USDA/APHIS Confirm HPAI H7N3 In South Carolina Turkey Flock

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One of the points I endeavored to make a few weeks ago in Because A Pandemic Doesn't Happen In A Vacuum, is that just because we are currently overwhelmed by COVID-19 and its economic impacts, the world won't stop serving up new challenges.

We are entering the peak months of our spring severe weather season, are less than two months from the start of the Atlantic Hurricane Season, earthquakes can occur at anytime, and there is nothing to say we couldn't be blindsided by yet another public health crisis in the months ahead.

While avian flu has been fairly subdued around the world for the past couple of years, and almost absent in the United States, today the USDA and APHIS are reporting the discovery of an HPAI H7N3 virus at a turkey farm in South Carolina.

This is the first reported HPAI outbreak in the United States since 2017 (see USDA Identifies Tennessee Bird Flu Virus as HPAI H7N9), and appears to be the result of an LPAI-to-HPAI mutation (see graphic at top of blog). This this can happen when a relatively harmless low path H5 or H7 virus is allowed to circulate in poultry.

North American H7 viruses are unlikely to produce the sort of human health concerns that the Asian H7N9 virus did in China, but we've seen a few mild human infections with that subtype in the past (see MMWR: Mild H7N3 Infections In Two Poultry Workers - Jalisco, Mexico).

For now, this outbreak appears to only impact one turkey farm, and the human health risk is low.  The affected poultry have been depopulated, and we will watch for any signs of spread to nearby farms, or via migratory birds, in the days ahead.

USDA Confirms Highly Pathogenic H7N3 Avian Influenza in a Commercial Flock in Chesterfield County, South Carolina

USDA Animal and Plant Health Inspection Service sent this bulletin at 04/09/2020 04:05 PM EDT

April 9, 2020, Washington, D.C. – The United States Department of Agriculture’s (USDA) Animal and Plant Health Inspection Service (APHIS) has confirmed the presence of highly pathogenic H7N3 avian influenza (HPAI) in a commercial turkey flock in Chesterfield County, South Carolina.

This is the first confirmed case of HPAI in commercial poultry in the United States since 2017. It appears this HPAI strain mutated from a low pathogenic strain that has been found in poultry in that area recently.

No human cases of this H7N3 avian influenza virus have been detected and there is no immediate public health concern. As a reminder, the proper handling and cooking of poultry and eggs to an internal temperature of 165 ˚F kills bacteria and viruses.

Samples from the affected flock, which experienced increased mortality, were tested at the Clemson Veterinary Diagnostic Center, part of the National Animal Laboratory Network, and confirmed at the APHIS National Veterinary Services Laboratories (NVSL) in Ames, Iowa. Virus isolation is ongoing. APHIS is working closely with the South Carolina State Veterinarian’s Office, part of Clemson University, on a joint incident response. State officials quarantined the affected premises, and birds on the property were depopulated to prevent the spread of the disease. Birds from the flock will not enter the food system. As part of existing avian influenza response plans, Federal and State partners are working jointly on additional surveillance and testing in the nearby area.

The United States has the strongest AI surveillance program in the world, and USDA is working with its partners to actively look for the disease in commercial poultry operations, live bird markets and in migratory wild bird populations. USDA will report this finding to the World Organisation for Animal Health (OIE) as well as international trading partners. USDA also continues to communicate with trading partners to encourage adherence to OIE standards and minimize trade impacts. OIE trade guidelines call on countries to base trade restrictions on sound science and, whenever possible, limit restrictions to those animals and animal products within a defined region that pose a risk of spreading disease of concern.

All bird owners, whether commercial producers or backyard enthusiasts, should continue to practice good biosecurity, prevent contact between their birds and wild birds, and report sick birds or unusual bird deaths to State/Federal officials, either through their state veterinarian or through USDA’s toll-free number at 1-866-536-7593. Additional information on biosecurity for can be found at

www.aphis.usda.gov/animalhealth/defendtheflock

Additional background Avian influenza (AI) is caused by an influenza type A virus which can infect poultry (such as chickens, turkeys, pheasants, quail, domestic ducks, geese and guinea fowl) and is carried by free flying waterfowl such as ducks, geese and shorebirds. AI viruses are classified by a combination of two groups of proteins: hemagglutinin or “H” proteins, of which there are 16 (H1–H16), and neuraminidase or “N” proteins, of which there are 9 (N1–N9). Many different combinations of “H” and “N” proteins are possible. Each combination is considered a different subtype, and can be further broken down into different strains. AI viruses are further classified by their pathogenicity (low or high) — the ability of a particular virus strain to produce disease in domestic poultry.

NYC: Age Adjusted Fatal Lab Confirmed COVID-19 Cases By Race/Ethnicity Group

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Over the past few days we've seen a good deal of reporting on the disparity of fatal outcomes among severe COVID-19 patients from minority populations 

While the exact causes are unknown, it has been suggested that minorities are more likely to have existing comorbidities (hypertension, diabetes, etc.) due to a pernicious lack of access to preventive health care, or that they work in higher risk environments. 

Whatever the cause or causes, the disparities are enormous. New York City has identified the race and/or ethnicity of 63% of the deaths as of April 6th (n=2,472), and has produced the following breakdown.

All data are preliminary and subject to change. Data are derived from the Bureau of Communicable Disease Surveillance System as of April 6, 2020.

*The vast majority of cases are reported by labs, and race/ethnicity information is often missing because it is not received on the test requisitions from providers. - Data about persons who identify as American Indian or Alaska Native, Native Hawaiian or Other Pacific Islander, or other races are not available. Hispanic/Latino includes people of any race.

ECDC COVID-19 Rapid Risk Assessment #8

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The ECDC has published a data rich, 39-page Rapid Risk Assessment (RRA) on COVID-19 that among other things, warns  `. . .  there is currently no indication at EU/EEA level that the peak of the epidemic has been reached'  and `. . .   it is currently too early to start lifting all community and physical distancing measures in the EU/EEA and the UK.'

The world, at least that part of the world now under lockdown, faces a dilemma not unlike what survivors hunkered down in a fallout shelter would have faced had the cold war of the 1950s-1980s turned incandescently hot. 

When it is safe to go outside again? 

A more recent, and more relatable analogy for anyone under the age of 40 is; when is it safe for residents to return to their homes near the ill-fated nuclear reactor in Fukushima, Japan?

Admittedly, your answer will depend upon your definition of `safe' and the costs and downsides of staying put.  A risk-reward calculation. 

As COVID-19 appears unlikely to go away anytime soon - at least until a safe and effective vaccine can be manufactured and widely distributed - we may face additional waves of illness. That may not happen again in the Northern Hemisphere until next fall or winter - but the concern is - if we de-escalate our community mitigation efforts too soon, we could spark an immediate rebound in cases.

Clawing our way back from our lockdowned state to a quasi-normal life may prove greatest challenge with this pandemic. Unless, of course, we find we can't.  In which case, our problems are only going to escalate.  

The ECDC's estimation is that full de-escalation - at least in the EU/EEA and UK - is still likely `some months' away.  Beyond the economic and societal hardships, that may leave precious little time for them to recover and prepare for a second wave next fall. 

A pandemic Catch-22 for the 21st century.  

Like all RRAs issued by the ECDC, you'll find a wealth of maps, charts, and detailed analysis.  So follow the link to download the entire report.

Rapid risk assessment: Coronavirus disease 2019 (COVID-19) pandemic: increased transmission in the EU/EEA and the UK – eighth update

Risk assessment
8 Apr 2020

Since 31 December 2019 and as of 7 April 2020, over 1.3 million (1 316 988) cases of COVID-19 have been reported worldwide, and more than 70 000 (74 066) deaths. Half of these cases (608 500) have been reported from the EU/EEA countries and the UK, and over 50 000 (51 059) of them have died.

Executive summary
Overall, large increases in COVID-19 cases and deaths continue to be reported from the EU/EEA countries and the UK. In addition, in recent weeks, the European all-cause mortality monitoring system showed all-cause excess mortality above the expected rate in Belgium, France, Italy, Malta, Spain, Switzerland and the United Kingdom, mainly in the age group of 65 years and above.

Recently, in a few EU/EEA countries, the number of new cases and new deaths reported daily appears to have decreased slightly. However, many EU/EEA countries are currently only testing severe or hospitalised cases, therefore these trends should be interpreted with caution. Despite early evidence from Italy and Austria that the number of cases and deaths are declining, there is currently no indication at EU/EEA level that the peak of the epidemic has been reached.

Based on data from EU/EEA countries, 32% of the diagnosed cases have required hospitalisation and 2.4% have had severe illness requiring respiratory support and/or ventilation. The crude fatality rate was 1.5% among diagnosed cases and 11% among hospitalised cases. The likelihood of hospitalisation, severe illness and death increases in persons over 65 years of age and those with defined risk factors including hypertension, diabetes, cardiovascular disease, chronic respiratory disease, compromised immune status, cancer and obesity.

Strain on health and social care systems and healthcare workers continues, with shortages reported in laboratory and testing capacity, personal protective equipment and healthcare capacity (including ICU ventilator and healthcare workforce capacity). In several EU/EEA countries with available data, between 9% and 26% of all diagnosed COVID-19 cases are in healthcare workers. There are also increasing reports of COVID-19 outbreaks in nursing homes across Europe, highlighting the vulnerability of the elderly in long-term care settings and the importance of infection control measures to protect vulnerable populations.

In the present situation, where continuous spread of the virus can be expected, the assessment is

• that the risk of severe disease associated with COVID-19 in the EU/EEA and UK is currently considered moderate for the general population and very high for populations with defined risk factors associated with elevated risk;
• that the risk of increasing community transmission of COVID-19 in the EU/EEA and the UK in the coming weeks is moderate if mitigation measures are in place, and very high if insufficient mitigation measures are in place;
• that the risk of health and social care system capacity in the EU/EEA and the UK being exceeded in the coming weeks is considered high with mitigation measures in place and very high if insufficient mitigation measures are in place.

Over the past few weeks, EU/EEA countries and the UK have implemented a range of measures to reduce further transmission of the virus, focussing in particular on physical distancing to decrease the burden on healthcare services, protect populations at risk of severe disease and reduce excess mortality. There is evidence from countries in Asia that were affected early in the pandemic, which is supported by modelling studies, and preliminary signs from Italy and Austria, that a combination of stringent measures can achieve meaningful reductions in transmission.

In the current situation, a strong focus should remain on comprehensive testing and surveillance strategies (including contact tracing), community measures (including physical distancing), strengthening of healthcare systems and informing the public and health community. The promotion of mental wellbeing among people living under physical distancing measures is necessary to ensure that populations have the resilience to maintain adherence to these measures.

Stringent physical distancing measures are highly disruptive to society, both economically and socially. There is therefore significant interest in defining a sound approach to de-escalation. However, unless the incidence of infections is reduced to a very low level in a given setting, transmission will continue until a population protection threshold is reached. Current estimates suggest that no EU/EEA country is close to achieving the necessary population protection threshold, meaning that sustained transmission of the virus is to be expected if current interventions are lifted too quickly. In the absence of a vaccine, physical distancing measures of some kind will therefore need to remain in place for at least some months, in order to ensure that demand for healthcare does not exceed availability.

Plans for de-escalation should therefore ensure that appropriate capacities and safeguards, based on public health principles underscored by scientific evidence, are in place to mitigate the risk of an overwhelming recurrence of increased transmission and the risk to vulnerable members of the population. Considerations for de-escalation should take into account the fact that the reported new infections on any given day reflect the measures that were in place around one week earlier, while the deaths reported on any given day reflect the epidemiological situation and measures in place two to three weeks earlier. This time lag complicates assessment of the impact of measures, and it may present a particular challenge when communicating to the public about the need to sustain the current restrictions and measures.

Based on the available evidence, it is currently too early to start lifting all community and physical distancing measures in the EU/EEA and the UK. Before considering the lifting of any measures, Member States should ensure enhanced population and hospital-based testing and surveillance systems are in place to inform and monitor escalation/de-escalation strategies and assess the epidemiological consequences.

Solidarity and coordination between Member States will remain essential in the de-escalation phase in order to increase the effect of measures taken and minimise the risk of infection ‘spill-over’ between countries if they de-escalate at different rates and in different ways.

What is new in this update?

• Updated data on the epidemiological situation in the EU/EEA and the UK.

• Updated data on disease and case severity from Europe.

• Current risk of severe disease associated with COVID-19 in the EU/EEA and UK for the general population and for those with defined risk factors associated with elevated risk.

• Risk of further increases in community transmission of COVID-19 in the EU/EEA and the UK in the coming weeks, with or without mitigation measures in place.

• Risk of health and social care systems capacity being exceeded in the EU/EEA and the UK in the coming weeks, with or without mitigation measures in place.

• Response measures in place in the EU/EEA and the UK.

• Considerations regarding surveillance and testing strategies, including updated contact tracing options.

• Considerations regarding de-escalation of measures.

CDC Revised Guidance For Essential Workers Exposed To COVID-19

#15,182

Up until now, the CDC's recommendation has been that if anyone is exposed (without proper PPEs) to a COVID-19 patient, they had to home quarantine for 14 days, regardless of whether they developed symptoms. 

While arguably optimal from an infection control point of view this has led to an inevitable, and unsustainable, loss of essential workers. Tens of thousands of doctors, nurses, EMTs, firefighters, police, etc. have been sidelined at a time they are needed the most. 

Partly because we know more about the disease, and partly out of necessity, last night the CDC announced revised, and relaxed, recommendations for essential workers that would allow more of them to continue to work (under strict conditions). 

Interim Guidance for Implementing Safety Practices for Critical Infrastructure Workers Who May Have Had Exposure to a Person with Suspected or Confirmed COVID-19 
To ensure continuity of operations of essential functions, CDC advises that critical infrastructure workers may be permitted to continue work following potential exposure to COVID-19, provided they remain asymptomatic and additional precautions are implemented to protect them and the community. 

A potential exposure means being a household contact or having close contact within 6 feet of an individual with confirmed or suspected COVID-19. The timeframe for having contact with an individual includes the period of time of 48 hours before the individual became symptomatic. 

Critical Infrastructure workers who have had an exposure but remain asymptomatic should adhere to the following practices prior to and during their work shift:

Pre-Screen: Employers should measure the employee’s temperature and assess symptoms prior to them starting work. Ideally, temperature checks should happen before the individual enters the facility.
Regular Monitoring: As long as the employee doesn’t have a temperature or symptoms, they should self-monitor under the supervision of their employer’s occupational health program.
Wear a Mask: The employee should wear a face mask at all times while in the workplace for 14 days after last exposure. Employers can issue facemasks or can approve employees’ supplied cloth face coverings in the event of shortages.
Social Distance: The employee should maintain 6 feet and practice social distancing as work duties permit in the workplace.
Disinfect and Clean work spaces: Clean and disinfect all areas such as offices, bathrooms, common areas, shared electronic equipment routinely.

If the employee becomes sick during the day, they should be sent home immediately. Surfaces in their workspace should be cleaned and disinfected. Information on persons who had contact with the ill employee during the time the employee had symptoms and 2 days prior to symptoms should be compiled. Others at the facility with close contact within 6 feet of the employee during this time would be considered exposed. 

Employers should implement the recommendations in the Interim Guidance for Businesses and Employers to Plan and Respond to Coronavirus Disease 2019 to help prevent and slow the spread of COVID-19in the workplace. Additional information about identifying critical infrastructure during COVID-19 can be found on the DHS CISA website  or the CDC’s specific First Responder Guidance page.

CDC EID Journal: High Contagiousness & Rapid Spread of SARS-CoV-2

R0  (pronounced R-naught) or
Basic Reproduction Number

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The yardstick by which disease transmissibility is measured is its R0 (pronounced R-naught) or Basic Reproductive Number. Essentially, the number of new cases in a susceptible population likely to arise from a single infection.

In the simplest of terms, with an R0  below 1.0, a virus (as an outbreak) begins to sputter and dies out. Above 1.0, and an outbreak can have `legs’.

Calculating the R0 is notoriously difficult, particularly since much hinges upon the existence and subtle differences between viral strains, the accuracy of surveillance and reporting, `seasonality’, and individual host responses to the virus (i.e. number of `super spreaders’).

Perhaps most importantly, the R0  can also be changed by the actions we take as a society to prevent the spread of the virus. Interventions, like social distancing, handwashing, isolating the sick, and even quarantines can reduce a sky-high R0  - at least for some diseases - to something far more manageable.  

We are seeing evidence of that in Italy, China, and a number of other countries which have imposed strong mitigation measures against COVID-19.  A result that, frankly, three months ago few would have predicted. 

Early in China's outbreak, we saw a number of attempts to quantify the R0 of the novel coronavirus (see here,  here, here, and here).  Most put that number between 2.5 and 4.0, all considerably higher than seasonal influenza. 

Yesterday the CDC's EID Journal published a new analysis, from scientists at Los Alamos, which calculates the early R0 in Wuhan, China at an even higher rate ( 5.7 (95% CI 3.8–8.9)) than previously estimated.

Despite these lofty pre-mitigation estimates, the authors point out that the `. . .  spread of the virus can be contained with early and appropriate measures'.

I've only reproduced the abstract and the discussion below. Follow the link to read the study in its entirety.

Volume 26, Number 7—July 2020
Research

High Contagiousness and Rapid Spread of Severe Acute Respiratory Syndrome Coronavirus 2

Steven Sanche1, Yen Ting Lin1, Chonggang Xu, Ethan Romero-Severson, Nick Hengartner, and Ruian Ke

Author affiliations: Los Alamos National Laboratory, Los Alamos, New Mexico, USA

Abstract

Severe acute respiratory syndrome coronavirus 2 is the causative agent of the 2019 novel coronavirus disease pandemic. Initial estimates of the early dynamics of the outbreak in Wuhan, China, suggested a doubling time of the number of infected persons of 6–7 days and a basic reproductive number (R0) of 2.2–2.7. 

We collected extensive individual case reports across China and estimated key epidemiologic parameters, including the incubation period. We then designed 2 mathematical modeling approaches to infer the outbreak dynamics in Wuhan by using high-resolution domestic travel and infection data. 

Results show that the doubling time early in the epidemic in Wuhan was 2.3–3.3 days. Assuming a serial interval of 6–9 days, we calculated a median R0  value of 5.7 (95% CI 3.8–8.9). We further show that active surveillance, contact tracing, quarantine, and early strong social distancing efforts are needed to stop transmission of the virus.

(SNIP)

Discussion

In this study, we estimated several basic epidemiologic parameters, including the incubation period (4.2 days), a time dependent duration from symptom onset to hospitalization (changing from 5.5 days in early January to 1.5 days in late January outside Hubei Province), and the time from symptom onset to death (16.1 days).

By using 2 distinct approaches, we estimated the growth rate of the early outbreak in Wuhan to be 0.21–0.30 per day (a doubling time of 2.3–3.3 days), suggesting a much faster rate of spread than initially measured. This finding would have important implications for forecasting epidemic trajectories and the effect on healthcare systems as well as for evaluating the effectiveness of intervention strategies.

We found R0  is likely to be 5.7 given our current state of knowledge, with a broad 95% CI (3.8–8.9). Among many factors, the lack of awareness of this new pathogen and the Lunar New Year travel and gathering in early and mid-January 2020 might or might not play a role in the high R0. A recent study based on structural analysis of the virus particles suggests SARS-CoV-2 has a much higher affinity to the receptor needed for cell entry than the 2003 SARS virus (21), providing a molecular basis for the high infectiousness of SARS-CoV-2.

How contagious SARS-CoV-2 is in other countries remains to be seen. Given the rapid rate of spread as seen in current outbreaks in Europe, we need to be aware of the difficulty of controlling SARS-CoV-2 once it establishes sustained human-to-human transmission in a new population (20). 

Our results suggest that a combination of control measures, including early and active surveillance, quarantine, and especially strong social distancing efforts, are needed to slow down or stop the spread of the virus.

If these measures are not implemented early and strongly, the virus has the potential to spread rapidly and infect a large fraction of the population, overwhelming healthcare systems. Fortunately, the decline in newly confirmed cases in China and South Korea in March 2020 and the stably low incidences in Taiwan, Hong Kong, and Singapore strongly suggest that the spread of the virus can be contained with early and appropriate measures. 

Dr. Sanche is a postdoctoral research associate at Los Alamos National Laboratory, Los Alamos, New Mexico, USA. His primary research interest lies in complex disease dynamics inferred from data science and mathematical modeling. Dr. Lin is also a postdoctoral research associate at Los Alamos National Laboratory. His primary research interest lies in applied stochastic processes, biological physics, statistical inference, and computational system biology.

CDC Advice On Running Essential Errands

Credit CDC


#15,180

This morning marks the 100th day since I awoke at 2am to find a message from Sharon Sanders on FluTrackers alerting me to curious report out of Wuhan China regarding 27 cases of unidentified pneumonia. 

Since then, the world has changed in ways that few could have imagined, and we find ourselves trying to find new, and safer, ways to do the kind of mundane tasks that 3 months ago we would never have given a second thought. 

I've left my home just 3 times in the past 3 weeks (excerpt for brief solo walks) - always for less than an hour - and only for essentials (2 grocery runs, 1 Rx pickup). All of my social contacts for the past month have been via Skype, facebook, or phone, and I've used Amazon delivery more in the past 30 days than I have in the past 6 months.

Since I'm retired and live alone,  I've kept busy scouring the news, writing blogs, reading the latest scientific studies, and hand crafting a half-dozen cloth face coverings, while at the same time indulging in some `non-pandemic' activities to decompress and preserve some semblance of mental health; reading fiction, watching old Marx Brothers movies, and playing (quite badly, I'm afraid) my ukulele. 

Compared to most people, I've got it pretty easy.  I don't have to go to work, or have kids at home, I've never been one to `go out' unless it was for a special occasion, I've several close friends I talk to regularly, and I've never had a problem entertaining myself. 

I was a semi-recluse before it became fashionable. 

For others, navigating this brave new world is much more difficult,  particularly for essential workers, who can't stay home.  But there are plenty of others who must venture out periodically in order to shop, fuel up their cars, or visit the doctor.

Yesterday the CDC published some advice on how to do these once-routine tasks more safely during a pandemic.  I suspect that even once this first pandemic wave subsides, we'll need to continue to follow many of these practices for months to come.

Running Essential Errands
Grocery Shopping, Take-Out, Banking, Getting Gas, and Doctor Visits.
As communities across the United States take steps to slow the spread of COVID-19 by limiting close contact, people are facing new challenges and questions about how to meet basic household needs, such as buying groceries and medicine, and completing banking activities. The following information provides advice about how to meet these household needs in a safe and healthy manner.

Find additional information for people who are at higher risk for severe illness from COVID-19.

Shopping for food and other household essentials

• Avoid shopping if you have a fever, cough, or shortness of breath.

• If possible, order food and other items online for home delivery or curbside pickup.

• Only visit the grocery store, or other stores selling household essentials, in person when you absolutely need to. This will limit your potential exposure to others and the virus that causes COVID-19.

• When you do have to visit in person, go during hours when fewer people will be there (for example, early morning or late night).

• Here are ways to protect yourself while shopping:

• Stay at least 6 feet away from others while shopping and in lines.

• Cover your mouth and nose with a cloth face covering when you have to go out in public.

• If you are at higher risk for severe illness, find out if the store has special hours for people at higher risk. If they do, try to shop during those hours. People at higher risk for severe illness include adults 65 or older and people of any age who have serious underlying medical conditions.

• Disinfect the shopping cart, use disinfecting wipes if available.

• Cover coughs and sneezes.

• Do not touch your eyes, nose, or mouth.

• If possible, use touchless payment (pay without touching money, a card, or a keypad). If you must handle money, a card, or use a keypad, use hand sanitizer right after paying.

• After leaving the store, use hand sanitizer. When you get home, wash your hands with soap and water for at least 20 seconds.

• At home, follow food safety guidelines: clean, separate, cook, chill. There is no evidence that food or food packaging has been linked to getting sick from COVID-19.

Accepting deliveries and takeout orders

• If possible, pay online or on the phone when you order.

• Accept deliveries without in-person contact whenever possible. Ask for deliveries to be left in a safe spot outside your house (such as your front porch or lobby), with no person-to-person interaction. Otherwise, stay at least 6 feet away from the delivery person.

• After receiving your delivery or bringing home your takeout food, wash your hands with soap and water for 20 seconds. If soap and water are not available, use a hand sanitizer with at least 60% alcohol.

• After collecting mail from a post office or home mailbox, wash your hands with soap and water for at least 20 seconds or use a hand sanitizer with at least 60% alcohol.

Banking

• Bank online whenever possible.

• If you must visit the bank, use the drive-through ATM if one is available. Clean the ATM keyboard with a disinfecting wipe before you use it.

• When you are done, use a hand sanitizer with at least 60% alcohol. Wash your hands with soap and water for at least 20 seconds when you get home.

Getting gasoline

• If available, use gloves or disinfecting wipes on handles and buttons before you touch them.

• After fueling, use a hand sanitizer with at least 60% alcohol. Wash your hands for at least 20 seconds when you get home or somewhere with soap and water.

Going to the doctor or getting medicine

• Visit the doctor when you need to, but only when you need to. Use telemedicine, if available, or contact your doctor or nurse by phone or e-mail.

• If you must visit the doctor, follow recommendations to protect yourself:

• Cover your mouth and nose with a cloth face covering when you have to go out in public.

• Do not touch your eyes, nose, or mouth.

• If available, use disinfecting wipes on frequently touched surfaces such as handles, knobs, touchpads.

• Stay at least 6 feet away from others while inside and in lines.

• When paying, use touchless payment methods if possible. If you cannot use touchless payment, sanitize your hands after paying with card, cash, or check. Wash your hands with soap and water for at least 20 seconds when you get home.

• If you think you have COVID-19, let the office know and follow guidance.

• Talk to your doctor about rescheduling procedures that are not urgently needed.

• If possible, plan to order and pick up all your prescriptions at the same time.

• If possible, call prescription orders in ahead of time. Use drive-thru windows, curbside services (wait in your car until the prescription is ready), mail-order, or other delivery services. Do the same for pet medicine.

• Check with your doctor and pharmacist to see if you can get a larger supply of your medicines so you do not have to visit the pharmacy as often.

If you or a member of your household has signs of COVID-19, call your doctor first, instead of going to the office or the emergency department. Call 911 if you believe it is an emergency. See also: What to do if you are sick.