East Respiratory Syndrome (MERS) (https://www.cdc.gov/coronavirus/mers/interim-guidance.html#evaluation). These criteria are subject to change as additional information becomes available. Clinical Features Epidemiologic Risk Fever1 or signs/symptoms of lower respiratory illness (e.g., cough or shortness of breath) AND Any person, including healthcare personnel2, who has had close contact3 with a laboratory-confirmed4COVID-19 patient within 14 days of symptom onset Fever1 and signs/symptoms of a lower respiratory illness (e.g., cough or shortness of breath) requiring hospitalization AND A history of travel from affected geographic areas5,within 14 days of symptom onset Fever1 with severe acute lower respiratory illness (e.g., pneumonia, ARDS (acute respiratory distress syndrome) requiring hospitalization and without an alternative explanatory diagnosis (e.g., influenza).6 AND No identified source of exposure These criteria are intended to serve as guidance for evaluation. In consultation with public health departments, patients should be evaluated on a case-by-case basis to determine the need for testing. Testing may be considered for deceased persons who would otherwise meet the PUI criteria. 1Fever may be subjective or confirmed. 2For healthcare personnel, testing may be considered if there has been exposure to a person with suspected COVID-19 without laboratory confirmation. Because of their often extensive and close contact with vulnerable patients in healthcare settings, even mild signs and symptoms (e.g., sore throat) of COVID-19 should be evaluated among potentially exposed healthcare personnel. Additional information is available in CDC’s Interim U.S. Guidance for Risk Assessment and Public Health Management of Healthcare Personnel with Potential Exposure in a Healthcare Setting to Patients with Coronavirus Disease 2019 (COVID-19) (https://www.cdc.gov/coronavirus/2019-ncov/hcp/guidance-risk-assesment-hcp.html). 3Close contact is defined as— – or – Additional information is available in CDC’s updated Interim Healthcare Infection Prevention and Control Recommendations for Patients with Confirmed COVID-19 or Persons Under Investigation for COVID-19 in Healthcare Settings (https://www.cdc.gov/coronavirus/2019-ncov/infection-control/control-recommendations.html). Data to inform the definition of close contact are limited. Considerations when assessing close contact include the duration of exposure (e.g., longer exposure time likely increases exposure risk) and the clinical symptoms of the person with COVID-19 (e.g., coughing likely increases exposure risk, as does exposure to a severely ill patient). Special consideration should be given to healthcare personnel exposed in healthcare settings, as described in CDC’s Interim U.S. Guidance for Risk Assessment and Public Health Management of Healthcare Personnel with Potential Exposure in a Healthcare Setting to Patients with COVID-19 (https://www.cdc.gov/coronavirus/2019-ncov/hcp/guidance-risk-assesment-hcp.html). 4Documentation of laboratory-confirmation of COVID-19 may not be possible for travelers or persons caring for COVID-19 patients in other countries. 5Affected areas are defined as geographic regions where sustained community transmission has been identified. Relevant affected areas will be defined as a country with at least a CDC Level 2 Travel Health Notice. Current information is available in CDC’s COVID-19 Travel Health Notices (https://www.cdc.gov/coronavirus/2019-ncov/travelers). 6Category includes single or clusters of patients with severe acute lower respiratory illness (e.g., pneumonia, ARDS (acute respiratory distress syndrome) of unknown etiology in which COVID-19 is being considered.

Summary The Centers for Disease Control and Prevention (CDC) continues to closely monitor and respond to the COVID-19 outbreak caused by the novel coronavirus, SARS-CoV-2. This CDC Health Alert Network (HAN) Update provides updated guidance on evaluating and testing persons under investigation (PUIs) for COVID-19. It supersedes guidance provided in CDC’s HAN 427 distributed on February 1, 2020. The outbreak that began in Wuhan, Hubei Province, has now spread throughout China and to 46 other countries and territories, including the United States. As of February 27, 2020, there were 78,497 reported cases in China and 3,797 cases in locations outside China. In addition to sustained transmission in China, there is evidence of community spread in several additional countries. CDC has updated travel guidance to reflect this information (https://www.cdc.gov/coronavirus/2019-ncov/travelers/index.html). To date, there has been limited spread of COVID-19 in the United States. As of February 26, 2020, there were a total of 61 cases within the United States, 46 of these were among repatriated persons from high-risk settings. The other 15 cases were diagnosed in the United States; 12 were persons with a history of recent travel in China and 2 were persons in close household contact with a COVID-19 patient (i.e. person-to-person spread). One patient with COVID-19 who had no travel history or links to other known cases was reported on February 26, 2020, in California. The California Department of Public Health, local health departments, clinicians, and CDC are working together to investigate this case and are identifying contacts with whom this individual interacted. CDC, state and local health departments, other federal agencies, and other partners have been implementing measures to slow and contain transmission of COVID-19 in the United States. These measures include assessing, monitoring, and caring for travelers arriving from areas with substantial COVID-19 transmission and identifying cases and contacts of cases in the United States. Recognizing persons at risk for COVID-19 is a critical component of identifying cases and preventing further transmission. With expanding spread of COVID-19, additional areas of geographic risk are being identified and PUI criteria are being updated to reflect this spread. To prepare for possible additional person-to-person spread of COVID-19 in the United States, CDC continues to recommend that clinicians and state and local health departments consider COVID-19 in patients with severe respiratory illness even in the absence of travel history to affected areas or known exposure to another case.

Distributed via the CDC Health Alert Network February 28, 2020, 1505 ET (3:05 PM ET) CDCHAN-00428

About death of patient associated with cruise ship under quarantine at Yokohama Port 　Today, February 28, a cruise ship-related patient who has been quarantined at the Port of Yokohama has died. I pray for the soul of the deceased. 　When reporting, please give due consideration to the privacy of the deceased and the bereaved. Patient (6th death) 1 Outline of patient (1) Gender: Male (2) Nationality: UK

Patient (6th death)1 Outline of patient(1) Gender: Male(2) Nationality: UK https://www.mhlw.go.jp/stf/newpage_09856.html

About death of patient associated with cruise ship under quarantine at Yokohama Port 　Today, February 28, a cruise ship-related patient who has been quarantined at the Port of Yokohama has died. I pray for the soul of the deceased. When reporting, please give due consideration to the privacy of the deceased and the bereaved. Patient (5th death) 1 Outline (1) Age: 70s (2) Gender: Female (3) Place of residence: Tokyo (4) Basic illness: Hypertension, Diabetes 2 Cause of death Pneumonia 3 Progress February 3 Yokohama Quarantine started at port quarantine anchorage. February 5 Cruise ship returns to Yokohama. Conducted a PCR test as a patient. February 6 A new coronavirus was found positive. February 7 She was transported to a medical institution and was hospitalized under the Infectious Diseases Law. February 12 Diagnosis of pneumonia by imaging examination. February 19 Respiratory condition worsened, and artificial respiration was started. February 28 Death confirmed.

Patient (5th death)1 Outline(1) Age: 70s(2) Gender: Female(3) Place of residence: Tokyo(4) Basic illness: Hypertension, Diabetes https://www.mhlw.go.jp/stf/newpage_09850.html

Feb 28 CDC Telebriefing Test kit issues Lack of positives Not credible Full sequence of Solano Co (community transmission case (46F) Pre-print of Furin protease sequence Comparison with HPAI ploybasic cleavage site Four inserted aa PRRA https://recombinomics.co/thedrnimanshow/2020/02/022820.mp3

Feb 27 Community Transmission Wed night Press Release Humboldt Co issued second press release indicating contact was "indeterminate" (so first confirmed case remained as first example of community transmission in US) Solano Co case began in Vacaville Transferred to Sacramento (UC Davis) Testing difficulties Patient (46F) intubated - HCWs exposed Whistle Blower report on problems with evacuees at Travis http://mediaarchives.gsradio.net/rense/special/rense_022720_hr3.mp3

Two additional cases from Diamond Princess

Claims of low cases due to border security have ZERO credibility

Case count low? Majority of cases have been in California Because of aggressive efforts at borders, cases has been low More kits to California

Cases low because of actions by US government

Contact tracing is broad by prior cases have been travelers and positive close contacts have been spouses

New kits available with only two components

Solutions for kits If only two components were validated, third component can be eliminated