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EDMUND G. BROWN JR.
Governor

State of California—Health and Human Services Agency
California Department of Public Health


AFL 23-29
September 26, 2023


TO:
Skilled Nursing Facilities

SUBJECT:
Coronavirus Disease 2019 (COVID-19) Treatment Resources for Skilled Nursing Facilities (SNFs)
(This AFL supersedes AFL-22-20)

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​All F​acilities Letter (AFL) Summary

  • This AFL provides guidance recommending that all SNF residents with symptomatic COVID-19 be evaluated by a prescribing clinician to be considered for COVID-19 therapeutics.
  • In addition, SNFs should evaluate all residents for any oral COVID-19 therapeutics drug-drug interaction risk, and/or renal and hepatic impairment in advance of a COVID-19 diagnosis and indicate such information in charts to facilitate access to appropriate therapeutics when a COVID-19 diagnosis is made.
  • This AFL also provides information regarding available guidance and resources for evaluating, prescribing, and obtaining COVID-19 therapeutics for SNF residents.
  • This AFL recommends SNFs provide information on appropriate therapeutics to their healthcare personnel (HCP) who have symptomatic COVID-19.
  • This AFL revision includes the latest authorized COVID-19 treatments, with the recommended timing for effectiveness. 

​SNF residents continue to be at high risk for severe illness, hospitalization and death from COVID-19, while COVID-19 therapeutics can substantially reduce these risks. All SNF residents should be considered eligible to receive treatment for mild-to-moderate COVID-19 and should be evaluated by a prescribing healthcare provider for consideration of COVID-19 therapeutics. 

As of May 2023, only 40 percent of weekly COVID-19 cases in SNFs were treated with COVID-19 therapeutics, despite the fact that all SNF residents are deemed at high risk for severe COVID-19 and should be evaluated for eligibility for COVID-19 therapeutic intervention. California ranked 23 out of 50 states for the percentage of SNF COVID-19 cases treated with therapeutics. The top 5 ranked states treat between 57 percent and 74 percent of SNF COVID-19 cases. 

For treatment to be effective, it must be started within the timeframes in the table below. The products currently approved or authorized for treating mild-to-moderately ill COVID-19 patients include the following:

TreatmentType​WhenWhoInformation

Remdesivir (Veklury)

Antiviral

​IV
​Within 7 days of symptom onset
Adults and children 28 days and older (minimum weight requirement 3 kg)

Highly effective in reducing deaths/hospitalizations; multi-day treatment.

FDA-approved for patients ≥12 years

EUA in patients younger than 12

Nirmatrelvir with Ritonavir (Paxlovid) (PDF)
Antiviral
Oral pillsWithin 5 days of symptom onsetAdults and children 12 years and older

Highly effective in reducing deaths/hospitalizations; drug-drug interaction risk; not recommended for eGFR <30mL/min or Child-Pugh Class C hepatic impairment.

FDA-approved for patients ≥18 years.

EUA for patients ≥12 years (greater than 40 kg).

Molnupiravir (Lagevrio)

Antiviral

Oral pillsWithin 5 days of symptom onsetAdults ≥18 years

Moderately effective in reducing deaths/hospitalizations; may cause fetal harm for pregnant individuals. Patients of reproductive age (male or female) should use a reliable form of birth control (contraception) consistently and correctly during treatment with Lagevrio and at least 4 days after the last dose of Lagevrio.

EUA for patients ≥18 years.

 

These medications are not in short supply and should be prescribed when clinically appropriate. The decision to not prescribe COVID-19 treatment should be reserved for situations in which the risk of prescribing clearly outweighs the benefits of treatment in preventing hospitalization, death, and the potential for reduced risk of long COVID.

The oral antivirals must be administered within 5-7 days of symptom onset, depending on the specific product. To facilitate therapeutic decisions, SNFs should evaluate all residents for oral COVID-19 therapeutics drug-drug interaction risk, and/or renal and hepatic impairment in advance of a COVID-19 diagnosis and indicate such information in charts to facilitate access to appropriate therapeutics when a COVID-19 diagnosis is made.

Additional information and resources for healthcare providers and SNFs can be found in the California Department of Public Health (CDPH’s) COVID-19 Treatments Resources for Providers webpage and the SNF Surge Readiness Fact Sheet (PDF). SNF healthcare providers can also sign up for CDPH COVID-19 therapeutics updates on the COVID Tx Providers Newsletter Sign Up portal.

SNFs should communicate with their pharmacy to ensure oral antiviral therapeutics are readily available. If the partnered pharmacy or SNF has difficulty obtaining supply, please contact CDPH at CDPHTherapeutics@cdph.ca.gov for assistance in obtaining supply.

In addition, SNFs should provide information for their HCP who test positive for COVID-19 to obtain treatment with appropriate therapeutics. SNF HCP may seek care from their regular healthcare provider or visit the California for All COVID-19 Treatment webpage if they have trouble connecting with their healthcare provider for COVID-19 treatment evaluation.


Sincerely,

Original signed by Cassie Dunham

Cassie Dunham

Deputy Director

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