How to contain Covid-19? Ministry issues fresh guidelines for Clinic Management

The Ministry of Health & Family Welfare has come out with Revised Guidelines on Clinical Management of COVID – 19 aimed at providing clinicians with updated interim guidance on timely, effective, and safe supportive management of patients particularly those with severe acute respiratory illness and critically ill.

Specific therapy

No specific antivirals have been proven to be effective as per currently available data.  However, based on the available information (uncontrolled clinical trials), the following drugs may

be considered as an off – label indication in patients with severe disease and requiring ICU management:

  • Hydroxychloroquine (Dose 400mg BD – for 1 day followed by 200mg BD for 4 days) In combination with
  • Azithromycin (500 mg OD for 5 days)

The revised guidelines issued by the Ministry of Health and Family Welfare, Directorate General of Health Services, however, say that these drugs should be administered under close medical supervision, with monitoring for side effects including QTc interval.

The above medication is presently not recommended for children less than 12 years, pregnant and lactating women.  These guidelines are based on currently available information and may be reviewed from time to time as new evidence emerges.

The Department of Pharmaceuticals is regularly monitoring distribution and addressing availability, supply and other issues and has claimed that there is no shortage of drugs. A Central control room [011-23389840] has been set up in the Department, which is working from 8 am to 6 pm. National Pharmaceutical Pricing Authority(NPPA) has set up another control room [Helpline No. 1800111255], which functions round the clock. The Control rooms deals with issues related to queries and messages dealing with COVID-19 outbreak as well as coordination of transport and other logistic services related to drugs and medical devices. The Department of Pharmaceuticals is working in close coordination with line departments like Ministry of Health & Family Welfare, Ministry of Commerce & Industry, Customs authorities, Central and State Drug Controllers, State Governments/UTs and various Drugs and Medical Device Associations.

The Department of Pharmaceuticals is continuously monitoring the production of medicines since the outbreak of Coronavirus. The Department is extensively using digital platforms forming WhatsApp groups and email systems and using video conferencing facilities to ensure prompt action at various levels.

When to suspect

  • All symptomatic individuals who have undertaken international travel in the last 14 days or
  • All symptomatic contacts of laboratory confirmed cases or
  • All symptomatic healthcare personnel (HCP) or
  • All hospitalized patients with severe acute respiratory illness ( SARI) (fever AND cough and/or shortness of breath) or
  • Asymptomatic direct and high risk contacts of a confirmed case (should be tested once between day 5 and day 14 after contact).  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.

Clinical features

COVID–19 may present with mild, moderate, or severe illness; the latter includes severe pneumonia, ARDS, sepsis and septic shock. Early recognition of suspected patients allows for timely initiation of IPC. Early identification of those with severe manifestations allows for immediate optimized supportive care treatments and safe, rapid admission (or referral) to intensive care unit .

Supplemental oxygen therapy be given immediately to patients with respiratory distress, hypoxaemia, or shock. Children with emergency signs (obstructed or absent breathing, severe respiratory distress, central cyanosis, shock, coma or convulsions) should receive oxygen therapy during resuscitation.  All areas where patients with Severe Acute Respiratory Infections-SARI should be equipped with pulse oximeters, functioning oxygen systems and disposable, single use, oxygen-delivering interfaces (nasal cannula, simple face mask, and mask with reservoir bag).

Uncomplicated illness patients with uncomplicated upper respiratory tract viral infection, may have non-specific symptoms such as fever, cough, sore throat, nasal congestion, malaise, headache. The elderly and immunosuppressed may present with atypical symptoms. Mild pneumonia Patient with pneumonia and no signs of severe pneumonia. Child with non-severe pneumonia has cough or difficulty in breathing/ fast breathing: (fast breathing – in breaths/min): 30 breaths/min.

Sepsis Adults

Life-threatening organ dysfunction caused by a deregulated host response to suspected or proven infection, with organ dysfunction. Signs of organ dysfunction include: altered mental status, difficult or fast breathing, low oxygen saturation, reduced urine output, fast heart rate, weak pulse, cold extremities or low blood pressure, skin mottling, or laboratory evidence of coagulopathy, thrombocytopenia, acidosis, high lactate or hyperbilirubinemia. Children: suspected or proven infection and abnormal temperature or white blood cell count.

Precautions

Standard precautions should always be routinely applied in all areas of health care facilities. Standard precautions include hand hygiene; use of PPE to avoid direct contact with patients’ blood, body fluids, secretions (including respiratory secretions) and non-intact skin.

Standard precautions also include prevention of needle-stick or sharps injury; safe waste management; cleaning and disinfection of equipment; and cleaning of the environment.

At triage

  • Give suspect patient a triple layer surgical mask and direct patient to separate area, an isolation room if available. Keep at least 1meter distance between suspected patients and other patients. Instruct all patients to cover nose and mouth during coughing or sneezing with tissue or flexed elbow for others.
  • Droplet precautions prevent large droplet transmission of respiratory viruses.

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

.Place patients in single rooms, or group together those with the same etiological diagnosis. If an etiological diagnosis is not possible, group patients with similar clinical diagnosis and based on epidemiological risk factors, with a spatial separation.

.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. Limit patient movement within the institution and ensure that patients wear triple layer surgical masks when outside their rooms

  • Droplet and contact precautions to prevent direct or indirect transmission from contact with contaminated surfaces or equipment .Use PPE (triple layer surgical mask, eye protection, gloves and gown) when entering room and remove PPE when leaving.

.Ensure that health care workers refrain from touching their eyes, nose, and mouth with potentially contaminated gloved or ungloved hands, door handles and light switches.

.Ensure adequate room ventilation.

.Apply airborne precautions when performing an aerosol generating procedure.

  • 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).

Sample collection

Throat and nasal swab in viral transport media (VTM) and transported on ice. Nasopharyngeal swab, BAL or endotracheal aspirate which has to be mixed with the viral transport medium and transported on ice

General guidelines

  • 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

Support to Treating Physicians

AIIMS, New Delhi is running a 24×7 helpline to provide support to the treating physicians on clinical management. The helpline number is 9971876591. The identified nodal doctor of the State, appointed for clinical management of COVID – 19 should only contact AIIMS Call Centre.

Helpline for Noval Coronavirus : +91-11-23978046