Nematodes

Preventive measures for COVID-19

If we look at the history of mankind, the flu virus is causing diseases for many decades. Coronavirus (COVID-19) is a new virus and we all are very much familiar with this. It started from Wuhan; China and spread to the whole world. WHO has declared it as a global pandemic disease. There is no specific treatment for COVID-19. If we want to save ourselves, our family, our nation, and the people of the whole world, we should follow safety or protective measures so that we can cope with this pandemic, until it is declared eradicated from our planet. This is the general guideline that must be followed in hospitals dealing with COVID-19 patients.

Contents

·         Guidelines

·         Objective

·         Rationale

·         Risk assessment

·         Individual responsibilities

·         Clinical management

·         Viral lab testing

·         Clinical classification of victim

·         Asymptomatic

·         Mild

·         Moderate

·         Severe

·         Critical

·         ARDS

·         Multi-organ dysfunction

·         Septic Shock

·         Criteria for admission of the patient

·         Asymptomatic and mild disease

·         Moderate, severe and critical disease

·         Management

·         Prophylaxis

·         Management of mild disease

·         Management of moderate, severe and critical disease

·         Specific therapy

·         Supportive care

·         Steroids

·         Anticoagulation

·         Remdesivir

·         Preventive measure for industries

·         Objective

·         Rationale

·         Individual precautions

·         Preventive Measure at Industrial Premises

·         References

Guidelines for working of outside patient department/Primary health care centre in wake of COVID-19 outbreak

Objective

To provide guidelines for patients seeking healthcare for various ailments and operationalizing Outpatient Departments (OPDs)/ Primary Health Care Centers (PHCC) during the COVID-19 outbreak.

Rationale

Major hospitals are required to reduce the number of unnecessary visits of patients which can be managed at OPDs and divert them to Primary Health Care Centers not only to reduce avoidable patient load at hospitals but also to protect these patients from unnecessary risk of getting COVID-19 infection. So certainly, there should be a separate approach for the COVID and general patients.

Risk Assessment

The following general guidelines for risk assessment, use of PPE and activities could also be adopted for developing local SOPs at hospital OPDs or PHCCs:

Sr. no.	Setting	Activity	Risk	Rec. PPE	Remarks
1	Screening area	Everyone entering the OPD/PHCC (patients, attendants/staff) should be screened for fever at this point.	Moderate Risk	Surgical/ medical mask Gloves/Gowns	1-The OPD/PHCC (patients, attendants/staff) should be screened for fever at this point 2-Moderate Risk Surgical/ medical mask Gloves/Gowns 3-All patients with fever to be managed at “Fever clinic”, Everyone should be wearing a face mask 4-Availability of sanitizers/hand disinfectants
2	Help desk area/ Registration counter	Provide information to patients/registration	-“-	-“-	Availability of sanitizers/hand disinfectants
3	Holding area/ waiting area	Nurses/ Paramedics interacting with patients	-“-	-“-	1- Social distancing of 6 feet needs to be maintained while seated 2-Handwashing facility with soap   3-Display of SOPs and information materials
4	Doctors Chamber	Clinical Management (Doctors & Nurses)	-“-	-“-	No aerosol-generating procedures should be allowed -Handwashing facility with soap
5	Sanitary staff	Cleaning frequently touched surfaces/ floor/cleaning linen	-“-	-“-
6	Visitors accompanying young children and elderlies	Support in navigating various services	Low risk	-“-	1-No attendants should be allowed to accompany patients in OPD settings unless necessary 2 -The visitors thus allowed should be screened for fever and they should practice social distancing

Individual responsibilities

·         Stay home when there is no urgent necessity to go out

·         Avoid physical contact with others as much as possible e.g. handshakes.

·         Do not leave home even when you are sick:

§ First call your doctor and follow her instructions.

§ Stay in contact with others.

§ Keep away from people when you or they are sick.

§ If you stay home and one or more of the following symptoms appear, immediately report to your doctor

o   Fever

o   Cough

o   Shortness of breath or trouble breathing

o   Persistent pain or pressure in the chest

o   New confusion or inability to arouse

o   Bluish lips or face

Clinical management guideline for COVID-19

Viral Lab testing for COVID 19

Testing should be performed using RT-PCR. Preferable samples are nasopharyngeal (NP) or lower respiratory samples. Other samples include oropharyngeal and nasal samples, though these may not be as sensitive and may require 2 or more samples to avoid a false negative test.  Serology (IgM/IgG tests) are NOT recommended as primary means for diagnosis. Symptoms will appear 2-14 days after exposure to the virus, however, contact history is not required to decide on testing. Individuals with the following symptoms may qualify for testing.

ü  Respiratory symptoms alone

·         Cough

·         Shortness of breath or difficulty breathing

ü  Or at least two of these symptoms

·         Fever

·         Chills

·         Repeated shaking with chills

·         Muscle pain

·         Headache

·         Sore throat

·         New loss of taste or smell

Clinical classification of  suspected COVID-19 patients

Patients can be classified into asymptomatic, mild, moderate, severe or critical based on their presentation.

Asymptomatic

SARS CoV2 infection but with no symptoms

Mild

Presence of symptoms consistent with COVID as above without any hemodynamic compromise needs for oxygen or chest x-ray findings. Oxygen saturation ≥94%

Moderate

Hypoxia (Oxygen saturation <94% but >90%) or chest X-ray with infiltrates involving <50% of the lung fields No complications and manifestations related to severe condition Severe In adults, clinical signs of pneumonia (fever/ cough) plus, any of the following:  Respiratory rate > 30 

Severe

Respiratory distress; SpO2 ≤ 90% on room air. Chest X-ray involving >50% of lung fields 

Critical 

Any of the three manifestations

1.ARDS

Onset: Within 1 week of a known clinical insult (i.e. pneumonia) or new or worsening respiratory symptoms.

Chest imaging: (X-ray or CT scan): bilateral opacities, not fully explained by volume overload, lobar or lung collapse, or nodules.

The origin of pulmonary infiltrates respiratory failure not fully understand by cardiac failure or fluid overload. Need objective assessment (e.g. echocardiography) to exclude hydrostatic cause of infiltrates/edema if no risk factor presents.

Oxygenation impairment in adults

·         Mild ARDS: PaO2/FiO2: >200 mmHg and ≤ 300 mmHg (with PEEP or CPAP ≥ 5 cmH2O).

·         Moderate ARDS: PaO2/FiO2 ≤ 200 mmHg and >100 mmHg (with PEEP≥ 5 cmH2O).

·         Severe ARDS: PaO2/FiO2 ≤ 100 mmHg (with PEEP ≥ 5 cmH2O)

2. MULTI-ORGAN DYSFUNCTION

Acute life-threatening organ dysfunction caused by a dysregulated host response to suspect or proven viral or bacterial infection.

Signs of organ dysfunction include  Altered mental status, difficult or fast breathing, low oxygen saturation, reduced urine output, fast heart rate, weak pulse, cold extremities or low blood pressure, skin mottling, laboratory evidence of coagulopathy, thrombocytopenia, acidosis, high lactate, or hyperbilirubinemia. 

3. SEPTIC SHOCK

Persistent hypotension despite volume resuscitation, requiring vasopressors to maintain MAP ≥ 65 mmHg and serum lactate level > 2 mmol.

Criteria for admission of or confirmed COVID-19 patients

Asymptomatic and mild disease

Asymptomatic and mild cases can be managed at home with home isolation.

Moderate, severe and critical disease

Patients with the above categories should be admitted to a hospital for further management.

·         Moderate disease:  Admit to a well-ventilated general ward

·         Severe disease:  Admit to high dependency unit with negative pressure room

·         Critical disease:  Admit to ICU with a negative pressure room.

In all the above wards, it is mandatory that oxygen and pulse oximetry be available.

Management

Prophylaxis

There is no role of prophylactic chloroquine or hydroxychloroquine currently. Both these drugs are being studied for the treatment of COVID. The results thus far are not robust enough that either drug can be clearly labeled as effective in the treatment of COVID. Moreover, given the side- effects associated with the use of chloroquine or hydroxychloroquine (especially chronic use), the limited stocks (for moderately sick), and the lack of data showing use will prevent the infection, prophylactic use is strongly discouraged.

Management of mild disease

            Mild cases should be treated with supportive care only. This includes acetaminophen for fever, oral hydration in case of diarrhea, and antihistamines for rhinorrhea. There is a theoretical risk with the use of NSAIDS or ACE-inhibitors in COVID-19. However, clinical data regarding this is lacking and at this point, a strong recommendation to avoid or to continue these medications cannot be made.

No specific treatment (including chloroquine hydroxychloroquine, azithromycin, ivermectin or, famotidine) is recommended for asymptomatic or mild disease. 

Management of moderate, severe, and critical disease

Patients with the moderate disease should receive supportive therapy.

Specific therapy

Currently, there is no specific therapy.

Supportive care

The mainstay of management for COVID-19 is oxygen therapy via nasal cannula or face mask. If available high flow oxygen can also be used to maintain saturation. All patients with low saturations should be placed in a prone position. For those not intubated, voluntary awake prone positioning should be encouraged for as long as the patient can manage. For patients on the ventilator, 12 to 15 hours of prone positioning should be attempted.

Steroids

All patients requiring oxygen should be started on steroids. The steroids recommended include dexamethasone or methylprednisone. The choice of steroid used is at the discretion of the clinician. However, dexamethasone is cheaper, easier to use in the outpatient setting, and has more potent glucocorticoid (anti-inflammatory) activity). On the other hand, methylprednisone may be superior in patients in shock due to its mineralocorticoid activity.  In patients with the severe and critical disease, intravenous steroids are preferred. Treatment should continue for 5 days. However, this may be prolonged in case of prolonged hypoxia. Dose: 6mg per day of dexamethasone (oral or intravenous) 0.5 to 1 mg/kg/d of methylprednisone.

Anticoagulation

As patients with COVID-19 may be hypercoagulable, anticoagulation plays an important role in therapy.

Remdesvir

Indication: Moderate and severe COVID requiring oxygen therapy regardless of if CRS is present. This can also be given in critical COVID, however, with the available data, it is unlikely to be of benefit in this patient population.

Dose:200 mg IV on day 1 followed by then 100 mg IV daily on days 2.

Preventive measures for industries and workers against COVID-19

(Ensuring Supply of Essential Goods in the times of COVID-19 Outbreak)

Objective

            To assure safe and healthful working conditions for employees in industries by authorizing enforcement of the guidelines to reduce the impact of the COVID-19 outbreak.

Rationale

Industrial workers are also exposed to hazards that put them at risk of infection with an outbreak pathogen, in this case, COVID-19. Hazards include long working hours, psychological distress, fatigue, and occupational burnout. These protocols have been designed in order to minimize the potential for contracting COVID-19 and subsequently reducing its spread at the industrial level including specific measures needed to protect occupational safety and health.

Individual Precautions  

Employees working in industries should strictly follow the preventive measures by

·         Using alcohol-based (70 percent) sanitizer or wipes at entry and exit points.

·         Discontinue Biometric attendance.

·         Covering cough or sneeze with a tissue or a shoulder or elbow.

·         Avoid touching eyes, nose, or mouth.

·         Repeated and diligent handwashing at least 20 seconds after every hour.

·         Clothes of the workers and management shall be frequently disinfected, especially following contact with any frequently-touched surfaces such as door handles, elevator buttons, machines, handrails, drinking fountains, computers, telephones, fax machines keyboards, etc.

·         Keeping up-to-date on the latest information on COVID-19 (Federal & provincial govt health websites, WHO, etc.)

·         Seeking the assistance of health care professionals if any work starts to feel unwell and avoid contact with others when unwell. Workers should not attend work while unwell.

Preventive Measure at Industrial Premises

Implementing controls to reduce environmental exposure, including:

·         Inspecting and reviewing air conditioning and ventilation systems.

·         Increasing cleaning and disinfection of high traffic areas or shared surfaces

·         Providing cleaning products and instruction for cleaning workspaces

·         Providing instruction and amenities for personal hygiene and infection control

·         Determining areas to be disinfected and cordon off using signs and physical barriers such as caution banner tape, safety cones, etc.

·         Encouraging workers to dedicate separate pairs of clothes for work within a unit or premise.  • Ban entry of unauthorized persons to industrial premises temporarily.

·         Standard SOPs of COVID-19 must be displayed in premises in the local language.

·         Ensuring availability of disposable cups, glasses, and plates for drinks and meals and they are disposable after one-time-use.

·         Isolation or quarantine area shall be maintained to lodge suspected workers who should be screened for the COVID-19 test and carry out a further process, in case of a positive result of the test.

·         Monitoring and Inspection should be done on regular basis to ensure the adaptation of protocols.

References

1.         Public Health England, Guidance on social distancing for everyone in the UK (www.gov.uk/government/publications/covid-19-guidance-on-social-distancing-and-for-vulnerable-people)

2.         https://www.who.int/docs/default-source/searo/whe/coronavirus19/the-guideline-for-homequarantinepdf?sfvrsn=1bc12565_4

3.         Guidance on Preparing Workplaces for COVID-19 OSHA

4.         https://www.clydeco.com/insight/article/whs-covid-19-health-and-safety-guidelines-for-workplace-obligationsprepare

5.         Guidelines for environmental infection Control in Health-Care Facilities. Recommendations of CDC and Health-Care Infection Control Practices Advisory Committee (HICPAC), 2003 (Updated July 2019

6.         COVID-19: General Guidance for Cleaning and Disinfecting for Non-Health Care Setting-NYC health

7.         Cleaning and disinfection of environmental surfaces in the context of COVID-19- Interim guidance-WHO

8.         Analysis and Applications of Adaptive Group Testing Methods for COVID-19; Cassidy Mentus, Martin Romeo, Christian DiPaola doi: https://doi.org/10.1101/2020.04.05.20050245

9.         Organization WH. Clinical management of severe acute respiratory infection (SARI) when COVID-19 disease is suspected: Interim guidance V 1.2. 2020 [Available from: https://www.who.int/publications-detail/clinical- management-of-severe-acute-respiratoryinfection-when-novel-coronavirus-(ncov)-infection-is-suspected.

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