COVID 19

TABLE OF CONTENTS
CHAPTER PAGE
TOPICS
NO. NO.
1. COVID 19 – INTRODUCTION & EPIDEMOLOGY……………………………..1

2. EVALUATION AND DIAGNOSIS…………………………….………..……………13

3. MANAGEMENT ACCORDING TO TRIAGE……………………………………..24

4. TREATMENT OF COVID 19 (CLINICAL STATUS)….…………………………30

5. NSAIDS, GLUCOCORTICOIDS AND CHLOROQUINE…………….…….….40

6. SPECIAL CARE FOR PREGNANT WOMEN……………………………………..44

7. PREVENTION OF GENERAL PUBLIC………………..……………….…………..51

8. PREVENTION IN HEALTHCARE PERSONNEL…………………………………59

9. PERSONAL PROTECTIVE EQUIPMENT……………………………………….…66

10. SHORTAGE OF PERSONAL PROTECTIVE EQUIPMENT……….….………82

11. WASTE DISPOSAL……………………………………………………………………….90

12. COVID – 19 EXPOSURE IN HEALTHCARE WORKERS……………………..94

13. MENTAL HEALTH DURING COVID – 19………………………………………102

14. COVID – 19 GOVERNMENT INITIATIVES…………………………………….110

 CHAPTER – 1

COVID 19 – INTRODUCTION & EPIDEMIOLOGY

LEARNING OBJECTIVES
 To know about virus causing COVID 19
 To know about pathology and pathogenesis of coronaviruses.
 To study the clinical manifestation and complications associated with COVID 19

Most of you by now have heard Mr. Narendra Modi, the honorable prime minister of India
requesting people to practice social distancing and declaring a lockdown in the country. Not only
India but most countries in the world are taking big steps to improve health, hygiene and
strengthening their health care systems.

Have you wondered what is the reason for this?

The reason is a virus that is highly contagious and is spreading very fast across the globe.
The name of the virus is SARS-CoV-2 and the disease it causes is called COVID 19.
At this time, there are no specific vaccines or treatments for COVID 19. Which makes its prevention
very important and the only way to fight the disease and also its spread. In this lesson, we're going
to take a look at SARS-CoV-2, belonging to the Coronaviridae family.

INTRODUCTION
According to the World Health Organization (WHO), viral diseases continue to come out and represent
a serious issue to public health. In the last twenty years, several viral epidemics such as the severe
acute respiratory syndrome - coronavirus (SARS-CoV) in 2002, Swine flu - H1N1 influenza in 2009, and
Middle East respiratory syndrome (MERS) - coronavirus (MERS-CoV) in 2012 have been recorded.
A case of pneumonia of unknown cause detected in Wuhan, China, was first reported to the WHO
Country Office in China on 31st December 2019. As they were unable to identify the causative agent,
these first cases were classified as "pneumonia of unknown etiology". The Chinese Center for Disease
Control and Prevention (CDC) and local CDCs organized an intensive outbreak investigation program.
A novel coronavirus was identified as the causative organism in a group of pneumonia cases in Wuhan.
It rapidly spread, resulting in an epidemic throughout China, followed by an increasing number of
cases in other countries throughout the world. In February 2020, the World Health Organization(WHO)
designated the disease COVID-19, which stands for coronavirus disease 2019.The etiology of this
illness is now assigned to a novel virus belonging to the coronavirus family (coronaviridae) designated
“severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)”. This name was chosen because the
virus is genetically related to the coronavirus responsible for the SARS outbreak of 2003. While
related, the two viruses are significantly different and hence, considered to be two distinct viruses
having distinct names.
As the disease is affecting and spreading around the world, the WHO has formally declared the COVID-
19 outbreak a pandemic on 11th March 2020.

EPIDEMIOLOGY

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A. Geographic distribution
Globally, more than 10 lakh confirmed cases of COVID-19 have been reported as of May.
 The outbreak began in Wuhan, China but has since spread around the world.
 Cases have been reported from all continents and almost all countries except Antarctica.
 India's first case was reported on January 30 in Kerala.

B. Mode of transmission
Understanding of the transmission risk is incomplete. Epidemiologic investigation in Wuhan at the
beginning of the outbreak identified an initial association with a seafood market that sold live
animals, where most patients had worked or visited and which was subsequently closed for
disinfection. However, as the outbreak progressed, person-to-person spread became the main
mode of transmission.

1. Person-to-person spread:
 The virus is thought to spread mainly from person-to-person, between people who are in
close contact with one another (within about 6 feet).
 It is thought to occur mainly via respiratory droplets, resembling the spread of influenza.
 With droplet transmission, virus released in the respiratory secretions when a person with
infection coughs, sneezes, or talks can infect another person if it makes direct contact with
the mucous membranes (mouth, nose, ears, etc.)
 Respiratory droplets typically do not travel more than six feet (about two meters) and do
not linger in the air.
 These droplets can land in the mouths or noses of people who are nearby or possibly be
inhaled into the lungs.
 COVID-19 may be spread by people who are not showing symptoms.

2. Spread from contact with contaminated surfaces or objects (Indirect transmission)

 It may be possible that a person can get COVID-19 by touching a surface or object (fomite)
in the immediate environment around the infected person and then touching their mouth,
nose, or possibly their eyes.
 This happens because the infected person sheds can transfer the virus to the objects
around him/her via droplets and possibly other body secretions.

C. Stages of transmission
With the coronavirus continuing to become pandemic across the globe,various stages of covid
transmission have been reported.

STAGE 1: STAGE OF IMPORTED CASES

 When cases are only imported from affected (virus -hit) countries and therefore only those
who have travelled abroad test positive. At this stage there is no spread of the disease locally.

STAGE 2: STAGE OF LOCAL TRANSMISSION

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  When there is local transmission from infected persons. This will usually be relatives or
acquaintances of those who travelled abroad who test positive after close contact with the
infected person.
 At this stage, fewer people are affected, the source of the virus is known and is therefore
easier to perform contact tracing and contain the spread via self-quarantining. Countries like
India are currently in Stage 2.

STAGE 3: STAGE OF COMMUNITY TRANSMISSION

 In this stage those who have not been exposed to an infected person or anyone who has not
a travel history to affected countries, still test positive. In other words, people are unable to
identify where they might have picked up the virus from. Countries like Singapore, Italy and
Spain are currently in Stage 3.

STAGE 4: STAGE OF EPIDEMIC

 This is the worst stage of the infection where it takes on the form of an epidemic. Massive
numbers are infected and it is very difficult to control and contain the spread. This is what
China dealt with.

Interesting point
 The virus that causes COVID-19 is spreading very easily and sustainably between people.
 Information from the ongoing COVID-19 pandemic suggests that this virus is spreading more
efficiently than influenza, but not as efficiently as measles, which is highly contagious.

Good to Know
Some reports indicate that SARS-CoV-2 can be detected in the urine and stool of laboratory-
confirmed patients, implying a risk of fecal-oral transmission. However, it is not yet certain that the
consumption of virus-contaminated foods will cause infection and transmission. There is still no
evidence that SARS-CoV-2 can be transmitted through aerosols or from mother to baby during
pregnancy or childbirth.

VIROLOGY
 The viruses in this family (coronaviridae) have a single-stranded, positive-sense RNA as their
genome.
 They are of medium size and their capsids take on a helical shape.
 These viruses have an envelope with a bunch of glycoproteins that stick out like spikes.
 They appear like a crown when seen under an electron microscope. This is how they get their
name ('corona' is a Latin word which means 'crown').
 In humans, they can cause a wide variety of respiratory infections ranging from the common cold
to more severe diseases such as Middle East Respiratory Syndrome (MERS) and Severe Acute
Respiratory Syndrome (SARS).
 The most recently discovered SARS-CoV-2 also targets the respiratory system causing COVID-19.

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 The family Coronaviridae is organized in 2 sub-families which are further subdivided into 5 genera
 Coronaviridae
 Orthocoronavirinae (also called coronaviruses)
1. Alphacoronavirus
2. Betacoronavirus
3. Deltacoronavirus
4. Gammacoronavirus
 Letovirinae
1. Alphaletovirus
 The human coronaviruses (HCoVs) are in two of these genera: alpha coronaviruses (cause the
common cold) and beta coronaviruses (cause SARS, MERS, COVID-19)
 SARS-CoV-2 has a round or elliptic and often pleomorphic form, and a diameter of approximately
60–140 nm.
 The SARS-CoV-2 virion has a genome size of 29.9 kb. It possesses a nucleocapsid composed of
genomic RNA and phosphorylated nucleocapsid (N) protein.
 The nucleocapsid is buried inside phospholipid bilayers and covered by two different types of spike
proteins:
 The spike glycoprotein trimmer (S) that exists in all CoVs,
 Hemagglutinin-esterase (HE) only shared among some CoVs.
 The membrane (M) protein and the envelope (E) protein are located among the S proteins in the
viral envelope
 Like other CoVs, it is sensitive to ultraviolet rays and heat.
 Furthermore, these viruses can be effectively inactivated by lipid solvents including ether (75%),
ethanol, chlorine-containing disinfectant, peroxyacetic acid and chloroform except for
chlorhexidine.

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PATHOGENESIS

 SARS-CoV-2 is thought to be transmitted predominantly via respiratory droplets and contact.

 Feco-oral transmission is also a possibility.
 The inhaled virus SARS COV2 binds with the epithelial cell in the nasal cavity and start replicating.
 The life cycle of the virus with the host consists of the following 5 steps: attachment, penetration,
biosynthesis, maturation and release. Once viruses bind to host receptors (attachment), they
enter host cells through endocytosis or membrane fusion (penetration). Once viral contents are
released inside the host cells, viral RNA enters the nucleus for replication. Viral mRNA is used to
make viral proteins (biosynthesis). Then, new viral particles are made (maturation) and released.

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 Human angiotensin-converting enzyme 2 (ACE2) is a functional receptor hijacked by SARS-CoV-2
for cell entry.
 Stage 1: Asymptomatic State
 Primary viral replication is presumed to occur in the mucosal epithelium of the upper
respiratory tract (nasal cavity).
 There is local propagation of the virus but a limited innate immune response.
 At this stage the virus can be detected by nasal swabs.
 Although the viral burden may be low,patients may be asymptomatic but these individuals
are infectious.
 Stage 2: Upper respiratory and conducting pathway response
 The virus propagates and migrates down the respiratory tract along the conducting airways,
and a more robust innate immune response is triggered.
 Nasal swabs or sputum should yield the virus (SARS-CoV-2) as well as early markers of the
innate immune response.
 At this time, the disease COVID-19 is clinically manifest.
 For about 80% of the infected patients, the disease will be mild and mostly restricted to the
upper and conducting airways.
Note: Most infections are controlled at this point and the patient remains asymptomatic or mildly
symptomatic.
 Stage 3: Hypoxia,ground glass infiltrates and progression to ARDS
 Unfortunately, about 20% of the infected patients will progress to stage 3 disease and will
develop pulmonary infiltrates and some of these will develop very severe disease.
 The virus now reaches the gas exchange units of the lung and infects particular alveolar cells
 SARS-CoV propagates within alveolar cells, large number of viral particles are released, and
the cells undergo apoptosis and die.
 The pathological result of SARS and COVID-19 is diffuse alveolar damage with fibrin rich
hyaline membranes and a few multinucleated giant cells. The abnormal wound healing may
lead to more severe scarring and fibrosis than other forms of ARDS
Note:
 ACE2 is broadly expressed in nasal mucosa, bronchus, lung, heart, esophagus, kidney,
stomach, bladder, and ileum, and these organs are all vulnerable to SARS-CoV-2.
 Some patients have also exhibited non-respiratory symptoms such as acute liver and heart
injury, kidney failure, diarrhea, implying multiple organ involvement.

Good to know
A. VIRUS ENTRY AND SPREAD
B. CYTOKINE STORM
 Clinical findings showed exuberant inflammatory responses during SARS-CoV-2 infection,
further resulting in uncontrolled pulmonary inflammation.
 The initial onset of rapid viral replication may cause massive epithelial and endothelial cell
death and vascular leakage, triggering the production of exuberant pro-inflammatory
cytokines and chemokines
C. ANTIBODY DEPENDANT ENHANCEMENT

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  In general, virus-specific antibodies are considered antiviral and play an important role in the
control of virus infections in a number of ways. However, in some instances, the presence of
specific antibodies can be beneficial to the virus. This activity is known as antibody-
dependent enhancement (ADE) of virus infection. The ADE of virus infection is a
phenomenon in which virus-specific antibodies enhance the entry of virus, and in some cases
the replication of virus
 In COVID 19, ADE can promote viral cellular uptake of infectious virus–antibody
complexes following their interaction with Fc receptors (FcR), FcR, or other receptors,
resulting in enhanced infection of target cells.
 The interaction of FcR with the virus-anti-S protein-neutralizing antibodies (anti-S-IgG)
complex may facilitate both inflammatory responses and persistent viral replication in
the lungs of patients

D. IMMUNE DYSFUNCTION
 Peripheral CD4 and CD8 T cells showed reduction and hyperactivation in a severe patient.
 High concentrations of proinflammatory CD4 T cells and cytotoxic granules CD8 T cells were
also determined, suggesting antiviral immune responses and overactivation of T cells.
 Additionally, several studies have reported that lymphopenia is a common feature of COVID-
19 suggestive of a critical factor accounting for severity and mortality.
 The postulated pathogenesis of SARS-CoV-2 infection is graphed in Figure

Figure: Postulated pathogenesis of SARS-CoV-2 infection. Antibody-dependent enhancement (ADE);

ACE2: angiotensin-converting enzyme 2; RAS: renin-angiotensin system; ARDS: acute respiratory
distress syndrome.

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RISK FACTORS
The virus that causes COVID-19 infects people of all ages. Two groups of people are at a higher risk of
getting severe COVID-19 disease.
 People over 60 years of age
 People with underlying medical conditions (such as cardiovascular disease, diabetes,
hypertension, chronic lung disease, chronic kidney disease, cancer, etc.).

IMPACT OF AGE
 Individuals of any age can acquire severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)
infection, although adults of middle age and older are most commonly affected, and older adults
are more likely to have severe disease.
 Symptomatic infection in children appears to be uncommon; when it occurs, it is usually mild,
although severe cases have been reported
 The risk of severe disease gradually increases with age starting from around 40 years. It’s
important that adults in this age range protect themselves and in turn protect others that may be
more vulnerable.

CLINICAL MANIFESTATION
Incubation period
 The period between exposure to an infection and the appearance of the first symptoms is termed
as incubation period
 Most estimates of the incubation period for COVID-19 range from 1-14 days, most commonly
around five days.
 During this period, the patient may be asymptomatic but a potent carrier of infection.

Period of infectivity
Period of communicability is the time during which an infectious agent may be transferred directly or
indirectly from an infected person to another person.
 The interval during which an individual with COVID-19 is infectious is uncertain.
 Data from clinical and virologic studies that have collected repeated biological samples from
confirmed patients provide evidence that shedding of the COVID-19 virus is highest in the upper
respiratory tract (nose and throat) early in the course of the disease. That is, within the first 3 days
from onset of symptoms.
 The duration of viral shedding is also variable; there appears to be a wide range, which may
depend on the severity of illness.
 The median duration of viral RNA shedding from oropharyngeal specimens was 20 days (range of
8 to 37 days), with mild cases being infective for shorter durations and severe cases being infective
for longer durations.
 Transmission of SARS-CoV-2 from asymptomatic individuals (or individuals within the incubation
period) has also been seen.

Initial presentation
It is characterized primarily by fever, cough, dyspnea, and bilateral infiltrates on chest imaging.
 There are no specific clinical features that can yet reliably distinguish COVID-19 from other viral
respiratory infections i.e. only laboratory testing can tell us whether a patient is suffering from
COVID 19 or not.

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 Common Symptoms: Fever, cough, myalgia or fatigue, pneumonia, and complicated dyspnea
 Less common symptoms: headache, diarrhea, hemoptysis, runny nose, and phlegm-producing
cough

SPECTRUM OF ILLNESS
The clinical spectrum of COVID-19 varies from asymptomatic or few symptoms to clinical conditions
characterized by respiratory failure that necessitates mechanical ventilation and support in an
intensive care unit (ICU), to multiorgan and systemic manifestations in terms of sepsis, septic shock,
and multiple organ dysfunction syndromes (MODS).
Asymptomatic infections (i.e. an individual to be infected with SARS-CoV-2 without having any
symptoms but still a carrier for a disease or infection) have been described but their frequency is
unknown.
According to WHO, the clinical manifestation in COVID 19 are categorized as:
A. MILD DISEASE (UNCOMPLICATED ILLNESS)
 Approximately 81% of all diagnosed cases have mild illness
 Patients have nonspecific symptoms such as fever, fatigue, cough (with or without sputum
production), anorexia, malaise, muscle pain, sore throat, dyspnea, nasal congestion, or
headache.
 Rarely, patients may also present with diarrhea, nausea, and vomiting
 Older and/or immunosuppressed patients may present with atypical symptoms.
 Symptoms due to physiologic adaptations of pregnancy or adverse pregnancy events (e.g.,
dyspnea, fever, gastrointestinal symptoms, fatigue) may overlap with COVID-19 symptoms.

B. MODERATE DISEASE (VIRAL PNEUMONIA)

 Approximately 14% of all diagnosed cases have mild illness
 Adults: pneumonia with no signs of severe pneumonia (see below) and no need for
supplemental oxygen.
 Children: pneumonia with cough or difficulty breathing plus fast breathing and no signs of
severe pneumonia

Good to know
In moderate disease breath rate will be <2 months of age: ≥60 breaths/minute; 2-11 months of
age: ≥50 breaths/minute; 1-5 years of age: ≥40 breaths/minute)

C. SEVERE DISEASE (SEVERE PNEUMONIA AND OTHER COMPLICATIONS)

Approximately 5% of all diagnosed cases have severe illness

I. In adults and adolescents

 Fever or suspected respiratory infection plus one of the following:
 Respiratory rate >30 breaths/minute (Tachypnea)
 Severe dyspnea
 Severe respiratory distress
 SpO₂ ≤93% on room air (Hypoxia)
Note: Fever must be interpreted carefully as in severe forms of the disease, it can be moderate
or even absent.

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 II. Severe pneumonia in children
 Cough or difficulty breathing plus at least one of the following:
 Central cyanosis or SpO₂ <90%
 Severe respiratory distress (e.g., grunting, very severe chest indrawing)
 Signs of pneumonia with a general danger sign (i.e. inability to breastfeed or drink,
lethargy or unconsciousness, or convulsions)
 Other signs of pneumonia may be present in children including chest indrawing or fast
breathing (i.e. <2 months of age: ≥60 breaths/minute; 2-11 months of age: ≥50
breaths/minute; 1-5 years of age: ≥40 breaths/minute).

COMPLICATIONS
As above, a symptomatic infection can range from mild to critical
Some patients with initially mild symptoms may progress over a week. Various complications seen
include:
1. ACUTE RESPIRATORY DISTRESS SYNDROME (ARDS)
 It is a major complication in patients with severe disease and can manifest shortly after the
onset of dyspnea. Age greater than 65 years, diabetes mellitus, and hypertension are the risk
factors associated with ARDS.
 It is a life-threatening lung condition that prevents enough oxygen from getting into the blood
circulation.
 It accounts for the mortality of most respiratory disorders and acute lung injury.
 Different forms of ARDS are distinguished based on the degree of hypoxia. The reference
parameter is the PaO2 (Partial pressure of oxygen in lungs or oxygen pressure in arterial blood)
/FiO2 (the fraction of inspired oxygen or percentage of inhaled oxygen):
 Mild ARDS: PaO2/FiO2 ≤ 200- 300 mmHg
 Moderate ARDS: PaO2/FiO2 ≤ 100- 200 mmHg
 Severe ARDS: PaO2/FiO2 ≤ 100 mmHg
When PaO2 is not available, a ratio SpO2/FiO2 ≤ 315 is suggestive of ARDS.

2. OTHER COMPLICATION INCLUDES

A. Sepsis

 Sepsis is a potentially life-threatening condition caused by the body's inflammatory

response to an infection. The body normally releases chemicals into the bloodstream to
fight an infection. Sepsis occurs when the body's response to these chemicals is out of
balance, triggering changes that can damage multiple organ systems.
 It is characterized by a wide range of signs and symptoms of multiorgan involvement.
These signs and symptoms include
 Respiratory manifestations such as severe dyspnea, hypoxemia, and tachycardia
 Renal impairment with reduced urine output
 Altered mental status
 Functional alterations of organs expressed as laboratory data of hyperbilirubinemia,
acidosis, high lactate, coagulopathy, and thrombocytopenia.

B. In severe cases, sepsis can lead to septic shock

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  Septic shock is a severe and potentially fatal condition that occurs when sepsis leads to
life-threatening low blood pressure. As a result, internal organs typically receive too little
blood, causing them to malfunction.
 It is associated with increased mortality
Note: According to the WHO, recovery time appears to be around two weeks for mild infections and
three to six weeks for severe disease.

KEY LEARNING POINTS

 In February 2020, the World Health Organization(WHO) designated the disease COVID-19,
which stands for coronavirus disease 2019
 The etiology of this illness is now assigned to a novel virus belonging to the coronavirus family
(coronaviridae) designated “severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)”.
 The outbreak began in Wuhan, China but has since spread around the world.
 Geographic distribution: Globally, more than 10 lakh confirmed cases of COVID-19 have been
reported as of may. India's first case was reported on January 30 in Kerala.
 Mode of transmission:
 Person-to-person spread
 Indirect transmission

 STAGES OF TRANSMISSION
 Stage 1: Stage of imported cases
 Stage 2: Stage of Local transmission
 Stage 3:Stage of Community transmission
 Stage 4: Stage of epidemic
 VIROLOGY
 They appear like a crown when seen under an electron microscope. This is how they get
their name ('corona' is a Latin word which means 'crown').
 The most recently discovered SARS-CoV-2 targets the respiratory system causing COVID-19.

 PATHOGENESIS:
 Stage 1: Asymptomatic State
 Stage 2: Upper respiratory and conducting pathway response
 Stage 3: Hypoxia, ground glass infiltrates and progression to ARDS

 RISK FACTORS: Two groups of people are at a higher risk of getting severe COVID-19 disease.
 People over 60 years of age
 People with underlying medical conditions

 IMPACT OF AGE
 The risk of severe disease gradually increases with age starting from around 40 years.

 CLINICAL MANIFESTATION
 INCUBATION PERIOD
 The incubation period for COVID-19 range from 1-14 days
 PERIOD OF INFECTIVITY

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  Period of communicability is the time during which an infectious agent may be
transferred directly or indirectly from an infected person to another person.
 INITIAL PRESENTATION
 Common Symptoms: Fever, cough, myalgia or fatigue, pneumonia, and complicated
dyspnea
 SPECTRUM OF ILLNESS
 Mild disease (uncomplicated illness)
 Moderate disease (Viral pneumonia)
 Severe disease (Severe pneumonia and other complications)

 COMPLICATIONS
 Acute respiratory distress syndrome (ARDS)
 Sepsis
 In severe cases, sepsis can lead to septic shock

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 CHAPTER – 2

EVALUATION AND DIAGNOSIS

LEARNING OBJECTIVES
 To know about the criteria to guide evaluation and laboratory testing.
 To know about priorities for testing COVID 19.
 To know about laboratory tests of COVID 19.
 To know about the laboratory, serological and image findings of COVID 19.

CRITERIA TO GUIDE EVALUATION AND LABORATORY TESTING FOR COVID – 19

As of writing this, ICMR had released version number 4 of “Strategy for COVID19 testing in India
(Version 4, dated 09/04/2020)”. According to ICMR, testing for COVID 19 should be done for:
1. All symptomatic individuals who have undertaken international travel in the last 14 days
2. All symptomatic contacts of laboratory-confirmed cases
3. All symptomatic health care workers
4. All patients with Severe Acute Respiratory Illness (fever AND cough and/or shortness of breath)
5. Asymptomatic direct and high-risk contacts of a confirmed case should be tested once between
day 5 and day 14 of coming in his/her contact
In hotspots/cluster (as per MoHFW) and large migration gatherings/evacuees centers
6. All symptomatic ILI (influenza like illness, fever, cough, sore throat, runny nose)
a. Within 7 days of illness – rRT-PCR
b. After 7 days of illness – Antibody test (If negative, confirmed by rRT-PCR)

Points to remember
 Symptomatic refers to fever/cough/shortness of breath.
 Direct and high-risk contacts include those who live in the same household with a confirmed
case and HCP who examined a confirmed case.
 Confirmed case is a person with laboratory confirmation of COVID-19 infection, irrespective of
clinical signs and symptoms

Note: Due to the absence of any discriminating symptom, the only way of knowing if a
patient/individual is suffering from COVID 19 is laboratory diagnosis. As asymptomatic individuals can
also transmit the virus, taking adequate safety precautions is absolutely essential.

PRIORITIES FOR TESTING PATIENTS WITH SUSPECTED COVID – 19 INFECTION

By now we understand who all should be evaluated or diagnosed for COVID 19, now what is necessary
is to categorize the suspected patients based on severity and prognosis to ensure the optimal
utilization of the available resources
PRIORITY 1
Ensure optimal care options for all hospitalized patients, lessen the risk of nosocomial infections,
and maintain the integrity of the healthcare system

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  Hospitalized patients
 Symptomatic healthcare workers

PRIORITY 2
Ensure that those who are at highest risk of complication of infection are rapidly identified and
appropriately triaged
 Patients in long-term care facilities with symptoms
 Patients 65 years of age and older with symptoms
 Patients with underlying conditions with symptoms
 First responders with symptoms

PRIORITY 3
As resources allow, test individuals in the surrounding community of rapidly increasing hospital
cases to decrease community spread, and ensure the health of essential workers

 Critical infrastructure workers with symptoms ( workers who conduct a range of operations and
services that are typically essential to continue critical infrastructure viability, including staffing
operations centers, maintaining and repairing critical infrastructure, operating call centers,
working construction, and performing operational function)s
 Individuals who do not meet any of the above categories with symptoms (patients who do not
fall in the above categories)
 Health care workers and first responders
 Individuals with mild symptoms in communities experiencing high COVID-19 hospitalizations

NON-PRIORITY
● Individuals without symptoms

LABORATORY TESTING
Patients who meet the testing criteria discussed above should undergo testing for SARS-CoV-2 (the
virus that causes COVID-19) in addition to testing for other respiratory pathogens (e.g. influenza,
respiratory syncytial virus).
Note: As per directive from MoHFW, Government of India, all suspected cases are to be reported to
district and state surveillance officers.

Sample collection
 Preferred sample: Throat and nasal swab in viral transport media (VTM) and transported on ice
 Alternate: Nasopharyngeal swab, BAL or endotracheal aspirate which has to be mixed with the
viral transport medium and transported on ice

General guidelines during sample collection

 Trained health care professionals to wear appropriate PPE with latex-free purple nitrile gloves
while collecting the sample from the patient. Maintain proper infection control when collecting
specimens
 Restricted entry to visitors or attendants during sample collection
 Complete the requisition form for each specimen submitted
 Proper disposal of all waste generated

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Materials required
 Primary container : Sample vials and Virus Transport Medium (VTM)
 Adsorbent material (cotton, tissue paper), paraffin, seizer, cello tape
 A leak-proof secondary container (e.g., ziplock pouch, cryobox, 50 mL centrifuge tube, plastic
container)
 Hard-frozen Gel Packs
 A suitable outer container (e.g., thermocol box, ice-box, hard-board box)

Specimen Type
1. UPPER RESPIRATORY SPECIMEN: For initial diagnostic testing
a. Nasopharyngeal (NP) and/or oropharyngeal (OP) swab
 These are the preferred choice for swab-based SARS-CoV-2 testing.
 Only synthetic fiber swabs with plastic shafts should be used
 Do not use calcium alginate swabs or swabs with wooden shafts, as they may contain
substances that inactivate some viruses and inhibit PCR testing.
 Place swabs immediately into sterile tubes containing 2-3 ml of viral transport media.

Technique for NP swab:

 Tilt the patient’s head back 70 degrees.
 Insert flexible swab through the nares parallel to the palate (not upwards) until resistance is
encountered or the distance is equivalent to that from the ear to the nostril of the patient.
 Gently, rub and roll the swab.
 Leave the swab in place for several seconds to absorb secretions before removing.
 Slowly remove the swab while rotating it.

Technique for OP swab:

 Tilt the patient’s head back 70 degrees.
 Rub swab over both tonsillar pillars and posterior oropharynx and avoid touching the tongue,
teeth, and gums.

LOWER RESPIRATORY TRACT

A. Bronchoalveolar lavage, tracheal aspirate
 Bronchoalveolar lavage (BAL) (also known as bronchoalveolar washing) is a diagnostic method
of the lower respiratory system in which a bronchoscope is passed through the mouth or nose
into an appropriate airway in the lungs, with a measured amount of fluid introduced and then
collected for examination.
 Tracheal aspirate is a method of obtaining tracheal secretions for culture and microbiological
diagnosis
 Collect 2-3 mL into a sterile, leak-proof, screw-cap sputum collection cup or sterile dry
container.
 Due to the increased technical skill and equipment needs, collection of specimens other than
sputum from the lower respiratory tract may be limited to patients presenting with more
severe disease, including people admitted to the hospital and/or fatal cases.

B. Sputum

15
 Educate the patient about the difference between sputum and oral secretions (saliva). Have the
patient rinse the mouth with water and then expectorate deep cough sputum directly into a
sterile, leak-proof, screw-cap collection cup or sterile dry container.

Specimen collection guidelines

Specimen Handling Guidelines

 Collect specimens and store them at 2-8°C (on ice) and send them as soon as possible.
 Ship overnight to an ice pack.
 All specimens should be properly labeled with the patient’s details (eg. ID number- medical record
number, name,age, gender), unique specimen ID (e.g., laboratory requisition number), specimen
type (e.g., serum), details of the sender (name/address/phone no.)and the date the sample was
collected.
 Specimens can be stored at 2-8°C for up to 72 hours after collection. If a delay in testing or
transport is expected, store specimens at -70°C or below.
 Maintain cool temperatures while transporting the specimen. This can be done by shipping the
specimen in dry ice.

16
Note: It is important to avoid repeated freezing and thawing of specimen

Procedure
 Use PPE (apron, masks,N-95 face shield and hand gloves)and other biosafety guidelines while
handling specimens to protect themself .
 Seal the neck of the sample vials using parafilm.
 Cover the sample vials using absorbent material.
 Arrange primary container (vial) in secondary container.
 Placing the centrifuge tube inside a zip-lock pouch.
 Placing the zip-lock pouch inside a sturdy plastic container and seal the neck of the container.
 Using a thermocol box as an outer container and placing the secondary container within it,
surrounded by hard frozen gel packs.
 Using a hard card-board box as an outer container and placing the secondary container and the
gel packs.
 Placing the completed Specimen Referral Form (available on www.niv.co.in) and request letter
inside a leak-proof, zip-lock pouch.
 Securing the zip-lock pouch with the Specimen Referral Form on the outer container.
 Attaching the labels: Senders’ address, contact number; Consignee’s address /contact number.

DIAGNOSTIC TESTS
 Nucleic acid amplification tests (NAAT)
 Serological tests

A. Nucleic acid amplification test (NAAT)

 Routine confirmation of cases of COVID-19 is based on the detection of unique sequences of
virus RNA by NAAT such as real-time reverse transcription polymerase chain reaction (rRT-
PCR).
 Principle: The real time assay uses the TaqMan fluorogenic probe based chemistry that uses
the 5´ nuclease activity of Taq DNA polymerase and enables the detection of a specific PCR
product as it accumulates during PCR cycles.
 In India, as of writing this, rRT-PCR for assaying the E gene of SARS-CoV-2 is being used as a
screening test.
 Along with novel coronavirus, the sample should also be tested for Influenza.
 If a sample tests positive in this screening test, it is sent to the Reference laboratory i.e. ICMR
– NIV Pune for Confirmatory testing. If the confirmatory test becomes positive, then the
sample can be declared positive. Confirmatory assays at ICMR NIV
 ORF 1b
 RdRp gene assay
 E gene assay
 A positive test confirms the presence of SARS-CoV-2
 One or more negative results do not rule out the possibility of COVID-19 virus infection.
 Several factors could lead to a negative result in an infected individual, including: -

17
  Poor quality of the specimen, containing little patient material (as a control, consider
determining whether there is adequate human DNA in the sample by including a human
target in the PCR testing)
 The specimen was collected late or very early in the infection
 The specimen was not handled and shipped appropriately
 Technical reasons which are inherent in the test, e.g. PCR inhibition.

Note: If a negative result is obtained from a patient with a high index of suspicion for COVID-19 virus
infection, particularly when only upper respiratory tract specimens were collected, additional
specimens, including from the lower respiratory tract if possible, should be collected and tested.
* Molecular tests can only help diagnose current cases of COVID-19. They cannot tell whether
someone has had the infection and since recovered.

LIMITATIONS

 RT-qPCR requires high-quality nasopharyngeal swabs containing sufficient amounts of viral

RNA. This can be a challenge because
 Amount of viral RNA varies tremendously between patient
 Itt can also varies within the same patient depending on the timing of the test and the
start of the infection and/or the onset of symptoms
 Nasopharyngeal swabs are not only very unpleasant to the patient, the sampling techniques
vary significantly from nurse to nurse.
 Without sufficient viral RNA RT-qPCR can return a false negative test result.
 It requires highly trained personnel to perform complex RNA extraction steps and PCR.
 RT-qPCR becomes an issue when dealing with a global pandemic with potentially millions of
people to test

B. Serological tests
These tests detect antibodies (Ig M and Ig G) that the body produces to fight the virus. These
antibodies are present in anyone who has recovered from COVID-19. The antibodies exist in blood
and tissues throughout the body
● A serological test usually requires a blood sample.
● Serological tests are particularly useful for detecting cases of infection with mild symptoms, it
can aid investigation of an ongoing outbreak and retrospective assessment of the attack rate
or extent of an outbreak.
● In cases where NAAT assays are negative and there is a strong epidemiological link to COVID-
19 infection, paired serum samples (in the acute and convalescent phase) could support
diagnosis.
● For serological test, Rapid antibody test have been advised by the government of India in
clusters (with containment zones), and in large migration gatherings/evacuees centres.

General Guidelines
● Healthcare workers doing the rapid antibody test to use gloves, mask, and head covers.
● Healthcare workers collecting throat/nasal swab to follow standard national infection control
guidelines.
● The rapid antibody tests approved by US-FDA/CE-IVD or non-CE-IVD validated by ICMR-NIV
with marketing approval by DCGI be used.

18
● In order to ensure that all such cases are monitored and necessary action is initiated with
respect to infectious disease management, details of all test results shall be uploaded in ICMR
portal.
● All such organizations are duty bound to register themselves to ICMR portal and upload the
data in real-time. Failure to do so, they will be held liable to action under Disaster
Management Act, 2005.

Advantages of serological test over RT-qPCR

 They are known to be much more stable than viral RNA.
 IgM/IgG serological specimens are less sensitive to spoilage during collection, transport,
storage and testing than RT-qPCR specimens.
 Less variation in results as antibodies are typically uniformly distributed in the blood, than
nasopharyngeal viral RNA specimens
 Specimens can be easily collected with minor phlebotomy discomfort to the patient.
 Unlike RT-qPCR, serological tests can detect past infection because virus-specific antibodies
(unlike viral RNA) can persist in the blood for several weeks/months after onset of symptoms.
 Can be used in large-scale, whole-population, testing to assess the overall immune response
to the virus and identify asymptomatic carriers of the virus

19
 Limitations
 Antibodies may not be detectable before 3 days after onset of symptoms (or at least 7 to 10
days after infection
 While IgM/IgG serological tests alone may not be enough to diagnose COVID-19, they can be
a valuable diagnostic tool when combined with RT-qPCR

CLINICAL SIGNIFICANCE OF IgG AND IgM SEROLOGICAL TEST RESULTS

While ,RT-qPCR testing may be appropriate for the detection of the SARS-CoV-2 virus during the
acute phase, IgM/IgG is an appropriate test during the chronic phase. Since the exact time of
infection is often unknown, combining RT-qPCR and IgM/IgG testing can improve the accuracy of
the COVID-19 diagnosis.

PCR vs Serological test

PCR Serological Test

Specimen Nasopharyngeal swab Blood sample

-The viral RNA is not evenly -antibodies are evenly distributed
distributed -specimens are less sensitive to
spoilage during collection,
transport, storage and testing

Detects Viral RNA Viral Antibodies

Patient comfort Nasopharyngeal swab - Blood sample- comparatively

uncomfortable for patient comfortable for patient

Ease of doing procedure Requires highly trained -

personnel to perform complex
RNA extraction steps and PCR

Detection of past infection Not possible Possible

* several studies are still on-
going, SARS-CoV-2 antibodies may

20
 not be detectable before 3 days
after onset of symptoms (or at
least 7 to 10 days after infection)

False result High chance of false negative False positive result can be shown
result, if the specimen doesn’t as antibodies persists in blood for
contain sufficient viral RNA a long duration

LABORATORY FINDINGS
 In the early stage of the disease, a normal or decreased total white blood cell count is usually seen
 Leukopenia and lymphopenia have been reported, although lymphopenia appears most common
and a negative prognostic factor.
 Increased values of liver enzymes, LDH, muscle enzymes(aminotransferase) , ferritin and C-
reactive protein can be found.
 On admission, many patients with pneumonia have normal serum procalcitonin levels; however,
in those requiring ICU care, they are more likely to be elevated
 In critical patients, D-dimer value is increased, blood lymphocytes decreased persistently, and
laboratory alterations of multiorgan imbalance (high amylase, coagulation disorders, etc.) are
found.

PATHOLOGICAL FINDINGS
 Pulmonary bilateral diffuse alveolar damage with cellular fibromyxoid exudates.
 The lung may show evident desquamation of pneumocytes and hyaline membrane formation,
indicating acute respiratory distress syndrome.
 Interstitial mononuclear inflammatory infiltrates, dominated by lymphocytes, could be observed
in both lungs.
 Multinucleated syncytial cells with atypical enlarged pneumocytes characterized by large nuclei,
amphophilic granular cytoplasm, and prominent nucleoli can be identified in the intra-alveolar
spaces, indicating viral cytopathic-like changes.
Note: These pulmonary pathological findings extremely resemble those seen in SARS and MERS
 Moderate microvascular steatosis and mild lobular and portal activity were
observed in liver biopsy specimens, which might be caused by either SARS-CoV-2 infection or drug
use.
 SARS-CoV-2 might not directly impair the heart as only a few interstitial mononuclear
inflammatory infiltrates were found in the heart tissue.
 Massive mucus secretion in both lungs was found in death cases with COVID-19, which was
different from SARS and MERS

IMAGE FINDINGS
 Chest CT in patients with COVID-19 most commonly demonstrates ground-glass opacification with
or without consolidative abnormalities, consistent with viral pneumonia.
 Case series have suggested that chest CT abnormalities are more likely to be bilateral, have a
peripheral distribution, and involve the lower lobes.
 Less common findings include pleural thickening, pleural effusion, and lymphadenopathy.

KEY NOTE

21
 Results of RT-qPCR and IgM/IgG serological tests do not necessarily need to agree.
 Disagreement between the two tests, traced to the after-infection time points at which the tests
were performed.
 RT-qPCR testing may be appropriate for the detection of the SARS-CoV-2 virus during the acute
phase, IgM/IgG is an appropriate test during the chronic phase.
 Since the exact time of infection is often unknown, combining RT-qPCR and IgM/IgG testing can
improve the accuracy of the COVID-19 diagnosis.

KEY LEARNING POINTS

 Criteria to Guide Evaluation and Laboratory Testing for COVID-1
1. All symptomatic individuals who have undertaken international travel in the last 14 days
2. All symptomatic contacts of laboratory-confirmed cases
3. All symptomatic health care workers
4. All patients with Severe Acute Respiratory Illness
(fever AND cough and/or shortness of breath)
5. Asymptomatic direct and high-risk contacts of a confirmed case should be tested once
between day 5 and day 14 of coming in his/her contact
 Priorities for testing patients with suspected COVID-19 infection
1. Priority 1 - Hospitalised patients, symptomatic HCP
2. Priority 2 - Symptomatic patienets, immunocompromised and old patients.
3. Priority 3 - Critical infrastructure workers with symptoms

 LABORATORY TESTING
1. Sample-Throat and nasal swab/ Nasopharyngeal swab/ Endotracheal aspirate
2. DIAGNOSTIC TESTS
 Nucleic acid amplification tests
 Serological tests

PCR vs Serological test

PCR Serological Test

Specimen Nasopharyngeal swab Blood sample

-The viral RNA is not evenly -antibodies are evenly distributed
distributed -specimens are less sensitive to spoilage during
collection, transport, storage and testing

Detects Viral RNA Viral Antibodies

Patient Nasopharyngeal swab- Blood sample- comparatively comfortable for

comfort uncomfortable for patient patient

22
 Ease of Requires highly trained -
doing personnel to perform
procedure complex RNA extraction
steps and PCR

Detection Not possible Possible

of past * several studies are still on-going, SARS-CoV-2
infection antibodies may not be detectable before 3 days after
onset of symptoms (or at least 7 to 10 days after
infection)

False result High chance of false False positive result can be shown as antibodies
negative result, if the persists in blood for a long duration
specimen doesn’t contain
sufficient viral RNA

 Laboratory finding-
1. Early stages- normal or decreased total white blood cell count
2. Critical patients- D-dimer value is increased, blood lymphocytes decreased persistently, and
laboratory alterations of multiorgan imbalance (high amylase, coagulation disorders, etc.)
are found.
 Pathological findings- Similar to SARS and MERS
 Pulmonary bilateral diffuse alveolar damage with cellular fibromyxoid exudates.
 Interstitial mononuclear inflammatory infiltrates, dominated by lymphocytes.
 Multinucleated syncytial cells with atypical enlarged pneumocytes.
 Massive mucus secretion in both lungs was found in death cases with COVID-19, which was
different from SARS and MERS
 IMAGE FINDINGS
 Ground-glass opacification with or without consolidative abnormalities, consistent with
viral pneumonia.
 Chest CT abnormalities- likely to be bilateral, have a peripheral distribution, and involve the
lower lobes.
 Less common findings- pleural thickening, pleural effusion, and lymphadenopathy.

23
 CHAPTER – 3

MANAGEMENT ACCORDING TO TRIAGE

LEARNING OBJECTIVES
 Triaging and its purpose
 Triaging Guiding principle
 Dedicated COVID Facilities
 Steps in triaging
 Patient Assessment
 Patient Categorization

INTRODUCTION
As of now, there is no specific antiviral treatment recommended for COVID-19, and no vaccine is
currently available. A series of measures have been taken by both the Central and State Governments
to break the chain of transmission. One of these is to isolate all suspect and confirmed cases of COVID-
19.
However, as the number of cases increases, it would be important to appropriately prepare the health
systems and use the existing resources judicially. Available data in India suggests that nearly 70% of
cases affected with COVID-19 either exhibit mild or very mild symptoms. Such cases may not require
admission to COVID-19 blocks/ dedicated COVID-19 hospitals.

TRIAGING
It is important to put in place mechanisms for triaging and decision making for identification of the
appropriate COVID dedicated facility for providing care to COVID-19 patients.

PURPOSE OF TRIAGING
 Ensuring optimal utilization of available resources
 Providing appropriate care to all the COVID-19 patients.
 Ensuring that available hospital beds capacity is used only for moderate to severe cases of COVID-
19
Once the triaging is done, the identified patients are provided with different types of facilities based
on various categories of COVID-19 cases and the guidelines for the same are mentioned below.

TRIAGING GUIDING PRINCIPLES

 All the selected facilities must be dedicated to COVID management.
 Three types of COVID dedicated facilities are proposed.
 All 3 types of COVID Dedicated facilities will have separate earmarked areas for the suspect
and confirmed cases.
 The suspect and confirmed cases should not be allowed to mix under any circumstances.
 All suspect cases (irrespective of the severity of their disease) will be tested for COVID-19.
 Further management of these cases will depend on their (i) clinical status and (ii) result of COVID-
19 testing.

24
COVID DEDICATED FACILITIES
1. COVID Care Center (CCC):
 These centers offer care only for cases that have been clinically assigned as mild or very mild
cases or COVID suspect cases
 The COVID Care Centers are makeshift facilities. These may be set up in hostels, hotels,
schools, stadiums, lodges, etc., both public and private. If need be, existing quarantine
facilities could also be converted into COVID Care Centers.
 Functional hospitals like CHCs, etc, which may be handling regular, non-COVID cases should
be designated as COVID Care Centers as a last resort.
 This is important as essential non-COVID Medical services like those for pregnant women,
newborns, etc, are to be maintained.
 Wherever a COVID Care Center is designated for admitting both the confirmed and the
suspected cases, these facilities must have separate areas for suspected and confirmed cases
with preferably separate entry and exit. The suspect and confirmed cases must not be allowed
to mix under any circumstances.
 As far as possible, wherever suspect cases are admitted in the COVID Care Center, preferably
individual rooms should be assigned for such cases.
 Every Dedicated COVID Care Centre must necessarily be mapped to one or more Dedicated
COVID Health Centres and at least one Dedicated COVID Hospital for referral purpose (details
are given below) and must also have a dedicated Basic Life Support Ambulance (BLSA)
equipped with sufficient oxygen support on 24x7 basis, for ensuring safe transport of a case
to Dedicated higher facilities if the symptoms progress from mild to moderate or severe.

2. Dedicated COVID Health Centre (DCHC):

 The Dedicated COVID Health Centre are hospitals that shall offer care for all cases that have
been clinically assigned as moderate.
 These should either be a full hospital or a separate block in a hospital with preferably separate
entry\exit/zoning.
 Private hospitals may also be designated as COVID Dedicated Health Centres.
 Wherever a Dedicated COVID Health Center is designated for admitting both the confirmed
and the suspect cases with moderate symptoms, these hospitals must have separate areas for
the suspect and confirmed cases. The suspect and confirmed cases must not be allowed to
mix under any circumstances.
 These hospitals would have beds with assured Oxygen support.
 Every Dedicated COVID Health Centre must necessarily be mapped to one or more Dedicated
COVID Hospitals.
 Every DCHC must also have a dedicated Basic Life Support Ambulance (BLSA) equipped with
sufficient oxygen support for ensuring safe transport of a case to a Dedicated COVID Hospital
if the symptoms progress from moderate to severe.

3. Dedicated COVID Hospital (DCH):

25
  The Dedicated COVID Hospitals are hospitals that shall offer comprehensive care primarily for
those who have been clinically assigned as severe.
 The Dedicated COVID Hospitals should either be a full hospital or a separate block in a hospital
with preferably separate entry\exit.
 Private hospitals may also be designated as COVID Dedicated Hospitals.
 These hospitals would have fully equipped ICUs, Ventilators and beds with assured Oxygen
support.
 These hospitals will have separate areas for suspect and confirmed cases. Suspect and
confirmed cases should not be allowed to mix under any circumstances.
 The Dedicated COVID Hospitals would also be referral centers for the Dedicated COVID Health
Centers and the COVID Care Centers.
All these facilities will follow strict infection prevention and control practices. (Refer chapter IPC)

STEPS IN TRIAGING
1. Assessment of patients:
 Sometimes the patients arrive directly through helpline/ referral to the below mentioned
categories of COVID dedicated facilities, in field settings during containment operations, the
supervisory medical officer to assess for severity of the case detected and refer to the
appropriate facility.
 States & Union Territories may identify hospitals with dedicated and separate space and set
up Fever Clinics in such hospitals.
 The Fever Clinics may also be set up in community health centers (CHCs), in rural areas
subject to availability of sufficient space to minimize the risk of cross infections.
 In urban areas, the civil\general hospitals, Urban CHCs and Municipal Hospitals may also
be designated as Fever Clinics.
These could be set up preferably near the main entrance for triage and referral to appropriate
COVID Dedicated Facility.
 Wherever space allows, a temporary makeshift arrangement outside the facility may be
arranged for this triaging. The medical officer at the fever clinics could identify suspect cases
and refer to COVID Care Centre, Dedicated COVID Health Centre or Dedicated COVID Hospital,
depending on the clinical severity

2. Categorization of patients
Patients may be categorized into three groups and managed in the respective COVID hospitals
Dedicated COVID Care Centre, dedicated COVID Health Centre and dedicated COVID Hospitals.
1. Group 1: Suspect and confirmed cases clinically assigned as mild and very mild
2. Group 2: Suspect and confirmed cases clinically assigned as moderate
3. Group 3: Suspect and confirmed cases clinically assigned as severe

GROUP 1: SUSPECT AND CONFIRMED CASES CLINICALLY ASSIGNED AS MILD AND VERY MILD
(COVID CARE CENTRES)
 Clinical criteria: Cases presenting with fever and/or upper respiratory tract illness (Influenza
Like Illness, ILI)

26
 These patients will be accommodated in COVID Care Centers.
 The patients would be tested for COVID-19 and till such time their results are available, they
will remain in the “suspect cases” section of the COVID Care Center preferably in an individual
room.
 Those who test positive, will be moved into the “confirmed cases” section of the COVID Care
Center.
 If test results are negative, the patient will be given symptomatic treatment and be discharged
with advice to follow prescribed medications and preventive health measures as per
prescribed protocols.
 If any patient admitted to the COVID Care Center qualifies the clinical criteria for moderate or
severe cases, such patient will be shifted to a Dedicated COVID Health Centre or a Dedicated
COVID Hospital.
 Apart from medical care, the other essential services like food, sanitation, counseling, etc. at
the COVID Care Centers will be provided by the local administration. Guidelines for quarantine
facilities (refer to chapter Precautions for the general public) may be used for this purpose.

GROUP 2: SUSPECT AND CONFIRMED CASES CLINICALLY ASSIGNED AS MODERATE (DEDICATED

COVID HEALTH CENTRES)
 Clinical criteria: Pneumonia with no signs of severe disease (Respiratory Rate 15 to
30/minute, SpO2 90%-94%)
 Such cases will not be referred to COVID Care Centers but instead will be admitted to
Dedicated COVID Health centers.
 It will be manned by allopathic doctors and cases will be monitored on the above mentioned
clinical parameters for assessing severity as per treatment protocol (refer chapter - Treatment
of COVID 19 according to clinical status.
 They will be kept in “suspect cases” section of Dedicated COVID Health Centres, till their
results are not available preferably in an individual room
 Those testing positive shall be shifted to “confirmed cases” section of the Dedicated COVID
Health Centre.
 Any patient, for whom the test results are negative, will be shifted to a non-COVID hospital
and will be managed according to clinical assessment. Discharge as per clinical assessment.
 If any patient admitted to the Dedicated COVID Health Center qualifies the clinical criteria for
a severe case, such patient will be shifted to a Dedicated COVID Hospital.

GROUP 3: SUSPECT AND CONFIRMED CASES CLINICALLY ASSIGNED AS SEVERE (DEDICATED

COVID HOSPITAL)
 Clinical criteria: Severe Pneumonia (with respiratory rate ≥30/minute and/or SpO2 < 90% in
room air) or ARDS or Septic shock
 Such cases will be directly admitted to a Dedicated COVID Hospital’s ICU till test results are
obtained.
 If test results are positive, such patients will remain in COVID-19 ICU and receive treatment as
per standard treatment protocol (refer chapter treatment of COVID 19).
 Patients testing negative will be managed with adequate infection prevention and control

27
Algorithm for isolation of suspected /confirmed cases of COVID 19

28
KEY LEARNING POINTS
TRIAGING: It is important to put in place mechanisms for triaging and decision making for
identification of the appropriate COVID dedicated facility for providing care to COVID-19 patients.
TRIAGING GUIDING PRINCIPLES
 All selected facilities must be dedicated to COVID management.
 Three types of COVID dedicated facilities.
 All 3 types of COVID Dedicated facilities will have separate earmarked areas for the suspect
and confirmed cases.
 The suspect and confirmed cases should not be allowed to mix under any circumstances.
 All suspect cases (irrespective of the severity of their disease) will be tested for COVID-19.
 Further management of these cases will depend on their (i) clinical status and (ii) result of
COVID-19 testing.
COVID DEDICATED FACILITIES
1. COVID Care Center (CCC)
2. Dedicated COVID Health Centre (DCHC)
3. Dedicated COVID Hospital (DCH)
STEPS IN TRIAGING
1. Assessment of patients
2. Categorization of patients
a. Group 1: Suspect and confirmed cases clinically assigned as mild and very mild (COVID Care
Centres)
b. Group 2: Suspect and confirmed cases clinically assigned as moderate (Dedicated COVID
Health Centres)
c. Group 3: Suspect and confirmed cases clinically assigned as severe (Dedicated COVID
Hospital)

29
 CHAPTER – 4

TREATMENT OF COVID – 19 ACCORDING TO SEVERITY OF CASE

(CLINICAL STATUS)

LEARNING OBJECTIVES
 Treatment of COVID 19 confirmed patients according to clinical status and severity

INTRODUCTION
Treatment of COVID 19 confirmed patients is symptomatic. Many of the symptoms can be treated and
therefore treatment based on the patient's clinical condition.
But special care has to be taken for patients with severe infection. Oxygen therapy represents the
major treatment intervention for such patients. Mechanical ventilation may be necessary in severe
and critical cases of respiratory failure refractory to oxygen therapy, whereas hemodynamic support
is essential for managing septic shock.
Here we are going to discuss the Treatment plan according to severity and is as follows:
 Management of mild and moderate covid-19: mainly isolation, symptomatic treatment and
monitoring (already discussed in management of COVID 19 suspect/confirmed cases))
 Management of severe covid-19:
 oxygen therapy and monitoring
 treatment of co-infections
 Management of critical covid-19:
 hypoxemic respiratory failure and ACUTE RESPIRATORY DISTRESS SYNDROME (ARDS)
 Management of critical illness and covid-19:
 septic shock
 prevention of complications

I. Management of severe COVID-19: oxygen therapy and monitoring

A. Give supplemental oxygen therapy immediately to patients with SARI (severe acute
respiratory illness) and respiratory distress, hypoxaemia or shock and target SpO2 > 94%.
(i.e. peripheral capillary oxygen saturation) Note: All areas where patients with SARI are
cared for should be equipped with pulse oximeters, functioning oxygen systems and
disposable, single-use, oxygen-delivering interfaces (nasal cannula, nasal prongs, simple face
mask, and mask with reservoir bag).
Use the following contact precautions when handling contaminated oxygen interfaces of
patients with COVID – 19. (Droplet and contact precautions prevent direct or indirect
transmission from contact with contaminated surfaces or equipment (i.e. contact with
contaminated oxygen tubing/interfaces).

B. Use conservative fluid management in patients with SARI when there is no evidence of
shock.

30
 Patients with SARI should be treated cautiously with intravenous fluids, because aggressive
fluid resuscitation may worsen oxygenation, especially in settings where there is limited
availability of mechanical ventilation. This applies for care of children and adults.

C. Closely monitor patients with COVID-19 for signs of clinical deterioration, such as rapidly
progressive respiratory failure and sepsis and respond immediately with supportive care
interventions immediately.
a) Patients hospitalized with COVID-19 require regular monitoring of vital signs and, where
possible, utilization of medical early warning scores (e.g. NEWS2) that leads to early
identification and advance treatment of the deteriorating patient
b) Haematology and biochemistry laboratory testing and ECG should be performed at
admission and as clinically indicated to monitor for complications, such as acute liver
injury, acute kidney injury, acute cardiac injury, or shock.
Note: Application of timely, effective, and safe supportive therapies is the cornerstone of
therapy for patients who develop severe manifestations of COVID-19.

D. Understand the patient’s co-morbid condition(s) to tailor the management of critical illness
and appreciate the prognosis: During intensive care management of SARI, determine which
chronic therapies should be continued and which therapies should be stopped temporarily.

E. Communicate early with patient and family

Communicate pro-actively with patients and families and provide support and prognostic
information. Understand the patient’s values and preferences regarding life-sustaining
interventions.

II. Management of severe COVID-19: treatment of co-infections

A. Give empiric antimicrobials to treat all likely pathogens causing SARI and sepsis as soon as
possible, within 1 hour of initial assessment for patients with sepsis.
a) Empiric antibiotic treatment should be based on the clinical diagnosis (community-
acquired pneumonia, health care-associated pneumonia [if infection was acquired in
health care setting] or sepsis).
b) Empirical therapy includes a neuraminidase inhibitor for treatment of influenza when
there is local circulation or other risk factors, including travel history or exposure to animal
influenza viruses.
B. Empiric therapy should be de-escalated on the basis of microbiology results and clinical
judgment.

III. MANAGEMENT OF CRITICAL COVID-19: hypoxemic respiratory failure and ACUTE

RESPIRATORY DISTRESS SYNDROME (ARDS)
 Recognize severe hypoxemic respiratory failure when a patient with respiratory distress is
failing to respond to standard oxygen therapy and prepare to provide advanced
oxygen/ventilatory support.

 High – flow nasal oxygenation (HFNO) or non – invasive mechanical ventilation (NIV):

31
  When respiratory distress and/or hypoxemia of the patient cannot be reduced after
receiving standard oxygen therapy, high – flow nasal cannula oxygen therapy or non –
invasive ventilation can be considered.
 If conditions do not improve or even get worse within a short time (1 – 2 hours), tracheal
intubation and invasive mechanical ventilation should be used
 Patients with hypercapnia (exacerbation of obstructive lung disease, cardiogenic
pulmonary oedema), hemodynamic instability, multi-organ failure, or abnormal mental
status should generally not receive HFNO, although emerging data suggest that HFNO may
be safe in patients with mild-moderate and non-worsening hypercapnia
 NIV guidelines make no recommendation on use in hypoxemic respiratory failure (apart
from cardiogenic pulmonary oedema and post-operative respiratory failure) or pandemic
viral illness (referring to studies of SARS and pandemic influenza).
 Risks include delayed intubation, large tidal volumes, and injurious transpulmonary
pressures.

 Endotracheal intubation should be performed by a trained and experienced provider using

airborne precautions.

 In patients with severe ARDS, prone ventilation for 12–16 hours per day is recommended.

IV. MANAGEMENT OF CRITICAL ILLNESS AND COVID-19: SEPTIC SHOCK

As we have already discussed that COVID 19 may lead to severe illness that can be Septic shock.
It is a severe and potentially fatal condition that occurs when sepsis leads to life-threatening low
blood pressure. Sepsis develops when the body has an overwhelming response to infection.
Note: Sepsis is a potentially life-threatening condition caused by the body's response to an
infection. It occurs when chemicals released in the bloodstream to fight an infection trigger
inflammation throughout the body. This can cause a cascade of changes that damage multiple
organ systems, leading them to fail, sometimes even resulting in death.

MANAGEMENT

 Recognize septic shock in adults when infection is suspected or confirmed and vasopressors
are needed to maintain mean arterial pressure (MAP) ≥ 65 mmHg and lactate is ≥ 2 mmol/L,
in absence of hypovolemia (Hypovolemia refers to the loss of extracellular fluid and should
not be confused with dehydration)
 Recognize septic shock in children with any hypotension (systolic blood pressure [SBP] < 5th
centile or two or more of the following:
1) Altered mental state
2) Bradycardia or tachycardia (HR < 90 bpm or > 160 bpm in infants and Heart Rate < 70 bpm
or > 150 bpm in children);
3) Prolonged capillary refill (> 2 sec) or feeble pulses
4) Tachypnoea
5) Mottled or cold skin or petechial or purpuric rash
6) Increased lactate
7) Oliguria
8) Hyperthermia or hypothermia

32
 Note:
a) In the absence of a lactate measurement, use blood pressure (i.e. MAP) and clinical signs of
perfusion to define shock.
b) Standard care includes - early recognition and the following treatments within 1 hour of
recognition:
 antimicrobial therapy, and initiation of fluid bolus and vasopressors for hypotension
 The use of central venous and arterial catheters should be based on resource availability
and individual patient needs.

Detailed guidelines are available for the management of septic shock in adults and children.

 In resuscitation for septic shock in adults, give at least 30 ml/kg of isotonic crystalloid (normal
saline and Ringer’s lactate) in adults in the first 3 hours.
 In resuscitation from septic shock in children, give 20 ml/kg as a rapid bolus and up to 40-60
ml/kg in the first 1 hr. Do not use hypotonic crystalloids, starches, or gelatins for resuscitation.
 Fluid resuscitation may lead to volume overload, including respiratory failure. If there is no
response to fluid loading and signs of volume overload appear (for example, jugular venous
distension, crackles on lung auscultation, pulmonary oedema on imaging, or hepatomegaly in
children), then reduce or discontinue fluid administration. This step is particularly important
where mechanical ventilation is not available. Alternate fluid regimens are suggested when
caring for children in resource-limited settings.
 In adults, administer vasopressors when shock persists during or after fluid resuscitation.
 In children administer vasopressors if:
 Signs of shock such as altered mental state; bradycardia or tachycardia (HR < 90 bpm or >
160 bpm in infants and HR < 70 bpm or > 150 bpm in children); prolonged capillary refill
(> 2 seconds) or feeble pulses; tachypnoea; mottled or cool skin or petechial or purpuric
rash; increased lactate
 Age-appropriate blood pressure targets are not achieved; or
 Signs of fluid overload are apparent

V. MANAGEMENT OF CRITICAL ILLNESS AND COVID-19: PREVENTION OF COMPLICATIONS

Implement the following interventions (Table 4) to prevent complications associated with critical
illness. These interventions are based on Surviving Sepsis or other guidelines, and are generally limited
to feasible recommendations based on high quality evidence

Prevention of complications
Anticipated outcome Interventions

Reduce days of invasive mechanical  Use weaning protocols that include daily
ventilation assessment for readiness to breathe
spontaneously
 Minimize continuous or intermittent sedation,
targeting specific titration endpoints (light
sedation unless contraindicated) or with daily
interruption of continuous sedative infusions

33
Reduce incidence of ventilator - associated  Oral intubation is preferable to nasal
pneumonia intubation in adolescents and adults
 Keep patient in semi-recumbent position (head
of bed elevation 30–45º)
 Use a closed suctioning system; periodically
drain and discard condensate intubing
 Use a new ventilator circuit for each patient;
once patient is ventilated, change circuit if it is
soiled or damaged, but not routinely
 Change heat moisture exchanger when it
malfunctions, when soiled, or every 5–7 days

Reduce incidence of venous  Use pharmacological prophylaxis (low

thromboembolism molecular-weight heparin [preferred if
available] or heparin 5000 units
subcutaneously twice daily) in adolescents and
adults without contraindications.
 For those with contraindications, use
mechanical prophylaxis (intermittent
pneumatic compression devices)
Reduce incidence of catheter-related  Use a checklist with completion verified by a
bloodstream infection real-time observer as reminder of each step
needed for sterile insertion and as a daily
reminder to remove catheter if no longer
needed
Reduce incidence of pressure ulcers  Turn patient every 2 hours
Reduce incidence of stress ulcers and  Give early enteral nutrition (within 24–48
gastrointestinal (GI) bleeding hours of admission)
 Administer histamine-2 receptor blockers or
proton-pump inhibitors in patients with risk
factors for GI bleeding.
 Risk factors for GI bleeding include mechanical
ventilation for ≥ 48 hours, coagulopathy, renal
replacement therapy, liver disease, multiple
comorbidities, and higher organ failure score
Reduce incidence of ICU-related weakness  Actively mobilize the patient early in the course
of illness when safe to do so

34
KEY LEARNING POINTS
 There is no specific antiviral treatment recommended for COVID-19, and no vaccine is currently
available.
 The treatment is symptomatic, and oxygen therapy represents the major treatment intervention
for patients with severe infection. Mechanical ventilation may be necessary in severe and critical
cases of respiratory failure refractory to oxygen therapy, whereas hemodynamic support is
essential for managing septic shock.

SEVERITY OF COVID 19 TREATMENT PLAN

I. MANAGEMENT OF MILD AND a) Patients with mild disease

MODERATE COVID-19:  No early hospitalization
SYMPTOMATIC TREATMENT AND  Isolation is necessary to prevent virus
MONITORING transmission
 Should avoid visiting hospitals or ambulatory
locations, Instead, call a healthcare provider
to determine the best course of treatment.
 Symptomatic treatment (such as Antipyretics
for fever)
 If develop any severe symptom (particularly
shortness of breath), should seek urgent care
through national referral systems
b) Patient having moderate symptoms
 No need to hospitalized unless trouble in
breathing or are dehydrated.
 Isolation is necessary.
c) Patient with mild to moderate symptoms who
despite that develops a mild form of pneumonia,
specially if having underlying health condition
 Require hospitalization and antibiotics along
with supplemental oxygen

35
 II. MANAGEMENT OF SEVERE COVID-  Give supplemental oxygen therapy immediately
19: OXYGEN THERAPY AND to patients with SARI and respiratory distress,
MONITORING hypoxaemia or shock and target SpO2 > 94%.
 Closely monitor patients with COVID-19 for signs
of clinical deterioration, such as rapidly
progressive respiratory failure and sepsis and
respond immediately with supportive care
interventions.
 Determine which chronic therapies should be
continued and which therapies should be stopped
temporarily. Monitor for drug-drug interactions.
 Use conservative fluid management in patients
with SARI when there is no evidence of shock.
(aggressive fluid resuscitation may worsen
oxygenation, especially in settings where there is
limited availability of mechanical ventilation)

III. MANAGEMENT OF SEVERE COVID-  Empiric antimicrobials to treat all likely pathogens
19: TREATMENT OF CO-INFECTIONS causing SARI and sepsis as soon as possible, within
1 hour of initial assessment for patients with
sepsis.
 Empiric therapy should be de-escalated on the
basis of microbiology results and clinical
judgment.

36
IV. MANAGEMENT OF CRITICAL COVID-  Recognize severe hypoxemic respiratory failure
19: Hypoxemic respiratory failure when a patient with respiratory distress is failing
and ACUTE RESPIRATORY DISTRESS to respond to standard oxygen therapy and
SYNDROME (ARDS) prepare to provide advanced oxygen/ventilatory
support.
 When respiratory distress and/or hypoxemia
of the patient cannot be reduced after
receiving standard oxygen therapy, high –
flow nasal cannula oxygen therapy or non –
invasive ventilation (NIV) can be considered.
 If conditions do not improve or even get
worse within a short time (1 – 2 hours),
tracheal intubation and invasive mechanical
ventilation should be used
 Endotracheal intubation should be performed by
a trained and experienced provider using airborne
precautions.
 In patients with severe ARDS, prone ventilation
for 12–16 hours per day is recommended.

37
V. MANAGEMENT OF CRITICAL ILLNESS 1. Reduce days of invasive mechanical ventilation
AND COVID-19: PREVENTION OF  Use weaning protocols
COMPLICATIONS  Minimize continuous or intermittent
sedation, targeting specific titration
endpoints (light sedation unless
contraindicated) or with daily interruption of
continuous sedative infusion
2. Reduce incidence of ventilator - associated
pneumonia
 Oral intubation preferred – adolescents and
adults
 Keep patient - Semi-recumbent position
(head of bed elevation 30–45º)
 Use closed suctioning system
 Use a new ventilator circuit for each patient

Change heat moisture exchanger - every 5–7
days
3. Reduce incidence of venous thromboembolism
 Use pharmacological prophylaxis or heparin
5000 units subcutaneously twice daily) in
adolescents and adults without
contraindications.
If in contraindicated - Use mechanical
prophylaxis (intermittent pneumatic
compression devices)
4. Reduce incidence of catheter-related
bloodstream infection

Use a checklist for : real-time observer as
reminder of each step needed for sterile
insertion and as a daily reminder to remove
catheter if no longer needed
5. Reduce incidence of pressure ulcers
Turn patient every 2 hours
6. Reduce incidence of stress ulcers and
gastrointestinal (GI) bleeding
 Give early enteral nutrition (within 24–48
hours of admission)
 Patients with risk factors for GI bleeding -
Administer histamine-2 receptor blockers or
proton-pump inhibitors
7. Reduce incidence of ICU-related weakness.
Actively mobilize the patient early in the course of
illness when safe to do so

38
VI.MANAGEMENT OF CRITICAL ILLNESS Recognize septic shock in adult and children as early
AND COVID-19: SEPTIC SHOCK as possible.

Recommendations pertain to resuscitation

strategies for adult and paediatric patients with
septic shock.

 Septic shock in Adults -give 250–500 mL

crystalloid fluid as rapid bolus in first 15–30
minutes and reassess for signs of fluid overload
after each bolus.
 septic shock in children - give 10–20 mL/kg
crystalloid fluid as a bolus in the first 30–60
minutes and reassess for signs of fluid after each
bolus.
Note:

 In adults, administer vasopressors when shock

persists during or after fluid resuscitation.
 In children administer vasopressors if:
 Signs of shock such as altered mental state;
bradycardia or tachycardia (HR < 90 bpm or >
160 bpm in infants and HR < 70 bpm or > 150
bpm in children); prolonged capillary refill (>
2 seconds) or feeble pulses; tachypnoea;
mottled or cool skin or petechial or purpuric
rash; increased lactate
 Age-appropriate blood pressure targets are
not achieved; or
 Signs of fluid overload are apparent

39
 CHAPTER – 5

NSAIDS, GLUCOCORTICOIDS AND CHLOROQUINE

LEARNING OBJECTIVES
 Uncertainty about the use of glucocorticoids and NSAID in COVID 19 patients
 Chloroquine use in prophylaxis of COVID 19

INTRODUCTION
Given the current SARS-CoV-2 (COVID-19) pandemic, the availability of reliable information is
important. There have been a number of reports stating that non-steroidal anti-inflammatory drugs
(NSAIDs) and corticosteroids may worsen the symptoms in COVID-19 patients.
These news reports followed a March 11, 2020 letter in The Lancet medical journal which
hypothesized that an enzyme (a molecule that aids a biochemical reaction in the body) is increased by
NSAIDs and could increase COVID-19 symptoms.
The Belgian Federal Agency for Medicines and Health Products released a statement on 16th March
2020 stating ‘It is well known that NSAIDs and corticosteroids can lead to serious complications’. A
report by French Authorities suggested the use of ibuprofen in COVID-19 patients was harmful to
patient condition and recovery. NSAIDs are often used for the management of mild pain in cancer
patients; hence, this topic is of particular importance to these patients.

Limited role of glucocorticoids

The WHO and CDC recommend glucocorticoids not be used in patients with COVID-19 pneumonia
unless there are other indications (eg, exacerbation of chronic obstructive pulmonary disease).

 Glucocorticoids have been associated with an increased risk for mortality in patients with
influenza and delayed viral clearance in patients with Middle East respiratory syndrome
coronavirus (MERS-CoV) infection.
 Although they were widely used in the management of severe acute respiratory syndrome (SARS),
there was no good evidence for benefit, and there was convincing evidence of adverse short- and
long-term harm.
Therefore, given a lack of effectiveness and possible harm, routine corticosteroids should be
avoided unless they are indicated for other reasons (such as septic shock)

UNCERTAINTY ABOUT NSAID USE —

Some clinicians have suggested the use of non-steroidal anti-inflammatory drugs (NSAIDs) early in the
course of the disease may have a negative impact on disease outcome. These concerns are based on
reports of a few young patients who received NSAIDs early in the course of infection and experienced
severe disease. However, there have been no clinical or population-based data that directly address
the risk of NSAIDs.

40
The European Medicines Agency (EMA) and the WHO does not recommend that NSAIDs be avoided
when clinically indicated. Given the uncertainty, they suggest acetaminophen as the preferred
antipyretic agent, if possible, and if NSAIDs are needed, the lowest effective dose should be used.
However, it is not suggested that NSAIDs be stopped in patients who are on them chronically for other
conditions unless there are other reasons to stop them (e.g. renal injury, gastrointestinal bleeding).

CHLOROQUINE IN TREATMENT OF COVID 19

Recent publications have brought attention to the possible benefit of chloroquine, a broadly used
antimalarial drug, in the treatment of patients infected by the novel emerged coronavirus (SARS-CoV-
2)

INTERESTING POINT
In a recent publication (Gao et al., 2020), Gao and colleagues indicate that, "results from more
than 100 patients have demonstrated that chloroquine phosphate is superior to the control
treatment in inhibiting the exacerbation(increasing) of pneumonia, improving lung imaging
findings, promoting a virus negative conversion, and shortening the disease course".
This would represent the first successful use of chloroquine in humans for the treatment of an
acute viral disease, and is undoubtedly excellent news, since this drug is cheap and widely
available.
However, it should be considered carefully before drawing definitive conclusions, since no data
has been provided yet to support this announcement.

ICMR (Indian council of medical research) has given following instruction regarding use of
hydroxychloroquine
 Hydroxy-chloroquine is found to be effective against coronavirus in laboratory studies and in-vivo
studies. However, as of today, there is no concrete study or data which shows a clear cut
advantage of using hydroxychloroquine. While it may help in preventing COVID 19 or reducing its
severity, it can have many serious adverse effects such as:
 Blood and lymphatic system disorders: Bone marrow failure, anemia, aplastic anemia,
agranulocytosis, leukopenia, and thrombocytopenia
 Cardiac disorders: Cardiomyopathy, QT interval prolongation, and ventricular arrhythmias
 Eye disorders: Irreversible retinopathy with retinal pigmentation changes, visual field defects,
visual disturbances, color vision abnormalities.
 Gastrointestinal disorders: Nausea, vomiting, diarrhea, abdominal pain
 Hepatobiliary disorders: Liver damage, acute hepatic failure acute
 Nervous system disorders: Headache, dizziness, seizure, tremor
 Psychiatric disorders: Affect/emotional lability, nervousness, irritability, nightmares,
psychosis, suicidal behaviour.

 Due to the possibility of such serious adverse effects, it is very strongly recommended that no one
should take the HCQ on his/her own. It should be taken only if a doctor prescribes it after carefully
evaluating you.

41
 The National Taskforce for COVID-19 constituted by the Indian Council of Medical Research
recommends the use of hydroxychloroquine for prophylaxis of SARS-COV-2 infection only for
individuals who are high risk.

 The protocol recommended by the National Taskforce has been approved by the Drug Controller
General of India for restricted use in emergency situations. The following individuals are “high
risk”:

 Asymptomatic Healthcare Workers involved in the care of suspected or confirmed cases of

COVID 19
 Asymptomatic household contacts of laboratory-confirmed cases
Dose
 Asymptomatic healthcare workers involved in the care of suspected or confirmed cases
of COVID-19:
 400 mg twice a day on Day 1, followed by 400 mg once weekly for next 7 weeks; to be
taken with meals
 Asymptomatic household contacts of laboratory confirmed cases
 400 mg twice a day on Day 1, followed by 400 mg once weekly for next 3 weeks; to be
taken with meals

 Exclusion/contraindications
 The drug is not recommended for prophylaxis in children under 15 years of age.
 The drug is contraindicated in persons with a known case of retinopathy, known
hypersensitivity to hydroxychloroquine, 4-aminoquinoline compounds.

Good to know
 The retina is the innermost, light-sensitive layer of tissue of the eye which enables vision.
 Retinopathy is any damage to the retina of the eyes, which may cause vision impairment.
 Chloroquine retinopathy, is a form of toxic retinopathy (damage of the retina) caused by the
drugs chloroquine or hydroxychloroquine, which are sometimes used in the treatment of
autoimmune disorders such as rheumatoid arthritis and systemic lupus erythematosus.

 Key considerations

 The drug has to be given only on the prescription of a registered medical practitioner.
 Advised to consult with a physician for any adverse event or potential drug interaction before
initiation of medication.
 The prophylactic use of hydroxychloroquine to be coupled with the pharmacovigilance for
adverse drug reactions through self-reporting using the Pharmacovigilance Program of India
(PvPI) helpline/app.
 If anyone becomes symptomatic while on prophylaxis he/she should immediately contact the
health facility, get tested as per national guidelines and follow the standard treatment
protocol.

42
  All asymptomatic contacts of laboratory confirmed cases should remain in home quarantine
as per the national guidelines, even if they are on prophylactic therapy.
 The contraindications mentioned in the recommendations should strictly be followed.

KEY LEARNING POINTS

 The WHO and CDC recommend glucocorticoids not be used in patients with COVID-19
pneumonia unless there are other indications.
 Acetaminophen is the preferred antipyretic agent, if necessary, and if NSAIDs are needed, the
lowest effective dose should be used.
 It is not suggested that NSAIDs be stopped in patients who are on them chronically for other
conditions unless there are other reasons to stop them.
 Hydroxy-chloroquine is found to be effective against coronavirus in laboratory studies and in-
vivo studies.
 Indian Council of Medical Research recommends the use of hydroxychloroquine for prophylaxis
of SARS-COV-2 infection only for individuals who are high risk.
 The drug is not recommended for prophylaxis in children under 15 years of age.
 The drug has to be given only on the prescription of a registered medical practitioner.

43
 CHAPTER – 6
GUIDANCE FOR MANAGEMENT OF PREGNANT WOMEN IN COVID –
19 PANDEMIC

LEARNING OBJECTIVES
 To study effect of COVID-19 on pregnancy
 To know general guidelines for obstetric health care providers
 To study specific obstetric management considerations
 To know the information to be shared with pregnant women
 To learn management of COVID-19 in pregnancy
 To study antenatal care
 To study Intrapartum care
 To study Care in labour
 To study management of patients with COVID-19 admitted to critical care
 To study postnatal management
 To study about correct method of breastfeeding in covid19 suspected cases
 To know guidelines for hospital discharge after delivery by covid19 suspected cases
 To study anaesthesia and advice regarding personal protective equipment for caesarean/vaginal
birth

INTRODUCTION
During this time of difficulty and panic as the pandemic (COVID 19) caused by SARS COV 2 virus spreads
across the globe, concerns have been raised about its course, complications, and management in

44
pregnant women and also the transmission of this virus from mother to fetus. It is always important
for pregnant women to protect themselves from illnesses as the body is already experiencing changes
and increased demands.
The coronavirus epidemic increases the risk of perinatal anxiety and depression. In this chapter we
would study about pregnancy and how it is affected by SARS COV 2 if mother is at risk of COVID19.
We would also focus on care for pregnant women affected by COVID 19.

1. Effect of COVID-19 on Pregnancy

 The general approach to prevention, evaluation, diagnosis, and treatment of pregnant women
with suspected COVID-19 is largely similar to that in non-pregnant individuals.
 Pregnant women do not appear more likely to contract the infection than the general
population. However, pregnancy itself alters the body’s immune system and response to viral
infections in general, which can occasionally be related to more severe symptoms and this will
be the same for COVID-19.
 Reported cases of COVID-19 pneumonia in pregnancy are milder and with good recovery.

2. Transmission
 With regard to vertical transmission (transmission from mother to baby antenatally or
intrapartum), emerging evidence now suggests that vertical transmission is probable.
 At present, there are no recorded cases of vaginal secretions being tested positive for COVID-
19.
 At present, there are no recorded cases of breast milk being tested positive for COVID-19.

3. Effect on Foetus
 There are currently no data suggesting an increased risk of miscarriage or early pregnancy loss
in relation to COVID-19.
 There is no evidence currently that the virus is teratogenic. Long term data is awaited.
 COVID-19 infection is currently not an indication for Medical Termination of Pregnancy.

4. General Guidelines for Obstetric Health Care Provider

Ob-gyns and other health care practitioners should contact their local and/or state health
department for guidance on testing persons under investigation(PUI) and should follow the
national protocol.

 Health care practitioners should immediately notify infection control personnel at their health
care facility and their local or state health department in the event of a PUI for COVID-19.
 A registry for all women admitted to with confirmed COVID-19 infection in pregnancy should
be maintained. Maternal and neonatal records including outcome should be completed in
detail and preserved for analysis in future.
 Pregnant women should be advised to increase their social distancing to reduce the risk of
infection and practice hand hygiene.

45
  A single, asymptomatic birth partner should be permitted to stay with the woman, at a
minimum, through pregnancy and birth.
 Visitors should be instructed to wear appropriate PPE, including gown, gloves, face mask, and
eye protection.
 Staff providing care should take Personal Protective Equipment (PPE) precautions
SPECIFIC OBSTETRIC MANAGEMENT CONSIDERATIONS
1. Medical History
For all pregnant women obtain the following information:

 A detailed travel history

 History of exposure to people with symptoms of COVID-19
 Symptoms of COVID-19
 Coming from hot spot area
 Immunocompromised conditions

2. Information to be shared with pregnant women

Pregnant women should be informed as follows:

 If they are infected with COVID-19, they are still most likely to have no symptoms or a mild
illness from which they will make a full recovery
 If they develop more severe symptoms or their recovery is delayed, this may be a sign that
they are developing a more significant chest infection that requires enhanced care.
 They should contact their maternity care team immediately.
 There may be a need to reduce the number of antenatal visits they have. However, do not
reduce the number of visits without agreeing first with the maternity team.

3. Do’s and Don’ts for Obstetric care providers in COVID-19 Pandemic

 If a woman meets criteria for COVID-19 testing, she should be tested. Until test results are
available, she should be treated as though she has confirmed COVID-19.
 Do Not delay obstetric management in order to test for COVID-19.
 Elective procedures like induction of labour for indications that are not strictly necessary,
routine growth scans not for a strict guidance-based indication and routine investigations
should be reduced to minimum at discretion of the care provider.
 If ultrasound equipment is used, it should be decontaminated after use.

MANAGEMENT OF COVID-19 IN PREGNANCY

Flowchart for Management in Pregnant Women is given below

46
47
Relevant terms
 RT – PCR
Reverse transcription polymerase chain reaction (RT-PCR) is a laboratory technique combining
reverse transcription of RNA into DNA.

The COVID-19 RT-PCR is a test for the qualitative detection of nucleic acid from SARS-CoV-2 in
upper and lower respiratory specimens (such as nasal, nasopharyngeal or oropharyngeal swabs,
sputum, lower respiratory tract aspirates, bronchoalveolar lavage, and nasopharyngeal
wash/aspirate or nasal aspirate) collected from individuals suspected of COVID-19 by their
healthcare provider.

 SOFA
The sequential organ failure assessment score (SOFA score) is used to track a person's status
during the stay in an intensive care unit (ICU) to determine the extent of a person's organ function
or rate of failure.

The score is based on six different scores, one each for the respiratory, cardiovascular, hepatic,
coagulation, renal and neurological systems.

Abbreviations
 T* :Temperature
 HR:Heart rate
 BP: Blood pressure
 RR: Respiratory rate
 FHR: Fetal heart rate
 USG: ultrasonography
 MTP: Medical termination of pregnancy
 WG: Week of gestation
 IRNP: Isolation room with negative pressure

INTERESTING POINT
A negative pressure room uses lower air pressure to allow outside air into the internal closed
environment.
This traps and keeps potentially harmful particles within the negative pressure room by preventing
internal air from leaving the space.
Negative pressure rooms in medical facilities isolate patients with infectious conditions and protect
people outside the room from exposure.

Good to know

48
 Cardiotocography (CTG) is a technical means of recording the fetal heartbeat and the uterine
contractions during pregnancy.
The machine used to perform the monitoring is called a cardiotocograph, more commonly known
as an electronic fetal monitor.

1. Breastfeeding
 During temporary separation, mothers who intend to breastfeed should be encouraged to
express their breast milk to establish and maintain milk supply.
 If possible, a dedicated breast pump should be provided.

Prior to expressing breast milk, mothers should practice hand hygiene.

After each pumping session, all parts that come into contact with breast milk should be
thoroughly washed and the entire pump should be appropriately disinfected as per the
manufacturer’s instructions.

 This expressed breast milk should be fed to the new-born by a healthy caregiver.
 If a mother and new-born do room-in and the mother wishes to feed at the breast, she should
put on a facemask and practice hand hygiene before each feeding.

49
2. Anaesthesia and Advice regarding Personal Protective Equipment for Caesarean Birth
 Intubation for general anaesthesia (GA) is an aerosol-generating procedure (AGP). This
significantly increases risk of transmission of coronavirus to the attending staff.
 Regional anaesthesia (spinal, epidural or CSE) is not an AGP.
 For the minority of caesarean births where GA is planned from the outset, all staff in theatre
should wear full PPE, including a filtering facepiece level 3 (FFP3) mask. The scrub team should
scrub and don PPE before the GA is commenced.
 When regional anaesthesia is planned,all the staff is not required for citing the regional
anaesthetic, they should stay outside the theatre until the block is effective.
 All staff in theatre should then don PPE with a fluid-resistant surgical mask (FRSM) and eye
protection (to prevent against droplet or indirect spread of the virus).

KEY LEARNING POINTS

 The general approach to prevention, evaluation, diagnosis, and treatment of pregnant women
with suspected COVID-19 is largely similar to that in nonpregnant individuals.
 Pregnancy alters the body’s immune system and response to viral infections in general, which
can occasionally be related to more severe symptoms and this will be the same for COVID-19.
 Pregnant women should be advised to increase their social distancing to reduce the risk of
infection and practice hand hygiene.
 A single, asymptomatic birth partner should be permitted to stay with the woman, at a
minimum, through pregnancy and birth.
 Visitors should be instructed to wear appropriate PPE, including gown, gloves, face mask, and
eye protection.
 Maternal and neonatal records including outcome should be completed in detail and preserved
for analysis in future.
 The number of antenatal visits may be needed to reduce. However, do not reduce the number
of visits without agreeing first with the maternity team.
 If ultrasound equipment is used, it should be decontaminated after use.
 If a woman meets criteria for COVID-19 testing, she should be tested. Until test results are
available, she should be treated as though she has confirmed COVID-19.
 All staff in theatre should then don PPE with a fluid-resistant surgical mask (FRSM) and eye
protection (to prevent against droplet or indirect spread of the virus).
 When regional anaesthesia is planned,all the staff is not required for citing the regional
anaesthetic, they should stay outside the theatre until the block is effective.
 During temporary separation, mothers who intend to breastfeed should be encouraged to
express their breast milk to establish and maintain milk supply.
 If a mother and new-born do room-in and the mother wishes to feed at the breast, she should
put on a facemask and practice hand hygiene before each feeding.

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 CHAPTER – 7

PREVENTION FOR GENERAL PUBLIC

LEARNING OBJECTIVES
 To know about the steps to prevent the spread of COVID 19 infection.
 To know about instructions for home quarantine.
 To know about instructions for the caretaker of the Home Quarantined person
 To know how to use a mask.

INTRODUCTION
As of April 2020, The outbreak of coronavirus disease (COVID-19) has been declared a Public Health
Emergency of International Concern (PHEIC) and the virus has now spread to almost all countries and
territories. While a lot is still unknown and the studies about the virus that causes COVID-19 are going
on, we do know that it is transmitted through direct contact with respiratory droplets of an infected
person (generated through coughing and sneezing). Individuals can also be infected by touching
surfaces contaminated with the virus and touching their face (eyes, nose, mouth). While COVID-19
continues to spread, communities must take action to prevent further transmission, reduce the impact
of the outbreak and support control measures taken by healthcare authorities.

STEPS TO PREVENT THE SPREAD OF THE INFECTION

a) Hand hygiene – Regularly and thoroughly clean hands with an alcohol-based hand rub or wash
them with soap and water. Specially Indicated:
 After coming home from outside or meeting other people especially if they are ill
 After having touched the face, coughing or sneezing.
 Before preparing food, eating or feeding children.
 Before touching eyes, nose and mouth.
 Before and after using the toilet, cleaning, etc.

SOAP AND WATER OR SANITIZER?

Soap and water is the best. If soap and water is not available, then use hand sanitizer with at least
60% alcohol.
Precautions must be taken after using alcohol based hand sanitizer as it can cause fire hazards.
For children under six years of age, hand sanitizer should be used with adult supervision
Note: Sanitizer may not be effective as many people may not use it correctly. They may not use
enough sanitizer drop or wipe the liquid off before it dries. Sanitizers may not be effective on dirty
and greasy hands.
Note: Duration of handwashing should be at least 20 seconds
DIRECTIONS FOR HAND WASHING
 Wet hands with water.

51
  Apply enough soap to cover all surfaces.
 Rub hands palm to palm.
 Place the right palm over the left dorsum with interlaced fingers and vice versa.
 Rub palm to palm with interlaced fingers.
 Rub back of the fingers with opposing palm keeping fingers interlocked.
 Rotate the palm along the thumb of the opposite hand and clean it thoroughly.
 Rotational rubbing, backwards and forwards with clasped fingers of right hand in left palm
and vice versa
 Rinse hands with water.
 Dry properly with a single use towel.

DIRECTIONS FOR USING HANDRUB

1. Apply a palmful of the product in a cupped hand and cover all surfaces.
2. Rub hands palm to palm.
3. Place the right palm over the left dorsum with interlaced fingers and vice versa.
4. Rub palm to palm with interlaced fingers.
5. Rub back of the fingers with opposing palm keeping fingers interlocked.
6. Rotate the palm along the thumb of the opposite hand and clean it thoroughly.
7. Rotational rubbing, backwards and forwards with clasped fingers of right hand in left palm
and vice versa
8. Let your hands dry.
Note: The duration of hand rub should be 20 - 30 seconds.

b) Maintain Social Distancing:

 It is a non-pharmaceutical infection prevention and control intervention.
 It avoids/decreases contact between those who are infected with a disease-causing pathogen
(SARS-CoV-2 in this case) and those who are not.
 This stops or slows down the rate and extent of disease transmission in a community.
 Maintain a safe distance of at least one meter (3 feet) from any other person when in public
places, especially if they are having symptoms such as cough, fever etc. to avoid direct droplet
contact.
 Stay at home as much as possible.
 Avoid visiting crowded places. Avoid gatherings such as melas, haats, gatherings in religious
places, social functions, etc.
 Since in crowded places it is difficult to maintain a distance of 1 meter, the chances of
getting in close contact with an infected individual are increased.
● Avoid physical contact like a handshake, hand-holding or a hug.

c) Avoid touching eyes, nose and mouth

Hands touch many surfaces and can pick up viruses. Once contaminated, hands can transfer the
virus to your eyes, nose or mouth. From there, the virus can enter your body.

d) Practice respiratory hygiene

 When someone coughs or sneezes, or even talks, they spray small liquid droplets from their
nose or mouth which may contain infectious microbes. If the other person is too close, she/he
can breathe in these droplets, including the COVID-19 virus if the person coughing has the
disease.

52
  Practicing respiratory hygiene can protect people from many diseases such as cold, flu, TB and
COVID-19.
 It is preferable to cover the mouth and nose with a bent elbow rather than the palm.
 This is because the palm of our hands touches various surfaces and the face as well and
can therefore spread an infection.
 While coughing or sneezing, cover the nose and mouth with a handkerchief/ tissue (Wash the
handkerchief at least daily and dispose off the tissue immediately)

e) Keep surroundings clean

 Viruses can settle on various surfaces and remain infective for varying durations of time.
 Hence it is very important to regularly clean your immediate surroundings to avoid diseases.
 Avoid touching surfaces such as table-tops, chairs, door handles, etc.
 Don’t spit or shout in public places to avoid the spread of droplets.

DIRECTIONS FOR CLEANING AND DISINFECTION

 All indoor areas such as entrance lobbies, corridors and staircases, escalators, elevators,
security guard booths, office rooms, meeting rooms, cafeteria should be mopped with a
disinfectant with 1% sodium hypochlorite or phenolic disinfectants.
 High contact surfaces such elevator buttons, handrails / handles and call buttons, escalator
handrails, public counters, intercom systems, equipment like telephone, printers/scanners,
and other office machines should be cleaned twice daily by mopping with a linen/absorbable
cloth soaked in 1% sodium hypochlorite. Frequently touched areas like table tops, chair
handles, pens, diary files, keyboards, mouse, mouse pad, tea/coffee dispensing machines etc.
should specially be cleaned.
 For metallic surfaces like door handles, security locks, keys etc. 70% alcohol can be used to
wipe down surfaces where the use of bleach is not suitable.
 Carefully clean the equipment used in cleaning at the end of the cleaning process. 

f) Home quarantine for 14 days

Quarantine is the separation and restriction of movement or activities of persons who are not ill
but who are believed to have been exposed to infection, for the purpose of preventing
transmission of diseases. Persons are usually quarantined in their homes, but they may also be
quarantined in community-based facilities
People who fall under the following categories should be quarantined in their homes for at least
14 days to decrease the chances of spread of COVID 19:
 People having the symptoms of COVID 19 (All people with these symptoms may not have
COVID 19 as symptoms of COVID 19 and seasonal respiratory illness are similar)
 People who have traveled to COVID 19 affected countries/areas in the past 14 days.
 People who have come in close contact with a suspected/confirmed COVID 19 patient.

1. INSTRUCTIONS FOR THE PERSON BEING HOME QUARANTINED

 Stay in a well-ventilated separate room at home, if possible with an attached/separate

toilet.
 Try to maintain a distance of at least 1 meter from others
 Stay away from elderly people, pregnant women, children, and persons with co-
morbidities within the household.

53
  Restrict his/her movement within the house.
 Under no circumstances attend any social/religious gathering e.g. wedding, condolences,
etc.
 Wash hand thoroughly with soap and water or with alcohol-based hand sanitizer as often
as possible
 Avoid sharing household items e.g. dishes, drinking glasses, cups, eating utensils, towels,
bedding, or other items with other people at home.
 Wear a surgical mask at all times. The mask should be changed every 6-8 hours and
disposed off. Disposable masks should never be reused.
 Masks used by patients/caregivers/close contacts during home care should be disinfected
using ordinary bleach solution (5%) or sodium hypochlorite solution (1%) and then
disposed of either by burning or deep burial.
 If symptoms appear (cough/fever/difficulty in breathing), he/she should immediately
inform the nearest health center or call 011-23978046.
 Surfaces such as the floor, tabletops, chairs, door handles, etc. should be cleaned at least
once a day
 Make sure that only one assigned family member is the caretaker

2. INSTRUCTIONS FOR THE CARETAKER OF THE HOME QUARANTINED PERSON

 Only an assigned family member should be tasked with taking care of the quarantined
person
 Avoid direct contact with the quarantined person’s skin or his/her used clothes
 Use disposable gloves when cleaning the surfaces or handling the clothes used by the
quarantined person
 Wash hands after removing gloves
 Visitors should not be allowed
 In case the person being quarantined becomes symptomatic, all his close contacts will be
home quarantined (for 14 days) and followed up for an additional 14 days or till the report
of such case turns out negative on lab testing
 Maintain a distance of at least one meter from the quarantined person.

Environmental sanitation

 Clean and disinfect frequently touched surfaces in the quarantined person’s room (e.g.
bed frames, tables, etc.) daily with a 1%Sodium Hypochlorite Solution.
 Clean and disinfect toilet surfaces daily with regular household bleach solution/phenolic
disinfectants
 Clean the clothes and other linen used by the person separately using common household
detergent and dry

3. HOW TO USE MASKS (OR CLOTH COVERING THE NOSE AND MOUTH)

 Wash the hands thoroughly before touching the face mask

 Always hold the facemask from the sides.
 Unfold the pleats; make sure that they are facing down.
 Place over nose, mouth and chin.

54
 Fit flexible nose piece (a metallic strip that can easily be located) over nosebridge. Secure
with tie strings (upper string to be tied on top of head above the ears – lower string at the
back of the neck.)
 Ensure there are no gaps on either side of the mask, adjust to fit. While in use, avoid
touching the mask.
 Do not let the mask hang from the neck.
 Disposable masks are never to be reused and should be disposed off.
 One must never reverse the face cover for reuse. Always thoroughly wash it after every
use.
 Never share the face cover with anyone. Every member in a family should have separate
face cover.
Note: A medical mask, if properly worn, will be effective for 8 hours. If it gets wet in
between, it needs to be changed immediately.

While removing mask

 While removing the mask great care must be taken not to touch the potentially
contaminated outer surface of the mask, remove it only with strings behind
 To remove mask first untie the string below and then the string above and handle the
mask using the upper strings.
 After removal, immediately clean your hands with 65% alcohol based hand sanitizer or
with soap and water for 40 seconds.

Disposal of face mask

 Used mask should be considered as potentially infected.

55
  Masks used by patients/ care givers/ close contacts during home care should be
disinfected using ordinary bleach solution (5%) or sodium hypochlorite solution (1%) and
then disposed of either by burning or deep burial

Special Care for Children in COVID 19 pandemic

 Based on available evidence, children do not appear to be at higher risk for COVID-19 than
adults. While some children and infants have been sick with COVID-19, adults make up
most of the known cases to date.
 Relatively few cases of COVID-19 caused by SARS-CoV-2 infection have been reported in
children compared with the total number of cases in the general population.

HELP STOP THE SPREAD OF COVID – 19

Steps to protect children and others from getting sick:

56
1) Teach the children to follow the steps of prevention that are already discussed above ,
e.g.
 Clean hands often using soap and water or alcohol-based hand sanitizer.
 Avoid people who are sick.
 Clean and disinfect high-touch surfaces daily in household common areas (like tables, hard-
backed chairs, doorknobs, light switches, remotes, handles, desks, toilets, and sinks).
 Launder items including washable plush toys as needed. Follow the manufacturer’s
instructions.

2) Limit time with other children, older adults and people with serious underlying medical
conditions
 Practice social distancing
 If someone at home is at particularly high risk for severe illness from COVID-19, consider extra
precautions to separate the child from those people.
 If someone at higher risk for COVID-19 will be providing care (older adults, such as a
grandparent or someone with a chronic medical condition), limit the children's contact with
other people.
 Consider postponing visits or trips to see older family members and grandparents. Connect
virtually or by writing letters and sending via mail.

3) Children 2 years and older should wear a cloth face covering

4) Respiratory hygiene (as mentioned above)

MAINTAINING CHILDHOOD IMMUNIZATIONS DURING COVID-19 PANDEMIC

It is the prime concern for healthcare providers to prioritize newborn care and vaccination of infants
and young children (up to 24month of age) when possible.
Ensuring the delivery of newborn and well-child care, including childhood immunization, requires
different strategies. Healthcare providers in communities affected by COVID-19 are using strategies
to separate well visits from sick visits. Examples include:

 Scheduling well visits in the morning and sick visits in the afternoon
 Separating patients spatially, such as by placing patients with sick visits in different areas of the
clinic or another location from patients with well visits.
 Collaborating with providers in the community to identify separate locations for holding well visits
for children.
Note: If the healthcare providers are unable to provide well child visits to all the patients because of
the prevailing conditions, then they should prioritize newborn care and vaccination.

KEY LEARNING POINTS

 The outbreak of coronavirus disease (COVID-19) has been declared a Public Health Emergency
of International Concern (PHEIC).
 Various steps to prevent the spread of COVID 19 should be taken.

57
 Hand hygiene – Regularly and thoroughly clean hands with an alcohol-based hand rub or wash
them with soap and water for atleast 20 seconds.
 Maintain Social Distancing: Stay at home as much as possible and keep a safe distance of 1
meter with anyone showing symptoms like fever, sneezing, cough etc.
 Avoid touching eyes, nose and mouth as it can pick up viruses. Once contaminated, hands can
transfer the virus to your eyes, nose or mouth and enter our body.
 Practice respiratory hygiene, use your elbows or tissue to cover your face while sneezing.
 Keep surroundings clean to avoid getting in contact with virus.
 Quarantine those people with similar symptoms as COVID 19 for 14 days.
 Home Quarantine instructions include keeping a safe distance of 1 meter from everyone,
wearing a mask at all times, using separate bedding and toiletries.
 Instructions for the caretaker of the Home Quarantined person include, keeping a safe
distance of 1 meter at all times with the quarantined person, wearing a mask, washing hands
after leaving the room.
 Instructions for using mask include, washing hands, making sure mask covers nose and mouth
completely, touch mask only from sides, wash hands after changing mask, change mask every
6-8 hours.

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 CHAPTER – 8

PREVENTION FROM COVID19: HEALTHCARE PERSONNEL

LEARNING OBJECTIVES

 To know the duties of Health Care Personnel (HCP) in a healthcare setting to prevent
infections
 Infection prevention control ( IPC) implementation
 Measures to prevent infection transmission among patients.
 Infection control measures during transportation and handling of the suspected covid19
patients
 Environmental Disinfection (ambulance and equipment)

INTRODUCTION

Health workers are at the front line of any outbreak response and as such are exposed to hazards
that put them at risk of infection with an outbreak pathogen (in this case COVID-19).
Various occupational hazards include
o Pathogen exposure
o Long working hours
o Psychological distress
o Fatigue
o Occupational burnout
o Stigma
o Physical and psychological violence.

DUTIES OF HEALTHCARE WORKERS

Health workers should practice following points to reduce occupational hazards and avoid exposure
to pathogens:
● Follow established occupational safety and health procedures, avoid exposing others to
health and safety risks
● Participate in employer-provided occupational safety and health training
● Use provided protocols to assess, triage and treat patients.
● Treat patients with respect, compassion, and dignity.
● Swiftly follow established public health reporting procedures of suspect and confirmed cases
● Provide or reinforce accurate infection prevention and control (IPC) and public health
information, including to concerned people who have neither symptoms nor risk
● Put on, use, take off and dispose of personal protective equipment properly
● Self-monitor for signs of illness and self-isolate or report illness to managers, if it occurs

59
 ● Tell their superiors if they are experiencing signs of undue stress or mental health challenges
that require support interventions
● Report to their immediate supervisor any situation which they have reasonable justification
to believe presents an imminent and serious danger to life or health.

Infection prevention control (IPC)

https://www.mohfw.gov.in/pdf/RevisedNationalClinicalManagementGuidelineforCOVID1931032
020.pdf

● Infection prevention control (IPC) is a critical and integral part of clinical management of
patients and should be initiated at the point of entry of the patient to hospital.

● Standard precautions should always be routinely applied in all areas of healthcare facilities.
○ Standard Precautions are the minimum infection prevention practices that apply to
all patient care, regardless of suspected or confirmed infection status of the patient,
in any setting where healthcare is delivered.It includes
- Hand hygiene
- Use of PPE to avoid direct contact with patients’ blood, body fluids,
secretions (including respiratory secretions) and non-intact skin.
- Prevention of needle-stick or sharps injury
- Safe waste management
- Cleaning and disinfection of equipment
- Cleaning of the environment.

● Implementation of IPC for COVID 19 suspected/confirmed cases

1. At triage
a. Give the suspect patient a triple layer surgical mask and direct the patient to
a separate area, an isolation room if available.
b. Keep at least 1meter distance between suspected patients and other
patients
c. Instruct all patients to cover nose and mouth during coughing or sneezing
with tissue or flexed elbow for others.
d. Perform hand hygiene after contact with respiratory secretions

GOOD TO KNOW
Triage is the process of determining the priority of patients' treatments based on the severity of
their condition or likelihood of recovery with and without treatment.

2. Apply droplet precautions

a. Droplet precautions prevent large droplet transmission of respiratory
viruses.
b. Use a triple layer surgical mask if working within 1-2 metres of the patient.
c. Place patients in single rooms, or group together those with the same
etiological diagnosis

60
 d. When providing care in close contact with a patient with respiratory
symptoms (e.g. coughing or sneezing), use eye protection (face-mask or
goggles), because sprays of secretions may occur.
e. Limit patient movement within the institution and ensure that patients wear
triple layer surgical masks when outside their rooms

3. Apply contact precautions

a. Droplet and contact precautions prevent direct or indirect transmission from
contact with contaminated surfaces or equipment.
b. Use PPE (triple layer surgical mask, eye protection, gloves and gown) when
entering room and remove PPE when leaving.
c. If possible, use either disposable or dedicated equipment (e.g. stethoscopes,
blood pressure cuffs and thermometers).
d. If equipment needs to be shared among patients, clean and disinfect
between each patient use.
e. Ensure that health care workers refrain from touching their eyes, nose, and
mouth with potentially contaminated gloved or ungloved hands.
f. Avoid contaminating environmental surfaces that are not directly related to
patient care (e.g. door handles and light switches).
g. Ensure adequate room ventilation.
h. Avoid movement of patients or transport.
i. Perform hand hygiene.

4. Apply airborne precautions when performing an aerosol generating procedure

a. Ensure that healthcare workers performing aerosol-generating procedures
(i.e. open suctioning of respiratory tract, intubation, bronchoscopy,
cardiopulmonary resuscitation) use PPE, including gloves, long-sleeved
gowns, eye protection, and fit-tested particulate respirators (N95).
b. Whenever possible, use adequately ventilated single rooms when
performing aerosol-generating procedures, meaning negative pressure
rooms.
c. Avoid the presence of unnecessary individuals in the room.
d. Care for the patient in the same type of room after mechanical ventilation
commences

MEASURES FOR ROUTINE PATIENT

https://www.uptodate.com/contents/coronavirus-disease-2019-covid-19#H1692182506
https://www.bloombergquint.com/business/coronavirus-india-to-deploy-rapid-test-kits-to-speed-
up-covid-19-screening

https://www.fda.gov/medical-devices/personal-protective-equipment-infection-control/n95-
respirators-and-surgical-masks-face-masks

● Screening patients for clinical manifestations consistent with COVID-19 (eg, fever, cough,
dyspnea) prior to entry into a healthcare facility can help identify those who may need

61
 additional infection control precautions.
● CDC recommends that standard, contact, and droplet precautions in addition to eye
protection be used for any patient with an undiagnosed respiratory infection who is not
under consideration for COVID-19.
● Make sure patients and HCP follow respiratory hygiene/cough etiquette which is also a part
of standard precautions..

○ Cover the mouth and nose with a tissue when coughing or sneezing

○ Use the nearest covered dustbin to dispose of the tissue after use.

○ Perform hand hygiene after having contact with respiratory secretions and
contaminated objects/materials.

○ During periods of increased respiratory infection activity in the community

offer masks to persons who are coughing.

MEASURES FOR SUSPECTED COVID PATIENTS

i. Transportation of patients

o There should be ambulances identified specifically for transporting COVID suspect

patients or those who have developed complications, to the health facilities.
o States may empanel two types of ambulances having basic equipment without a
ventilator (like that of BLS )and having a ventilator (ACLS) used for COVID patients.
o Both the EMT(Emergency medical technician) and driver of an ambulance will wear PPE
while handling, managing and transporting the COVID identified/ suspect patients.
o Patient and attendant should be provided with a triple layer mask and gloves. Simple
public health measures like hand hygiene, respiratory etiquettes, etc. need to be
adhered by all.

ii. Handing over the patient at the hospital

o On reaching the receiving hospital, the EMT will hand over the patient and details of
medical interventions if any during transport.
o After handing over the patient, the PPEs will be taken off as per protocol followed by
hand washing.
o The biomedical waste generated (including PPE) to be disposed off in a bio-hazard bag
(yellow bag). This shall again be followed by hand washing

Note: 102 ambulances should not be used for corona patients and should only be used for
transporting pregnant women and sick infants.

iii. In healthcare setting

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 In the health care setting, the World Health Organization (WHO) and CDC recommendations
for infection control for suspected or confirmed infections differ slightly:
● The WHO recommends standard, contact, and droplet precautions (ie, gown, gloves, and
medical mask), with eye or face protection. The addition of airborne precautions (ie,
respirator) is warranted during aerosol-generating procedures.

● The CDC recommends that

- Patients with suspected or confirmed COVID-19 be placed in a single-occupancy room with a
closed door and dedicated bathroom .
- The patient should wear a medical mask if being transported out of the room (eg, for studies
that cannot be performed in the room).
- An airborne infection isolation room (ie, a single-patient negative pressure room) should be
reserved for patients undergoing aerosol-generating procedures (as detailed below).
However, patients with suspected or confirmed COVID-19 should not be in a positive-pressure
room.

Any personnel entering the room of a patient with suspected or confirmed COVID-19
- Should wear the appropriate personal protective equipment (PPE): gown, gloves, eye
protection, and a respirator (eg, an N95 respirator).
- If supply of respirators is limited, the CDC acknowledges that medical masks are an acceptable
alternative (in addition to contact precautions and eye protection), but respirators should be
worn during aerosol-generating procedures.

Note: Health care workers should pay special attention to the appropriate sequence of putting
on and taking off PPE to avoid contamination.

Do you know
● Aerosol-generating procedures include tracheal intubation and extubation, noninvasive
ventilation, manual ventilation before intubation, bronchoscopy, administration of high-flow
oxygen or nebulized medications, tracheotomy, cardiopulmonary resuscitation, and upper
endoscopy.
● The CDC does not consider nasopharyngeal or oropharyngeal specimen collection an aerosol-
generating procedure that warrants an airborne isolation room

Interesting point: Equipment used for protection in other industries is also being explored as an
alternative to standard health care PPE, such as elastomeric half-mask respirators in place of N95
respirators

ENVIRONMENT DISINFECTION

To help reduce the spread of COVID-19 virus, environmental infection control procedures should
also be implemented.
It is unknown how long SARS-CoV-2 can persist on surfaces, other coronaviruses have been tested
and may survive on inanimate surfaces for up to six to nine days without disinfection.It includes:

Disinfection of ambulance and equipment

● All surfaces that may have come in contact with the patient or materials contaminated during
patient care (e.g., stretcher, rails, control panels, floors, walls and work surfaces) should be
thoroughly cleaned and disinfected using 1% Sodium Hypochlorite solution.

63
● Clean and disinfect reusable patient-care equipment before use on another patient with
alcohol based rub.
● Gloves and N-95 masks are recommended for sanitation staff cleaning the ambulance.
● Cleaning of all surfaces and equipment should be done morning, evening and after every use
with soap/detergent and water.
● Disinfect (damp wipe) all horizontal, vertical and contact surfaces with a cotton cloth saturated
(or microfiber) with a 1% sodium hypochlorite solution. These surfaces include, but are not
limited to: stretcher, Bed rails, Infusion pumps, IV poles/Hanging IV poles, Monitor cables,
telephone, Countertops, sharps container. Spot clean walls (when visually soiled) with
disinfectant-detergent and windows with glass cleaner. Allow contact time of 30 minutes and
allow air dry.
● Damp mop floor with 1% sodium hypochlorite disinfectant.
● Discard disposable items and Infectious waste in a Bio/Hazard bag.
● Do not place cleaning cloth back into the disinfectant solution after using it to wipe a surface.
● Remove gloves and wash hands.

KEY LEARNING POINTS

● Health workers are at the front line of any outbreak response and as such are exposed to
hazards that put them at risk of infection with an outbreak pathogen (in this case COVID-
19).

● Infection prevention control (IPC) is a critical and integral part of clinical management of
patients and should be initiated at the point of entry of the patient to hospital.

● Standard Precautions are the minimum infection prevention practices that apply to all
patient care, regardless of suspected or confirmed infection status of the patient.

● Droplet precautions prevent large droplet transmission of respiratory viruses.

● Use a triple layer surgical mask if working within 1-2 metres of the patient.

● Health care workers should refrain from touching their eyes, nose, and mouth with
potentially contaminated gloved or ungloved hands.

● Apply airborne precautions when performing an aerosol generating procedure which

include N95 respirator and PPE.

● CDC recommends that standard, contact, and droplet precautions in addition to eye
protection be used for any patient with an undiagnosed respiratory infection who is not
under consideration for COVID-19.

● There should be ambulances identified specifically for transporting COVID suspect patients
or those who have developed complications, to the health facilities.

● The biomedical waste generated (including PPE) to be disposed off in a bio-hazard bag
(yellow bag).

64
● Patients with suspected or confirmed COVID-19 be placed in a single-occupancy room with
a closed door and dedicated bathroom .

● Patients with suspected or confirmed COVID-19 should be in a negative-pressure room.

● Health care workers should pay special attention to the appropriate sequence of putting on
and taking off PPE to avoid contamination.

● To help reduce the spread of COVID-19 virus, environmental infection control procedures
should also be implemented.

● All surfaces that may have come in contact with the patient or materials contaminated
during patient care (e.g., stretcher, rails, control panels, floors, walls and work surfaces)
should be thoroughly cleaned and disinfected using 1% Sodium Hypochlorite solution.

● Cleaning of all surfaces and equipment should be done morning, evening and after every
use with soap/detergent and water.

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 CHAPTER – 9

PERSONAL PROTECTIVE EQUIPMENT

LEARNING OBJECTIVE
● To study the importance of PPE in preventing the current spread of SARS-CoV-2.
● To study the type of personal protective equipment to be used in different settings.

INTRODUCTION
Some jobs can be dangerous. Workers who face potential injury on the job often have to use
protective equipment and healthcare workers are amongst those Jobs. Healthcare workers are also
put at risk of being diseased when they are exposed to germs that are in the environment. And we
have already understood that there is clear evidence of human-to-human transmission of SARS-CoV-
2. It is thought to be transmitted mainly through respiratory droplets that get generated when people
cough, sneeze, or exhale.

Healthcare-associated infection by SARS-CoV-2 virus has been documented among healthcare

workers in many countries.

The people most at risk of COVID-19 infection are those who are in close contact with a
suspect/confirmed COVID-19 patient or who care for such patients. Any individual who are at risk of
getting the disease can protect themselves by right use of PPE (Personal Protective Equipment)

Personal Protective Equipment (PPE)

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Personal Protective Equipments (PPEs) are protective gears designed to protect the health of
workers by minimizing the exposure to a biological agent(pathogen)

● Components of PPE are goggles, face-shield, mask, gloves, coverall/gowns (with or without
aprons), head cover and shoe cover.
Each component and rationale for its use is given in the following paragraphs:

A. Face shield and goggles

Contamination of mucous membranes of the eyes, nose and mouth is likely to happen:

- In a case of droplets generated by cough, sneeze of an infected person or during aerosol-

generating procedures carried out in a clinical setting.
- Inadvertently touching the eyes/nose/mouth with a contaminated hand is another likely
scenario.
Hence protection of the mucous membranes of the eyes/nose/mouth by using face shields/ goggles
is an integral part of standard and contact precautions.

Note: The flexible frame of goggles should provide a good seal with the skin of the face, covering the
eyes and the surrounding areas and even accommodating for prescription glasses

B. Masks
Respiratory viruses that include Coronaviruses target mainly the upper and lower respiratory tracts.
Hence protecting the airway from the particulate matter generated by droplets / aerosols prevents
human infection, which can be done using Masks.

Different Types of mask

The type of mask to be used is related to particular risk profile of the category of personnel and
his/her work. There are two types of masks which are recommended for various categories of
personnel working in hospital or community settings, depending upon the work environment:

■ Triple layer medical mask

■ N-95 Respirator mask

1. Triple layer medical mask:

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A triple layer medical mask is a disposable fluid-resistant mask that provides protection to the
wearer from droplets of infectious material emitted during coughing/sneezing/talking.

2. N-95 Respirator mask:

■ An N-95 respirator mask is a respiratory protective device with high filtration
efficiency to airborne particles.
■ To provide the required air seal to the wearer, such masks are designed to
achieve a very close facial fit.
■ If correctly worn, the filtration capacity of these masks exceeds those of
triple-layer medical masks.

C. Gloves

○ When a person touches an object/surface contaminated by COVID-19 infected

person, and then touches his own eyes, nose, or mouth, he may get exposed to the
virus. This can be prevented by use of gloves.
○ Although this is not thought to be a predominant mode of transmission, care should
be exercised while handling objects/surface potentially contaminated by
suspect/confirmed cases of COVID-19
○ Nitrile gloves are preferred over latex gloves because they resist chemicals, including
certain disinfectants such as chlorine.

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 ○ There is a high rate of allergies to latex and contact allergic dermatitis among health
workers. However, if nitrile gloves are not available, latex gloves can be used.

○ Non Powdered gloves are preferred to powdered gloves.

INTERESTING POINT:

The powder is sometimes added to gloves to make them easier to take on and off. But if the powder
on latex gloves becomes airborne, it can cause allergic reactions.

D. Coverall/Gowns

● Coverall/gowns are designed to protect the torso of healthcare providers from exposure to
viruses.
● Although coveralls typically provide 360-degree protection because they are designed to
cover the whole body, including back and lower legs and sometimes head and feet as well,
the design of medical/isolation gowns do not provide continuous whole-body protection
● Coveralls and gowns are deemed equally acceptable as there is a lack of comparative
evidence to show whether one is more effective than the other in reducing transmission to
health workers.
● Gowns are considerably easier to put on and for removal.
● Coveralls/gowns have strict standards to prevent exposure from biologically contaminated
solid particles to protecting from chemical hazards.
● Coverall

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 ○ Gown

E. Shoe covers

● Shoe covers should be made up of impermeable fabric to be used over shoes to facilitate
personal protection and decontamination

F. Head covers

● Coveralls usually cover the head.

● Those using gowns, should use a head cover that covers the head and neck while providing
clinical care for patients.
● Hair and hair extensions should fit inside the head cover.

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Points when using PPE

● PPEs are not alternative to basic preventive public health measures such as hand hygiene,
respiratory etiquettes which must be followed at all times.
● PPE must be put on in the proper order as it cannot be modified while in the patient-care
area.
● An observer should check the integrity of the PPE, making sure it is well adjusted, and write
the name and role of the person as well as the time of entry into the high-risk zone on the
apron.
● Always (if possible) maintain a distance of at least 1 meter from contacts/suspect/confirmed
COVID-19 cases
● The sequence of removal of PPE should be in the reverse order of putting on the PPE. Eye
protection should be put on in a way that it can be taken off as late as possible during the
PPE removal process.

NOTE: PPE should be put on and taken off in correct sequence and disposed in accordance with the
Biomedical Waste Management and Handing Rules 2016, 2018.

https://www.mohfw.gov.in/pdf/National%20Guidelines%20for%20IPC%20in%20HCF%20-
%20final%281%29.pdf

Rational use of PPE

The PPEs are to be used based on the risk profile of the health care worker.

The document describes the PPEs to be used in different settings according to risk profiles.

Following are the recommended PPE according to risk profile

A. Low risk profile:

1. Triple-layer medical mask
2. Gloves

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B. Moderate Risk profile

1. N-95 masks
2. Gloves
C. High risk

1. Full component of PPE

Risk profile for various activities in different settings are as follows :

1. Point of Entry:

● The Point of Entries (POEs) means the area where any international passenger may enter
legally from one country into another country.
● Health units responsible for undertaking measures for surveillance and response health
activities at airports/seaports/Land Border in C
● Primary objective of these organizations is preventing entry and transmission of infectious
diseases/ PHEIC across international borders along with ensuring a safe environment for
travellers at Point of Entries.

A. Low-risk profile includes activities such as:

● Provide information to travellers at Health Desk
● Provide services to the passengers at Immigration counters, customs and airport
security
● Record Temperature with hand held thermal recorder at a temperature recording
station.

B. Moderate-risk profile includes activities such as:

● Interview & Clinical examination by doctors/ nurses at Holding area/ Isolation facility
of APHO/ PHO.
● Clinical management at Isolation facility of APHO.
● Cleaning frequently touched surfaces/ Floor/ cleaning linen by sanitary staff

C. High-risk profile includes activities such as:

● Attending to severely ill passenger at Isolation facility of APHO.

2.Pre-hospital (Ambulance) Services

A. Low-risk profile includes activities such as:

○ Driving the ambulance
B. Moderate-risk profile includes activities such as:

72
 ○ Transporting patients not on any assisted ventilation
C. High-risk profile includes activities such as:
○ Management of SARI(severe acute respiratory illness) patient while transporting
3. Hospital Setting:

I. Out-Patient Department

A. Low-risk profile includes activities such as:

● Support in navigating various service areas for visitors accompanying young children
and elderlies.

NOTE: No other visitors should be allowed to accompany patients in OPD settings. The visitors thus
allowed should practice hand hygiene

B. Moderate-risk profile includes activities such as:

● People that provide information to patients at Screening area help desk/ Registration
counter
● Nurses / paramedic interacting with patients.
● Clinical management (doctors, nurses) in Doctors chamber
● Sanitary staff

II. In-patient Services

A. Low-risk profile includes activities such as:

○ Dead body transport to mortuary from ICU/ Critical care.
○ Taking care of the admitted patient by caretaker accompanying the admitted patient
B. Moderate-risk profile includes activities such as:
○ Clinical management in Individual isolation rooms
○ Sanitation of frequently touched surfaces/ floor/ changing linen
C. High-risk profile includes activities such as:

○ Critical care in ICU

○ Dead body packing in ICU/ Critical care

III. Emergency Department

A. Moderate-risk profile includes activities such as:

○ Attending emergency cases
B. High-risk profile includes activities such as:

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 ○ Attending to severely ill patients of SARI(severe acute respiratory illness).

6.Health Workers in Community Setting

A. Low-risk profile includes activities such as:

○ Field Surveillance by ASHAs/ Anganwadi and other field staff
B. Moderate-risk profile includes activities such as:
○ Field surveillance Clinical examination by doctors at supervisory level conducting
field investigation

Sequence of wearing PPE (Donning)

https://www.cdc.gov/hai/pdfs/ppe/ppe-sequence.pdf

To ensure proper infection control and asepsis it is important to wear the protective equipment in
correct order which is explained below

Step 1: Wear Gown

● Fully cover torso from neck to knees, arms to end of wrists, and wrap around the back
● Fasten in back of neck and waist

Step 2. Wear Mask or respirator

● Secure ties or elastic bands at middle of head and neck

● Fit flexible band to nose bridge
● Fit snug to face and below chin
● Fit-check respirator

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Step 3. Wear Goggles or face shield

● Place over face and eyes and adjust to fit

Step 4. Wear gloves

● Wear the gloves in dominant hand first (Touch only the inside of the glove cuff -the side of
the cuff that will be touching the skin.)
● Put the fingers of the gloved hand into the folded cuff of the other glove and place the glove
over the hand.
● Extend to cover the wrist of the isolation gown..

Note:

● Always put on essential required PPE when handling either a suspected, probable or
confirmed case of viral disease.
● The dressing and undressing of PPE should be supervised by another trained member of the
team.
● Gather all the necessary items of PPE beforehand. Put on the scrub suit in the changing
room.

Sequence to take off personal protective equipment (Doffing)

There are a variety of ways to safely remove PPE without contaminating your clothing, skin, or
mucous membranes with potentially infectious materials.Remove all PPE before exiting the patient
room except a respirator, if worn. Remove the respirator after leaving the patient room and closing
the door. Remove PPE in the following sequence:

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Note: Always remove PPE under the guidance and supervision of a trained observer (colleague)

Ensure that infectious waste containers are available in the doffing area for safe disposal of PPE.
Separate containers should be available for reusable items.

METHOD 1.

Step1. Remove gloves

● Outside of gloves are contaminated!

● If the hands get contaminated during glove removal, immediately wash the hands or use an
alcohol-based hand sanitizer
● Using a gloved hand, grasp the palm area of the other gloved hand and peel off first glove
● Hold removed glove in gloved hand
● Slide fingers of ungloved hand under remaining glove at wrist and peel off second glove over
first glove
● Discard gloves in a waste container

Step 2: Remove goggles and face shield

● Outside of goggles or face shield are contaminated

● If the hands get contaminated during goggle or face shield removal, immediately wash the
hands or use an alcohol-based hand sanitizer
● Remove goggles or face shield from the back by lifting head band or ear pieces
● If the item is reusable, place in designated receptacle for reprocessing. Otherwise, discard in
a waste container

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Step 3: Remove Gown

● Gown front and sleeves are contaminated!

● If the hands get contaminated during gown removal, immediately wash the hands or use an
alcohol-based hand sanitizer
● Unfasten gown ties, taking care that sleeves don’t contact the body when reaching for ties
● Pull gown away from neck and shoulders, touching inside of gown only
● Turn gown inside out
● Fold or roll into a bundle and discard in a waste container

Step 4: Remove mask or respirator

● Front of mask/respirator is contaminated — DO NOT TOUCH!

● If the hands get contaminated during mask/respirator removal, immediately wash the hands
or use an alcohol-based hand sanitizer
● Grasp bottom ties or elastics of the mask/respirator, then the ones at the top, and remove
without touching the front
● Discard in a waste container

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Step 5: Perform hand hygiene

Wash hands or use alcohol based hand sanitizer immediately after removing all PPE.

METHOD 2:

Step 1. Remove gown and gloves:

● Gown front and sleeves and the outside of gloves are contaminated!
● If the hands get contaminated during gown or glove removal, immediately wash the hands
or use an alcohol-based hand sanitizer
● Grasp the gown in the front and pull away from the body so that the ties break, touching
outside of gown only with gloved hands
● While removing the gown, fold or roll the gown inside-out into a bundle
● As you are removing the gown, peel off the gloves at the same time, only touching the
inside of the gloves and gown with the bare hands.

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 ● Place the gown and gloves into a waste container

Step 2: Remove goggles and face shield

Step 3: Remove Mask or respirator

Step 4: Perform hand hygiene

Step 2, step 3 and step 4 already explained above.

GOOD TO KNOW

● While working in the patient care area, outer gloves should be changed between patients
and prior to exiting (change after seeing the last patient).
● Appropriate decontamination of boots includes stepping into a footbath with 0.5% chlorine
solution (and removing dirt with toilet brush if heavily soiled with mud and/or organic
materials) and then wiping all sides with 0.5% chlorine solution.
● At least once a day boots should be disinfected by soaking in a 0.5% chlorine solution for 30
min, then rinsed and dried.

KEY LEARNING POINTS

● The people most at risk of COVID-19 infection are those who are in close contact with a
suspect/confirmed COVID-19 patient or who care for such patients. Any individual who are

79
 at risk of getting the disease can protect themselves by right use of PPE (Personal Protective
Equipment)
● Personal Protective Equipments (PPEs) are protective gears designed to protect the health
of workers by minimizing the exposure to a biological agent(pathogen)
● Components of PPE are goggles, face-shield, mask, gloves, coverall/gowns (with or without
aprons), head cover and shoe cover.
● Protection of the mucous membranes of the eyes/nose/mouth by using face shields/
goggles is an integral part of standard and contact precautions.
● A triple layer medical mask is a disposable fluid-resistant mask that provides protection to
the wearer from droplets of infectious material emitted during coughing/sneezing/talking.
● An N-95 respirator mask is a respiratory protective device with high filtration efficiency to
airborne particles.
● Coverall/gowns are designed to protect the torso of healthcare providers from exposure
to viruses.
● Coveralls typically provide 360-degree protection because they are designed to cover the
whole body, including back and lower legs and sometimes head and feet as well, the
design of medical/isolation gowns do not provide continuous whole-body protection.
● Shoe covers should be made up of impermeable fabric to be used over shoes to facilitate
personal protection and decontamination
● Those using gowns, should use a head cover that covers the head and neck while
providing clinical care for patients.
● PPEs are not alternative to basic preventive public health measures such as hand hygiene,
respiratory etiquettes which must be followed at all times.
● PPE must be put on in the proper order as it cannot be modified while in the patient-care
area
● An observer should check the integrity of the PPE, making sure it is well adjusted, and
write the name and role of the person as well as the time of entry into the high-risk zone
on the apron.
● The PPEs are to be used based on the risk profile of the health care worker.
A. Low risk profile:
1. Triple-layer medical mask
2. Gloves

B. Moderate Risk profile

1. N-95 masks
2. Gloves

C. High risk
1. Full component of PPE

● To ensure proper infection control and asepsis it is important to wear the protective
equipment in correct order as told
○ Wear Gown.
○ Wear Mask or respirator
○ Wear Goggles or face shield
○ Wear gloves

● Sequence to take off personal protective equipment (Doffing)

● Remove gloves

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● Remove goggles and face shield
● Remove Gown
● Remove mask or respirator
● Perform hand hygiene

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 CHAPTER – 10

SHORTAGE OF PERSONAL PROTECTIVE EQUIPMENT

LEARNING OBJECTIVES
 To know about optimum usage of PPE

INTRODUCTION

The World Health Organization has warned that severe and increasing interference to the global
supply of personal protective equipment (PPE) – caused by rising demand, panic buying, stocking and
misuse – is putting lives at risk from the novel coronavirus and other infectious diseases.

Healthcare workers rely on personal protective equipment to protect themselves and their patients
from being infected and infecting others.

But shortages are leaving doctors, nurses and other frontline workers dangerously ill-equipped to care
for COVID-19 patients, due to limited access to supplies such as gloves, medical masks, respirators,
goggles, face shields, gowns, and aprons.

“Without secure supply chains, the risk to healthcare workers around the world is real. Industry and
governments must act quickly to boost supply, ease export restrictions and put measures in place to
stop speculation and hoarding. COVID 19 can’t be stopped without protecting health workers first.

Since the start of the COVID-19 outbreak, prices have burst. Surgical masks have seen a sixfold
increase, N95 respirators have trebled and gowns have doubled.

Do you know: Based on WHO modelling, an estimated 890 lacs medical masks are required for the
COVID-19 response each month. For examination gloves, that figure goes up to 760 lacs, while
international demand for goggles stands at 16 lacs per month.

https://apps.who.int/iris/bitstream/handle/10665/331215/WHO-2019-nCov-IPCPPE_use-2020.1-
eng.pdf

Recommendations for optimizing the availability of PPE.

In view of the global PPE shortage, the following strategies can facilitate optimal PPE availability.

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Strategies to optimize the availability of personal protective equipment (PPE)

(1) Minimize the need for PPE

● Consider using telemedicine to evaluate suspected cases of COVID-19 disease, thus

minimizing the need for these individuals to go to healthcare facilities for evaluation.
● Use physical barriers to reduce exposure such as glass or plastic windows.
- This approach can be implemented in areas such as triage areas, the registration desk
at the emergency department or at the pharmacy window where medication is
collected.
● Restrict healthcare workers from entering the rooms of COVID-19 patients if they are not
involved in direct care.
- Consider bundling activities to minimize the number of times a room is entered (e.g.,
check vital signs during medication administration or have food delivered by
healthcare workers while they are performing other care) and plan which activities
will be performed at the bedside.
● Ideally, visitors will not be allowed but if this is not possible, restrict the number of visitors to
areas where COVID-19 patients are being isolate
- Restrict the amount of time visitors are allowed to spend in the area.
- Provide clear instructions about how to put on and remove PPE and perform hand
hygiene to ensure visitors avoid self-contaminationThe following interventions can
minimize
(2.) Ensure PPE use is rationalized and appropriate

PPE should be used based on the risk of exposure (e.g., type of activity) and the transmission dynamics
of the pathogen (e.g., contact, droplet or aerosol). The overuse of PPE will have a further impact on
supply shortages. Observing the following recommendations will ensure that the use of PPE
rationalized. The type of PPE used when caring for COVID-19 patients will vary according to the setting
and type of personnel and activity (Table 1).

● Healthcare workers involved in the direct care of patients should use the following PPE:
gowns, gloves, medical mask and eye protection (goggles or face shield).

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 ● Specifically, for aerosol-generating procedures (e.g., tracheal intubation, non-invasive
ventilation, tracheostomy, cardiopulmonary resuscitation, manual ventilation before
intubation, bronchoscopy) healthcare workers should use respirators, eye protection, gloves
and gowns; aprons should also be used if gowns are not fluid resistant.
● Respirators (e.g., N95, FFP2 or equivalent standard) have been used for an extended timey.
This refers to wearing the same respirator while caring for multiple patients who have the
same diagnosis without removing it, and evidence indicates that respirators maintain their
protection when used for extended periods.

Note: Using one respirator for longer than 4 hours can lead to discomfort and should be
avoided.

● Among the general public, persons with respiratory symptoms or those caring for COVID-19
patients at home should receive medical masks.
● For asymptomatic individuals, wearing a mask of any type is not recommended.

DID YOU KNOW:

Wearing medical masks when they are not indicated may cause unnecessary cost and a
procurement burden and create a false sense of security that can lead to the neglect of other
essential preventive measures.

(3.) Coordinate PPE supply chain management mechanisms.

The management of PPE should be coordinated through essential national and international supply
chain management mechanisms that include but are not restricted to:

● Using PPE forecasts that are based on rational quantification models to ensure the
rationalization of requested supplies;
● Monitoring and controlling PPE requests from countries and large responders;
● Promoting the use of a centralized request management approach to avoid duplication of
stock and ensuring strict adherence to essential stock management rules to limit wastage,
● Overstock and stock ruptures;
● Monitoring the end-to-end distribution of PPE;
● Monitoring and controlling the distribution of PPE from medical facilities stores.

GOOD TO KNOW:

❖ There has also been interest in decontamination of PPE for reuse, in particular for N95
respirators.
❖ The three methods for decontamination of respirators when supplies are critically low are as
follows:
○ Ultraviolet light
○ Hydrogen peroxide vapor
○ Moist heat

Note: These methods have been observed to inactivate other coronavirus but optimal time and
temperature, dose to inactivate SARS-CoV-2 are uncertain.

REFERENCES

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https://www.who.int/news-room/detail/03-03-2020-shortage-of-personal-protective-equipment-
endangering-health-workers-worldwide

https://apps.who.int/iris/bitstream/handle/10665/331215/WHO-2019-nCov-IPCPPE_use-2020.1-
eng.pdf

https://www.uptodate.com/contents/coronavirus-disease-2019-covid-19#H775838145.

85
86
87
KEY LEARNING POINTS

● Healthcare workers rely on personal protective equipment to protect themselves and their
patients from being infected and infecting others.
● But shortages are leaving doctors, nurses and other frontline workers dangerously ill-
equipped to care for COVID-19 patients, due to limited access to supplies such as gloves,
medical masks, respirators, goggles, face shields, gowns, and aprons.
● Strategies to optimize the availability of personal protective equipment (PPE)
-Minimize the need for PPE- Consider telemedicine, use physical barriers, restricted entry
to wards where patients stay.
- Ensure PPE use is rationalized and appropriate- PPE should be used based on the risk of
exposure (e.g., type of activity) and the transmission dynamics of the pathogen (e.g.,
contact, droplet or aerosol).
-Coordinate PPE supply chain management mechanisms- The management of PPE should
be coordinated through essential national and international supply chain management
mechanisms.

88
● Different PPE recommendations are made on the basis of healthcare setting, type of
healthcare personnel.
● Different settings can be
- Healthcare facility
-Community
- Points of entry

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 CHAPTER – 11

GUIDELINES FOR HANDLING, TREATMENT AND DISPOSAL OF

WASTE GENERATED DURING TREATMENT/DIAGNOSIS/
QUARANTINE OF COVID-19 PATIENTS

https://www.mohfw.gov.in/pdf/63948609501585568987wastesguidelines.pdf

LEARNING OBJECTIVES
● To study waste disposal in COVID19 isolation wards
● To study waste disposal from COVID 19 quarantine camps
● To study disposal protocol of PPE.
● To brief about BMWM rules 2016

Relevant terms

● CBWTF:Common Bio-medical Waste Treatment Facility

Common Bio-medical Waste Treatment Facility is a set up where biomedical waste,
generated from a number of healthcare units, is provided necessary treatment to reduce
adverse effects that this waste may pose.

The treated waste may finally be sent for disposal in a landfill or for recycling purposes.

● SPCB/PCC:State Pollution Control Board (SPCB)/ Pollution Control Committee (PCC)

They regulate and authorise safe handling and management of hazardous waste in an
environmentally sound manner.

● ULB’s:
Urban Local Bodies are the constitutionally provided administrative units, who provides
basic infrastructure and services in urban areas i.e cities and towns.

In order to deal with COVID-19 pandemic, State and Central Governments have initiated various
steps, which include setting up of quarantine centers/camps, Isolation wards, sample collection
centers and laboratories.

90
Guidelines for handling, treatment and disposal of COVID-19 waste at Healthcare Facilities,

Quarantine Camps/ Quarantine-homes/ Home-care, Sample Collection Centers, Laboratories,

SPCBs/PCCs, ULBs and CBWTFs is give below;

A. COVID-19 Isolation wards:

● Keep separate color coded bins/bags/containers in wards and maintain proper segregation
of waste as mentioned below in this chapter in BMWM rules 2016 .

● As precaution double layered bags (using 2 bags) should be used for collection of waste from
COVID-19 isolation wards so as to ensure adequate strength and no-leak

● Use dedicated trolleys and collection bins in COVID-19 isolation wards. A label “COVID-19
Waste” to be pasted on these items also.

● Use dedicated collection bin labelled as “COVID-19” to store COVID-19 waste and keep
separately in a temporary storage room prior to handing over to authorized staff of CBWTF.

- This marking would enable CBWTF to identify the waste easily for priority treatment
and disposal immediately upon the receipt.
● Collect and store biomedical waste separately prior to handing over the same CBWTF.

● Biomedical waste collected in such isolation wards can also be lifted directly from ward into
CBWTF collection van.
● Maintain separate record of waste generated from COVID-19 isolation wards

● The (inner and outer) surface of containers/bins/trolleys used for storage of COVID-19 waste
should be disinfected with 1% sodium hypochlorite solution daily.

● Report opening or operation of COVID-19 ward and COVID ICU ward to SPCBs and respective
CBWTF located in the area.

● Depute dedicated sanitation workers separately for biomedical waste and general solid
waste so that waste can be collected and transferred timely to temporary waste storage
area.

B.Sample collection centres and laboratories for covid-19 suspected patient

● Report opening or operation of COVID-19 sample collection centres and laboratories to

SPCBs and respective CBWTF located in the area.
● Guidelines given for isolation wards are suitably applied in case of test centres and
laboratories also

C. Responsibilities of persons operating Quarantine Camps/Homes or Home-Care facilities:

The persons responsible for operating quarantine camps/centers/home-care for suspected COVID-
19 persons need to follow the below mentioned steps to ensure safe handling and disposal of
waste

1. General solid waste (household waste)

- It should be handed over to the waste collector identified by Urban Local Bodies.

91
 2. Biomedical waste

Note: Biomedical waste at Quarantine Camps / Home-care will comprise of used syringes, date
expired or discarded medicines, used masks/gloves and in case of patients with other chronic
diseases may also include drain bags, urine bags, body fluid or blood soaked tissues/cotton, empty
ampules etc.

- It should be collected separately in yellow colored bags (suitable for biomedical waste
collection) provided by ULBs.
- These bags can be placed in separate and dedicated dust-bins of appropriate size.
- Contact details of CBWTFs would be available with Local Authorities and they should call
them as and when the biomedical waste gets generated.
- Persons operating Quarantine camps/centers or Quarantine-homes/Home-care should
report to ULBs in case of any difficulty in getting the services for disposal of solid waste or
biomedical waste

Note:

● CBWT facility reports to SPCBs/PCC about receiving waste and they dispose of that waste
immediately after receipt.They should maintain a separate record of collection, treatment
and disposal of COVID 19 waste.
● At CBWTF regular sanitization of workers as well as adequate PPE is provided. They use a
dedicated vehicle to collect COVID 19 waste which is further sanitized with sodium
hypochlorite and any other disinfectant after every trip.
● SPCBs maintain proper records of COVID 19 treatment wards/ quarantine centres/home
care in respective states and ensure proper collection and disposal of biomedical waste as
per guidelines.

Disposal protocol for PPE

http://www.hp.gov.in/dhsrhp/Guidelines_healthcare_June_2018.pdf

Bio Medical Waste Management Rules, 2016 categorises the bio-medical waste generated from the
health care facility into four categories based on the segregation pathway and colour code.

Various types of bio medical waste are further assigned to each one of the categories, as detailed
below:

1. Yellow Category:
● Human Anatomical Waste
● Animal Anatomical Waste(applicable to research centres)
● Soiled Waste(Items contaminated with blood, body fluids like dressings, plaster
casts, cotton swabs and bags containing residual or discarded blood and blood
components.)
● Discarded or Expired Medicine
● Chemical Waste

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 ● Chemical liquid (Separate collection system leading to an effluent treatment system,
e.g silver X-ray film developing liquid, discarded Formalin, etc).
● Microbiology, Biotechnology, and other clinical laboratory waste - Use Autoclave
safe plastic bags or containers (eg. - Blood bags, Laboratory cultures, stocks or
specimens of microorganisms, live or attenuated vaccines, human and animal cell
cultures used in research)
● Discarded linen, mattresses, beddings contaminated with blood or body fluid,
routine mask & gown.

2. Red Category
● Wastes generated from disposable items such as tubing, bottles, intravenous tubes
and sets, catheters, urine bags, syringes without needles, fixed needle syringes with
their needles cut, vaccutainers and gloves

3. White Category
● Waste Sharps including discarded and contaminated metals
● Puncture proof, Leakproof, tamper-proof containers

4. Blue Category
● Glassware - Broken or discarded and contaminated glass including medicine vials
and ampoules except those contaminated with cytotoxic wastes.
● Metallic Body Implants

Disposable PPE come under yellow category and are to be disposed off in yellow bin after proper
removal.

KEY LEARNING POINTS

 Keep separate color coded bins/bags/containers in wards and maintain proper segregation of
waste as mentioned below in this chapter in BMWM rules 2016 .
 Double layered bags (using 2 bags) should be used for collection of waste from COVID-19
isolation wards.
 Use dedicated collection bin labelled as “COVID-19” to store COVID-19 waste
 The (inner and outer) surface of containers/bins/trolleys used for storage of COVID-19 waste
should be disinfected with 1% sodium hypochlorite solution daily.
 At CBWTF regular sanitization of workers as well as adequate PPE is provided. They use a
dedicated vehicle to collect COVID 19 waste which is further sanitized with sodium
hypochlorite and any other disinfectant after every trip.
 Bio Medical Waste Management Rules, 2016 categorises the bio-medical waste generated
from the health care facility into four categories based on the segregation pathway and colour
code namely yellow, red, white and blue.

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 CHAPTER – 12

COVID 19 EXPOSURE IN HEALTH CARE WORKERS

https://www.cdc.gov/coronavirus/2019-ncov/hcp/guidance-risk-assesment-hcp.html

https://www.uptodate.com/contents/coronavirus-disease-2019-covid-19#H3694780754

LEARNING OBJECTIVES
● To know about monitoring of covid 19 signs/symptoms.
● To understand assessment of risk exposures.
● To study monitoring recommendations based on exposure risk categories.
● To know about insurance scheme for HCP

INTRODUCTION
Health workers are at the front line of the COVID-19 outbreak response and as such are exposed to
hazards that put them at risk of infection. For health care workers who have had a potential exposure
to COVID-19, the CDC has provided guidelines for work restriction and monitoring.

The approach depends upon

● The duration of exposure,

● Patient's symptoms, whether the patient was wearing a medical mask
● Type of PPE used by the provider, and whether an aerosol-generating procedure was
performed.

1. Monitoring for signs/symptoms

HCP should be carefully monitored for any signs or symptoms of disease.Monitoring can be as
follows:

A. Self-monitoring
○ Self-monitoring means HCP should monitor themselves for fever by taking their
temperature twice a day and remain alert for symptoms of COVID-19.

B. Active monitoring
○ Active monitoring means that the state or local public health authority assumes
responsibility for establishing regular communication with potentially exposed people
to assess for the presence of fever or symptoms of COVID-19
○ For HCP with high- or medium-risk exposures, CDC recommends this communication
occurs at least once each day.

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 Modes of communication may include telephone calls or any electronic or internet-
based means of communication.

C. Self-Monitoring with delegated supervision

○ On days HCP are scheduled to work, healthcare facilities could consider measuring
temperature and assessing symptoms prior to starting work.
○ HCP perform self-monitoring with oversight by their healthcare facility’s occupational
health

2. Exposure risk category

Any public health decisions that place restrictions on an individual’s or group’s movements or impose
specific monitoring requirements should be based on an assessment of risk for the individual or group.

● High-risk exposures
○ high-risk exposures refer to HCP who have had prolonged close contact with patients
with COVID-19 who were not wearing a facemask while HCP nose and mouth were
exposed to material potentially infectious with the virus causing COVID-19.
○ Being present in the room for procedures that generate aerosols or during which
respiratory secretions are likely to be poorly controlled (e.g., cardiopulmonary
resuscitation, intubation, extubation, bronchoscopy, nebulizer therapy, sputum
induction) on patients with COVID-19 when the healthcare providers’ eyes, nose, or
mouth were not protected, is also considered high-risk.

● Medium-risk exposures
○ Medium-risk exposures generally include HCP who had prolonged close contact with
patients with COVID-19 who were wearing a facemask while HCP nose and mouth
were exposed to material potentially infectious with the virus causing COVID-19.

● Low-risk exposures
○ Low-risk exposures generally refer to brief interactions with patients with COVID-19
or prolonged close contact with patients who were wearing a facemask for source
control while HCP were wearing a facemask or respirator. Use of eye protection, in
addition to a facemask or respirator would further lower the risk of exposure.

Note:

● HCP with no direct patient contact and no entry into active patient management areas who
adhere to routine safety precautions do not have a risk of exposure to COVID-19 (i.e., they
have no identifiable risk).
● Currently, this guidance applies to HCP with potential exposure in a healthcare setting to
patients with confirmed COVID-19. However, HCP exposures could involve a person under
investigation (PUI) who is awaiting testing.

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 - Implementation of monitoring and work restrictions described in this guidance could be
applied to HCP exposed to a PUI if test results for the PUI are not expected to return within 48
to 72 hours.

-A record of HCP exposed to a PUI should be maintained and HCP should be encouraged to perform
self- monitoring while awaiting test results.

- - If the results will be delayed more than 72 hours or the patient is positive for COVID-19, then
the monitoring and work restrictions described in this document should be followed.

Note: Some local health departments allow health care workers to return to work following an
exposure if they adhere to cough and hand hygiene, wear a medical mask while at the health care
facility until 14 days after the exposure, and monitor daily for fever or respiratory symptoms, the
presence of which would prompt immediate self-isolation

Epidemiologic risk Exposure category Recommended Work Restrictions for

factors Monitoring for COVID- Asymptomatic HCP
19

Prolonged close contact with a patient with COVID-19 (beginning 48 hours before symptom onset)
who was wearing a cloth face covering or facemask (i.e., source control)

HCP Medium Active Exclude from work for

14 days after last
PPE: None exposure

HCP Medium Active Exclude from work for

14 days after last
PPE: Not wearing a face exposure
mask or respirator

HCP Low Self with delegated None

supervision
PPE: Not wearing eye
protection

HCP Low Self with delegated None

supervision
PPE: Not wearing gown
or gloves

HCP Low Self with delegated None

supervision
PPE: Wearing all
recommended PPE

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 (except wearing a
facemask instead of a
respirator)

Prolonged close contact with a patient with COVID-19 (beginning 48 hours before symptom onset)
who was not wearing a cloth face covering or facemask (i.e., no source control)

HCP High Active Exclude from work for

14 days after last
PPE: None exposure

HCP High Active Exclude from work for

14 days after last
PPE: Not wearing a exposure
facemask or respirator

HCP Medium Active Exclude from work for

14 days after last
PPE: Not wearing eye exposure
protection

HCP Low Self with delegated None

supervision
PPE: Not wearing gown
or gloves

HCP Low Self with delegated None

supervision
PPE: Wearing all
recommended PPE
(except wearing a
facemask instead of a
respirator)

III. Recommendations for Monitoring Based on COVID-19 Exposure Risk

HCP in any of the risk exposure categories who develop signs or symptoms compatible with COVID-19
must contact their established point of contact for medical evaluation prior to returning to work.

● HCP in the high- or medium-risk category

○ They should undergo active monitoring, including restriction from work in any
healthcare setting until 14 days after their last exposure.
○
● HCP in the low-risk category
○ They should perform self-monitoring with delegated supervision until 14 days after
the last potential exposure.
○ Asymptomatic HCP in this category are not restricted from work.

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 ○ They should check their temperature twice daily and remain alert for symptoms
consistent with COVID-19
○ On days HCP are scheduled to work, healthcare facilities could consider measuring
temperature and assessing symptoms prior to starting work.

● HCP who Adhere to All Recommended Infection Prevention and Control Practices
○ Proper adherence to currently recommended infection control practices, including all
recommended PPE, should protect HCP having prolonged close contact with patients
infected with COVID-19.
○ However, to account for any inconsistencies in use or adherence that could result in
unrecognized exposures, HCP should still perform self-monitoring with delegated
supervision as described under the low-risk exposure category.
● HCP in the no identifiable risk category
○ They do not require monitoring or restriction from work.
● HCP with community- or travel-associated exposures to COVID-19
○ HCP with community- or travel-associated exposures to COVID-19 should inform their
facility’s occupational health program that they have had a community or travel-
associated exposure.
○ Decisions about restriction from work should be made in consultation with the
occupational health program.

If HCP’S develop any fever/ symptoms consistent with COVID-19 they should immediately self-isolate
(separate themselves from others) and notify their local or state public health authority and
healthcare facility promptly so that they can coordinate consultation and referral to a healthcare
provider for further evaluation.

Pradhan Mantri Garib Kalyan Package:Insurance Scheme for Health Workers Fighting COVID-19

While most citizens stay confined to their respective homes, healthcare workers at hospitals are
attending to the infected, being exposed to the dreadful virus.
HCP are rightfully described as warriors by many.

All the recognition and cheering from windows, balconies, and mobile phones may have brought
smiles on the faces of HCP but most of them are overworked personnel who are under
overwhelming stress, aggravated further by the lack of enough protective gear in the country.
The New India Assurance has initiated immediate risk coverage for healthcare workers on March 30,
2020, following the announcement by the Finance Minister recently.

Here are few details about the scheme

A. Policy
An accident insurance scheme to provide insurance cover of Rs. 50 lakh for ninety (90) days to a
total of around 22.12 lakh on loss of life due to COVID and COVID 19 related duties.

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 B. People Covered under the scheme
● Public health care workers like community health workers,
- In direct contact and care of COVID-19 patients
- At risk of being impacted by this.
Note: It will also include accidental loss of life on account of contracting COVID-19.

● Private hospital staff/ retired/volunteer/ local urban bodies/contract/daily wage/ ad-

hoc/outsourced staff requisitioned by States/ Central hospitals/autonomous hospitals of
Central/States/UTs, AIIMS & INIs/ hospitals of Central Ministries can also be drafted for
COVID-19 related responsibilities.

C. Process of submission of claim

1. The claimant needs to fill up a claim form along with necessary documents as prescribed
(can be referred from and submit the same to the Healthcare Institution/ organization/
office where the deceased was an employee of /engaged by the institution.

2. The respective institution will give necessary certification and forward it to competent
authority.

GOOD TO KNOW

● Competent authority for State/UT is

○ Director General Health Services
○ Director Health Services
○ Director Medical Education
● Competent authority for Central Government, Central Autonomous / PSU Hospitals, AIIMS,
INIs and Hospitals of other Central Ministries is
○ Director or Medical Superintendent or Head of the concerned institution.

3. Competent authorities will forward and submit claims to the insurance company for
approval.
Note:

● The duration of the policy is for a period of 90 days, starting from March 30, 2020.
● The entire amount of premium for this scheme is being borne by the Ministry of Health and
Family Welfare, Government of India.

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 ● Laboratory report certifying positive medical test is required for loss of life on account of
COVID-19. However, it is not required in case of Accidental loss of life on account of COVID-
19 related duty.

KEY LEARNING POINTS

● Healthcare workers are the first line of response
● Monitoring for signs/symptoms
-Self-monitoring- check temperature twice daily.
-Active monitoring- alert the public health authorities, maintain proper communication.
-Self-Monitoring with delegated supervision- temperature and associated symptoms
checked before joining work everyday.
● HCP can be categorized into-
1. HIGH EXPOSURE RISK
-Interaction with patient without facemask.
- If HCP is present during aerosol generating procedure

2.MEDIUM RISK EXPOSURE

-Prolonged close contact with patients with COVID-19 who were wearing a facemask.

3.LOW RISK EXPOSURE

-Brief interactions with patients
-Prolonged close contact with patients and HCP wearing facemask
-Use of eye protection, in addition to a face mask or respirator would further lower risk of
exposure
● HCP monitoring can be categorized into-
○ HCP in the high- or medium-risk category
■ They should undergo active monitoring, including restriction from work in
any healthcare setting until 14 days after their last exposure.
○ HCP in the low-risk category
■ They should perform self-monitoring with delegated supervision until 14
days after the last potential exposure.
■ Asymptomatic HCP in this category are not restricted from work.
■ They should check their temperature twice daily and remain alert for
symptoms consistent with COVID-19
●

○ HCP who Adhere to All Recommended Infection Prevention and Control Practices
■ Proper adherence to recommended infection control practices, including
all recommended PPE, should protect HCP having prolonged close contact
with patients infected with COVID-19.
■ HCP should still perform self-monitoring with delegated supervision as
described under the low-risk exposure category.
○ HCP in the no identifiable risk category
■ They do not require monitoring or restriction from work.
○ HCP with community- or travel-associated exposures to COVID-19

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 ■ HCP with community- or travel-associated exposures to COVID-19 should
inform their facility’s occupational health program that they have had a
community or travel-associated exposure.
■ Decisions about restriction from work should be made in consultation with
the occupational health program.

● Pradhan Mantri Garib Kalyan Package: Insurance Scheme for Health Workers Fighting
COVID-19
● Accident insurance scheme to provide insurance cover of Rs. 50 lakh for ninety (90) days to
a total of around 22.12 lakh on loss of life due to COVID and COVID 19 related duties
● People Covered under the scheme
-Public health care workers like community health workers
-In direct contact and care of COVID-19 patients
-At risk of being impacted

REFERENCES:

https://www.mohfw.gov.in/pdf/FAQPradhanMantriGaribKalyanPackageInsuranceSchemeforHeal
thWorkersFightingCOVID19.pdf
https://economictimes.indiatimes.com/news/economy/policy/government-approves-insurance-
scheme-for-health-workers-fighting-covid-
19/articleshow/74875243.cms?utm_source=contentofinterest&utm_medium=text&utm_campaign=
cppst
https://www.mohfw.gov.in/pdf/PMInsuranceSchemePosterC.pdf
https://www.uptodate.com/contents/coronavirus-disease-2019-covid-19#H3694780754

FAQPradhanMantriGaribKalyanPackageInsuranceSchemeforHealthWorkersFightingCOVID19.pdf)

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 CHAPTER – 13

MENTAL HEALTH DURING COVID – 19

LEARNING OBJECTIVES
● Advice to prevent mental and social stigma for general public
● Caring for elderly during lockdown
● Care for children during lockdown
● Handling emotional problems
● Mental health of patients recovered from covid19
● Mental health of depressed individuals
● Messages for healthcare workers
● Messages for team leaders or managers in health facilities

Hearing about the spread of COVID-19 from all over the world, through television, social media,
newspapers, family and friends and other sources can be difficult times for everyone .The most
common emotion faced by all is Fear. It makes everyone anxious, panicky and can even possibly make
them think, say or do things that might not be considered appropriate under normal circumstances.

Since work style and routine have changed so drastically, also the negative affect on financial stability
along with fact of being confined at home can lead to symptoms of depression

Under this chapter, we will be studying various strategies, to improve the individual well being and
tackle this situation in a better manner.

Do’s to prevent mental and social stigma for general public

1. Be busy and distract oneself from negativity

● Have a regular schedule. Help in doing some of the work at home(Cooking and cleaning)
● Listen to music, read, watch an entertaining programme on television.
● Engage in old hobbies like painting, gardening or stitching, go back to them.

2. Eat well and drink plenty of fluids.

3. Be physically active
● Do simple indoor exercises like yoga that will keep the person physically as well as mentally
fit.

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 4. Spend quality time with family
● Understand if someone around you needs advice, food or other essentials. Be willing to
share.
● Connect to loved one on video calls/ phone to keep the stress at bay
● Elderly people may feel confused, lost and need help. Offer them help by getting them what
they need, their medicines, daily needs etc.
● Children are very sensitive and vulnerable, provide them assurance whenever needed.
5. Focus on facts:
- It reduces the fear one may feel.
- Make sure to access and believe only the most reliable sources of information for self-
protection.

DON’TS TO PREVENT MENTAL AND SOCIAL STIGMA

1. Avoid tobacco, alcohol and other drugs.

- Their use to cope with emotions and boredom can worsen physical, mental health and
reduce immunity.
- People who already have a substance use problem may require professional help,especially
when they feel low in mood or stressed.

2. Avoid watching news on covid-19 pandemic and discussing it all the time
- Do not follow sensational news or social media posts which may impact the mental state.
- Do not spread or share any unverified news or information further.
- Do not keep discussing all the time about who got sick and how. Instead learn about who got
well and recovered.
- Avoid spreading fear and panic.

3. Do not target/harm healthcare and sanitary workers or police. They are there to help you.

4. Don’t discriminate against COVID 19 patients, have empathy for them.

a. Avoid addressing those under treatment as COVID victims. Address them as ‘’people
recovering from COVID.
b. Never spread names or identity of those affected or under quarantine or their
locality on the social media.
c. Do not label any community or area for spread of COVID-19.

SPECIAL CARE FOR CHILDREN: Parenting guide

https://www.who.int/emergencies/diseases/novel-coronavirus-2019/advice-for-public/healthy-
parenting

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Parents should plan with their kids one-on-one time, staying positive, creating a daily routine,
avoiding bad behaviour, managing stress, and talking about COVID-19.

1. One on one time

● School shutdown is also a chance to make better relationships with our children and
teenagers.
● One-on-One time is free and fun. It makes children feel loved and secure, and shows
them that they are important.
● It can be for just 20 minutes, or longer.
● It can be at the same time each day so children or teenagers can look forward to it.
● If children want to do something that isn’t OK with physical distancing, then this is a
chance to talk with them and explain about social distancing.

Interesting idea:

Tell a story, read a book, or share pictures

Make drawings with crayons or pencils

Dance to music or sing songs

Cook a favorite meal together

Exercise together to children’s favorite music

2. Keeping it positive
● Use positive words when telling a child what to do; like ‘Please put your clothes
away’ (instead of ‘Don’t make a mess’)
● Get your child’s attention by using their name. Speak in a calm voice.
● Try praising your child or teenager for something they have done well. They may not
show it, but you'll see them doing that good thing again. It will also reassure them
that you notice and care.
● Teens especially need to be able to communicate with their friends. Help your teen
connect through social media and other safe distancing ways.
3. Create a daily routine
● Create a flexible but consistent daily routine
● Children or teenagers can help plan the routine for the day – like making a school
timetable. Children will follow this better if they help to make it.
● At the end of each day, take a minute to think about the day. Tell your child about
one positive or fun thing they did.

4. Avoid bad behaviour

● All children misbehave. It is normal when children are tired, hungry, afraid, or
learning independence

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 ● Catch bad behavior early and redirect your kids’ attention from a bad to a good
behavior
● Stop it before it starts! When they start to get restless, distract them with something
interesting or fun: “Come, let’s play a game together."
● Consequences help to teach children responsibility for what they do.
● Using consequences is more effective than hitting or shouting.
● Once the consequence is over, give the child a chance to do something good, and
praise them for it.

5. Managing stress
● Listen to the kids: Listen to the children when they share how they are feeling.
Accept how they feel and give them comfort.

● Take a break: When the children are asleep, do something fun or relaxing for
yourself. Make a list of healthy activities that YOU like to do.
● Take a Pause 1-minute relaxation activity that you can do whenever you are feeling
stressed or worried

6. Talk about COVID-19

● Allow children to talk freely. Ask them open questions and find out how much they
already know.
● Always answer their questions truthfully. Think about how old the child is and how
much they can understand.
● Explain that COVID-19 has nothing to do with the way someone looks, where they
are from, or what language they speak.
Tell the children that it is good to be compassionate to people who are sick and
those who are caring for them

ADVICE FOR CARE FOR ELDERLY

Older people who are lonely and don't have strong social networks and support can be at risk of
developing mental health conditions such as depression.

Here are few suggestions for elderly which help in staying healthy mentally and physically

1. Spend quality time with family

2. Get involved in daily activities
3. Spending time on recreational activities.
4. Stay connected to loved one
5. Make some time for exercise such as yoga and breathing exercise

Mental health of recovered COVID - 19 patients

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While it is wonderful to recover from Covid infection, one may actually face stress after they have
recovered and wish to get back into the community.

- They may have fear about their loved ones falling ill.
- People who do not understand the illness well may actually keep you at a distance, which is
also very stressful and isolating.
- They may experience feelings of guilt that they were not able to work or care for others.
- This may lead to feelings of depression, helplessness or frustration.

Use the ways mentioned earlier to deal with these feelings.

Share positive stories of people that recovered from SARS COV 2 infection.

Mental health of depressed individuals

Persons who had previous mental illness may face new challenges during self-isolation:

1.They would also have the same fears and stress as others which may worsen their previous
mental health condition

2.Social isolation may make them more withdrawn, moody and irritable

3.They may not seek/ get easy access to medicines and counselling

Handling emotions of anxiety / fear / sadness

● Practice breathing slowly for a few minutes.

● Try and distance the thoughts that are making you anxious.
● Think of something calm and serene, and slow down your mind
● Calm your mind, counting back from 10 to 1, distracting yourself helps.
● Discuss happy events, common interests, exchange cooking tips, share music.
● Talk to yourself and try and come out of this with positivity
Note: If any of these emotions persist continuously for several days,despite trying to get out of it,
talk about it with someone.

If the feelings worsen, a person may feel helpless, hopeless and feel that life is not worth living.

If that happens, call at helpline number(080-46110007) for advice from a mental health professional
or contact your doctor.

Important note :

- Recognize mental health problems in your near and dear ones by observing the following:
1. Changes in sleep patterns

2. Difficulty in sleeping and concentrating

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 3. Worsening of health problems

4. Increased use of alcohol, tobacco or drugs

- Be supportive to them. If the problems persist, please contact the helpline (080-
46110007) or contact your doctor or a mental health professional.

Mental health of HEALTHCARE WORKERS

https://www.who.int/docs/default-source/coronaviruse/mental-health-considerations.pdf

Like most of the general public, the healthcare professionals are also going through mental stress
and feeling under pressure is a likely experience for them and many of their colleagues.It is quite
normal to be feeling this way in the current situation. Stress and the feelings associated with it are
by no means a reflection that they cannot do your job or that they are weak.

Managing the mental health and psychosocial well-being during this time is as important as
managing physical health.

Remember - This is not a sprint; it’s a marathon

Methods to relieve stress and cope up.

● Try and use helpful coping strategies such as ensuring sufficient rest and respite during work
or between shifts,
● Eat sufficient and healthy food,
● Engage in physical activity, and stay in contact with family and friends.
● Stay connected for support
Some healthcare workers may unfortunately experience avoidance by their family or community
owing to stigma or fear. This can make an already challenging situation far more difficult.

- If possible, staying connected with loved ones, including through digital methods, is one way
to maintain contact.
- Turn to colleagues, manager or other trusted persons for social support – they may be
having similar experiences.

Messages for team leaders or managers in health facilities

1.Focus on long term well being of staff

● Keeping all staff protected from chronic stress and poor mental health during this response
means that they will have a better capacity to fulfil their roles.

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 ● Be sure to keep in mind that the current situation will not go away overnight and you should
focus on longer-term occupational capacity rather than repeated short-term crisis
responses.

2. Healthy communication encourages support and up to date information

● Ensure that good quality communication and accurate information updates are provided to
all staff.
● Rotate workers from higher-stress to lower-stress functions. Partner inexperienced workers
with their more experienced colleagues.
● The buddy system helps to provide support, monitor stress and reinforce safety procedures.
Ensure that outreach personnel enter the community in pairs. Initiate, encourage and
monitor work breaks. Implement flexible schedules for workers who are directly impacted or
have a family member affected by a stressful event.
● Ensure that you build in time for colleagues to provide social support to each other.

3. Psychological first aid

Orient all responders, including nurses, ambulance drivers, volunteers, case identifiers, teachers and
community leaders and workers in quarantine sites, on how to provide basic emotional and practical
support to affected people using psychological first aid.

4.Dont delay mental health/neurological complaints

Manage urgent mental health and neurological complaints (e.g. delirium, psychosis, severe anxiety
or depression) within emergency or general healthcare facilities.

https://apps.who.int/iris/bitstream/handle/10665/44615/9789241548205_eng.pdf;jsessionid=40
03C2282A733642F9224A1EFBCBE27E?sequence=1

GOOD TO KNOW

Psychological First Aid (PFA) describes a humane, supportive response to a fellow human being who
is suffering and who may need support.

PFA involves the following :

»providing practical care and support, which does not intrude;

»assessing needs and concerns;

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»helping people to address basic needs (for example, food and water, information);

»listening to people, but not pressuring them to talk;

»comforting people and helping them to feel calm;

»helping people connect to information, services and social supports;

»protecting people from further harm.

INTERESTING POINT

It is not something that only professionals like psychiatrists can do but any health care worker or
ordinary person can also help too.

KEY LEARNING POINTS

● Do’s to prevent mental and social stigma for general public
○ Be busy and distract oneself from negativity
○ Eat well and drink plenty of fluids.
○ Be physically active
○ Spend quality time with family
○ Focus on facts
● DON’TS TO PREVENT MENTAL AND SOCIAL STIGMA
○ Avoid tobacco, alcohol and other drugs.
○ Avoid watching news on covid-19 pandemic and discussing it all the time
○ Do not target/harm healthcare and sanitary workers or police.
○ Don’t discriminate against COVID 19 patients, have empathy for them
● Parents should plan with their kids one-on-one time, staying positive, creating a daily
routine, avoiding bad behaviour, managing stress, and talking about COVID-19.
● Explain to children that COVID-19 has nothing to do with the way someone looks, where
they are from, or what language they speak.
● Older people who are lonely and don't have strong social networks and support can be at
risk of developing mental health conditions such as depression. Getting them more
involved in family and daily activities along with some yoga helps in staying motivated.
● Share positive stories of people that recovered from SARS COV 2 infection.
● Like most of the general public, the healthcare professionals are also going through mental
stress.
● Some healthcare workers may unfortunately experience avoidance by their family or
community owing to stigma or fear. They should turn to colleagues, manager or other
trusted persons for social support – they may be having similar experiences.
● Team leaders should focus on long term well being of staff.
● Team leaders should ensure that good quality communication and accurate information
updates are provided to all staff

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 CHAPTER – 14

COVID 19: GOVERNMENT INITIATIVES

LEARNING OBJECTIVES
● To know about important measures taken by the government of India to fight against COVID 19
1. Protecting Health care workers
2. Engaging communities to protect those at highest risk of severe disease
3. Supporting vulnerable countries in containing infection
● To know about the impact of government measures.
1. Effect on disease control
2. Socio-economic impact

INTRODUCTION
On January 30, 2020, the WHO declared the COVID-19 outbreak a public health emergency of
international concern. In March 2020, WHO began to characterize it as a pandemic in order to
emphasize the gravity of the situation and urge to take action in detecting infection and preventing
spread.

MEASURES TO PREVENT THE FURTHER SPREAD

The WHO has indicated three priorities for countries:
1. Protecting Health care workers
2. Engaging communities to protect those at highest risk of severe disease
3. Supporting vulnerable countries in containing infection

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The Government of India is taking all necessary steps to ensure that we are prepared well to face the
challenge and threat posed by the growing pandemic of COVID-19 the CoronaVirus.
Several proactive preventive and mitigating measures taken by government include

1. LOCKDOWN IMPOSED BY THE GOVERNMENT OF INDIA

● Lock down is a state of isolation or restricted access instituted as a security measure to prevent
the further spread of the COVID 19.
● On March 25, the government invoked the Disaster Management Act, 2005 and imposed a
21-day nationwide lockdown to prevent the spread of COVID-19 until April 14 (Restricted
movements with access to emergency services only). On April 14, Prime Minister Narendra
Modi extended the nationwide lockdown until May 3. - State borders are sealed, inter-state
movement within the country stopped.

Again the government announced the extension of lockdown from 4th May to 17th with
some restrictions and guidelines as COVID 19 cases increases.

● Camps have been set up at state borders to stop migrant workers walking back to their
villages. According to the government, these camps are also providing workers with basic
amenities such as shelter and food.
● All health services (including AYUSH) remains functional such as
- Hospitals.nursing homes, clinics, telemedicine facilities.
- Dispensaries, chemists, pharmacies, and medical equipment shops.
- Medical laboratories and collection centres.
- Pharmaceutical and medical research labs, institutions carrying out COVID 19 related
research.
- Veterinary hospitals, dispensaries, clinics, pathology labs, sale and supply of vaccine
and medicine.
- Authorised private establishment, which support the provisioning of essential
services, including home care providers, diagnostics, supply chain firms serving
hospitals.
- Manufacturing units of drugs, pharmaceuticals, medical devices, medical oxygen etc.
- Construction of medical/ health infrastructure, including ambulance.
- Movement of all medical personnels.
2. PROGRESSIVE TIGHTENING OF INTERNATIONAL BORDERS

- All international flights are suspended, except for the ones that have been granted
permission to evacuate foreign nationals. All existing visas, barring a few categories
have been suspended.

3. Temporary suspension of metro and rail services as well as domestic air traffic.

- All domestic flights are suspended, except those carrying essential goods across the country.

- All bus, train, and metro services are suspended.

4. Contact tracing of persons infected by the virus and various social distancing measures.
- The process of identification of persons who may have come into contact with an
infected person ("contacts") and subsequent collection of further information about

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 these contacts. By tracing the contacts of infected individuals, testing them for
infection, treating the infected and tracing their contacts in turn, public health aims
to reduce infections in the population.
- Several states have identified COVID-19 hotspots, and have taken measures to seal
and sanitize such high-risk zones.

5. Setting up quarantine facilities

- Dedicated COVID-19 quarantine sites have been set-up including hotels and railway
wagons.

6. Issue of health advisories for the members of the public

- Frequent handwashing
- Coughing and sneezing etiquettes
- Proper Disposal of waste
- Social distancing

7. Several advisories have been issued to States and Union Territories (UTs) for taking
necessary measures to contain the spread of this virus.
8. Other measures:
● Providing health facilities

- 586 hospitals and 100,000 isolation beds designated exclusively for treatment and
care of COVID-19 patients across the country. This number is continuously increasing
with the measures being taken by the state governments and the health ministry.
- INR 150 billion (US$2.14 billion) will be spent to set up isolation wards and intensive
care units (ICUs), procure ventilators and personal protection equipment for medical
professionals, and to train health workers to fight COVID-19.
-
● Providing food facilities to the needy
- INR 170000 crore (US$24.3 billion) relief package in the form of food grains, cash
transfers for the poor and vulnerable sections of the population announced to deal
with the hardships caused due to the lockdown.
- PM-CARES fund launched to provide food and care to the poor. Donations being
sought to augment resources for this fund.
● Financial support
- The finance ministry has extended several compliance deadlines under the various
corporate, mercantile and taxation laws, and allowed individuals to make partial
withdrawals from their provident fund accounts.
- The Reserve Bank of India (RBI) has taken a number of steps to ease the stress
caused by COVID-19. This includes ease in interest rates and other liquidity
improvement measures such as moratorium on repayment of loans by businesses
and EMIs by individual borrowers.
● Aarogya Setu App has been launched by the government to disseminate information related
to COVID-19 and to provide a platform for the population to reach out to the government.

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Note: The most important factor in preventing the spread of the Virus locally is to empower the
citizens with the right information and taking precautions as per the advisories being issued by the
Ministry of Health & Family Welfare.

EFFECT OF MEASURES
A. ON DISEASE CONTROL

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 ● Flattened the COVID 19 growth curve
- By reducing the projected number of symptomatic novel coronavirus cases in India,
thereby reducing the exponential increase in covid 19 cases.
● Gain more opportunities for interventions to control the spread of the virus meantime, and
reduce the burden on the health care system.

Do you know:
Measures had prevented the shift of India from second phase of the COVID-19 outbreak, with the
disease spreading to close contacts,to third phase of it ie community transmission.
All measures that limit the spread of virus must be continued, which not only limit any individual's
infection hazard, but also protect the entire community. These measures may include, avoiding large
gatherings, 14-day quarantine for suspected cases of infection, systematic surveillance, and expanded
testing for the identification of COVID-19 infections, continued work at home for employees.

B. Socio-economic impact

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 ● Amidst nationwide lockdown, the country’s growth is estimated to have dipped below 5
percent for FY 2019-20.

● Around 400 million workers employed in the informal economy are at risk of falling deeper
into poverty during this crisis, as per a report by the International Labour Organization (ILO).

● According to the estimates by Centre for Monitoring Indian Economy (CMIE),

unemployment has risen from 8.4 percent in the week that ended on March 22 to 23.4
percent as of the week that ended on April

KEY LEARNING POINTS

● On January 30, 2020, the WHO declared the COVID-19 outbreak a public health
emergency of international concern.
● Priorities for countries to prevent spread
● Protecting Health care workers
● Engaging communities to protect those at highest risk of severe disease
● Supporting vulnerable countries in containing infection
● Steps by The Government of India
o Nationwide lockdown to prevent the spread of COVID-19
o PROGRESSIVE TIGHTENING OF INTERNATIONAL BORDER
o Temporary suspension of metro and rail services as well as domestic air traffic.
o Contact tracing of persons infected by the virus and various social distancing
measures.
o Setting up quarantine facilities
o Issue of health advisories for the members of the public

● Amidst nationwide lockdown, the country’s growth is estimated to have dipped below 5
percent for FY 2019-20.

● The Reserve Bank of India (RBI) has taken a number of steps to ease the stress caused by
COVID-19. This includes ease in interest rates and other liquidity improvement measures
such as moratorium on repayment of loans by businesses and EMIs by individual
borrowers.

● Aarogya Setu App has been launched by the government to disseminate information
related to COVID-19 and to provide a platform for the population to reach out to the
government.

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