Guidelines Update

COVID-

The clinical guidance provided in this booklet is for informa on and educa on purpose only. The content of this booklet is intended to offer healthcare professionals guidance regarding the best prac ces in caring for and trea ng pa ents infected by COVID-19. It is not necessary that adhering to any of the recommenda ons contained in this booklet will ensure successful treatment in every situa on. Moreover, the recommenda ons presented in this booklet should not be deemed as se ng a standard of care. The ul mate judgment regarding the standard procedures of any specific therapy must be made by the physician in light of all the circumstances presented by the individual pa ent.

The recommenda ons presented in this booklet are based on the guidelines issued by regulatory authori es involved in healthcare. These recommenda ons reflect the best available informa on at the me this booklet was prepared, i.e. 31st May 2020. The results of future studies may require revisions to the recommenda ons presented in this booklet to reflect new data.

Conceptualized, Edited & Designed by

Preface

The World Health Organiza on (WHO) has declared coronavirus disease (COVID-19) as a pandemic. COVID-19 is caused by a novel corona virus. This new strain of corona virus was not previously known to be found in humans. People affected with COVID-19 experience respiratory problems and symptoms such as fever and cough, and can lead to pneumonia and death. The first reported case of COVID-19 was in Wuhan district of China. Since then, the virus has spread extensively to reach a pandemic propor on. COVID-19 is highly contagious with the possibility of causing severe respiratory disease.

The encouragement for the prepara on of this booklet came from Dr. Sudhir V. Shah, who iden fied the need for a comprehensive yet easy-to-read booklet on COVID-19 guidelines. He along with the other eminent Neurophysicians contributed in compiling a set of very user-friendly guidelines from healthcare regulatory bodies around the world, iden fying the steps in assessments of pa ents for risk, outlining the objec ves for care from the me pa ents enters a healthcare facility ll the me they leaves and even a er that. This booklet provides guidance on the applica on of basic infec on preven on and control precau ons along with recommenda ons related to best prac ces in different clinical scenarios in context with COVID-19. The efforts of all contribu ng authors are humbly acknowledge. They have provided substance for each sec on. They have all spent a huge amount of me & efforts reviewing guidelines on COVID-19 published by regulatory authori es to bring out a beau fully illustrated, contemporary, easy-to-read and well-referenced booklet on COVID-19 guidelines.

It is hoped that this booklet will give Prac ce Pearls to help the healthcare professionals in implemen ng the IPC measures and contribute to improving health-care prac ces. This document mandatorily deserves to be on the bookshelves on the clinic, hospital library, and nursing home as a Ready Reckoner.

Contribu on and Guidance from:

Dr. Sudhir V. Shah

Consultant Neurologist,
Professor& HOD, Dept. of Neurology,
Smt. NHL Municipal Medical College, Ahmedabad
Director of Neurosciences, Sterling Hospitals, Ahmedabad

Dr. A. V. Srinivasan

Emeritus Professor,
The Tamilnadu Dr MGR Medical University Former Head and Prof of Neurology Ins tute of Neurology, Madras Medical College, Chennai

Dr. Pahari Ghosh

Consultant Neurologist,
Woodlands Mul specialty Hospital, Kolkata,

Dr. Sushil Razdan

Eminent Neurologist, Jammu
Consul ng Neurologist, Medanta Hospital, Gurgaon

Dr. Arabinda Mukherjee

Consultant Neurologist,
CMRI and Kothari Medical Centre, Kolkata

Dr. R. Lakshmi Narasimhan

Director & Professor,
Ins tute of Neurology, Madras Medical College, Chennai

Dr. Sudhir Kothari

Consultant Neurologist Pune, Maharashtra

Table of Contents

Introduc on …………………………………………………………………………………………………………………………… 1 Epidemiology ………………………………………………………………………………………………………………. 1 Riskgroups ………………………………………………………………………………………………………………….. 2 ClinicalPresenta on ……………………………………………………………………………………………………. 2

Rolesandresponsibili esofhealthcareworkersduringCOVID-19 ……………………………………………. 3 Du esofHealthcareworkers ……………………………………………………………………………………… 3 Guidelinesforphysicians ………………………………………………………………………………………………………… 4 Preparingyourprac ceorhealthsystemforCOVID-19 …………………………………………………. 4 Protec ngyourselfandyouremployeesfromtheeffectsofCOVID-19 ………………………….. 4 Priori zingurgentandemergencyvisits ……………………………………………………………………….. 5 Con ngencyplanning ……………………………………………………………………………………………………………… 5 Con ngencyplanningwithintheprimarycarese ng ………………………………………………….. 5 Con ngencyplanningwithinthehospitalse ng …………………………………………………………. 6

Disinfec onofenvironmentsinhealthcarese ng …………………………………………………………………… 7 Authorizeddisinfectantproduct ………………………………………………………………………………….. 7 Cleaning op ons for healthcare se ngs a er the management of asuspectedorconfirmedcaseofCOVID-19 …………………………………………………………………. 7 Cleaningop onsforhealthcarese ngs ……………………………………………………………………….. 8

Infec onpreven onandcontrol …………………………………………………………………………………………….. 9 Communica ngwithpa entsandminimizingrisk ………………………………………………………… 9 Generalinfec onpreven onandcontrolmeasures ……………………………………………………. 10 Ensuringtriage,earlyrecogni on,andsourcecontrol …………………………………………………. 10 Personalprotec veequipment …………………………………………………………………………………. 11

Ra onaluseofPPE ………………………………………………………………………………………… 11

DonningandDoffingofPPE ……………………………………………………………………………. 15 Howlongdocoronavirusesliveonsurfaces? …………………………………………………………………….17 Sugges onsfortheuseofPPEinICUandinOPD ……………………………………………………………….. 18 Applyingstandardprecau onsforallpa ents ……………………………………………………………………….. 18 Implemen ngempiricaddi onalprecau ons ………………………………………………………………………… 19

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Airborneprecau onsforaerosol-genera ngprocedures ………………………………………………………. 20 TheABCsforba lingagainstCOVID-19 …………………………………………………………………………………… 20 Generalguidelinesforhospitals ……………………………………………………………………………………………. 22

OutPa entDepartment(OPD)Guidelines ………………………………………………………………….. 22 In-Pa entDepartment(IPD)&HospitalStaffGuidelines ……………………………………………… 23 A endants’Guidelines ………………………………………………………………………………………………. 23 PharmacyGuidelines …………………………………………………………………………………………………. 24

Considera onsforquaran neofindividualsincontextofCOVID-19 ………………………………………. 24 Quaran neofpersons ……………………………………………………………………………………………….. 24 Whentousequaran ne …………………………………………………………………………………………… 24

Ensuringanappropriatese ngandadequateprovisions ……………………………………………………….. 25 Immuniza onac vi esduringtheCOVID-19 ……………………………………………………………………….. 26 GuidelinesforsafeandadequatebloodsupplyduringCOVID-19 ……………………………………………. 26

Mi ga ng the poten al risk of transmission through the transfusion of blood and blood components …………………………………………………………………………………………………….. 26 Mi ga ngtheimpactofreducedavailabilityofblooddonors …………………………………….. 27

COVID-19 Treatment Guidelines
ProphylaxisforCOVID-19 ……………………………………………………………………………………………………… 28

Pre-exposureprophylaxis(PrEP) ………………………………………………………………………………… 28 Advisoryontheuseofhydroxy-chloroquineasprophylaxisforSARS-CoV-2infec on …… 28 WhoshouldnotbeprescribedHydroxychloroquine ……………………………………….. 29

Combina onTherapy ……………………………………………………………………………………. 29 Druginterac ons ………………………………………………………………………………………….. 29 Useinpregnancy ………………………………………………………………………………………….. 31

Considera onsforCertainConcomitantMedica onsinPa entswithCOVID-19 …………………….. 31 Guidelineswhenasuspect/confirmedCOVID-19HCWisiden fied …………………………………………. 32 Asymptoma corPresymptoma cInfec on …………………………………………………………………………… 34

MildIllness ………………………………………………………………………………………………………………… 34 SevereIllness ……………………………………………………………………………………………………………. 34

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ModerateIllness ………………………………………………………………………………………………………… 35

Cri calIllness …………………………………………………………………………………………………………….. 35 Oxygena onandVen la on ………………………………………………………………………………………………… 35 Formechanicallyven latedadultswithCOVID-19andARDS ………………………………………. 35 Formechanicallyven latedadultswithCOVID-19andmoderate-to-severeARDS ……….. 36

Formechanicallyven latedadultswithCOVID-19,severeARDS,andhypoxemia ………… 36 Hemodynamics …………………………………………………………………………………………………………………….. 36 Addi onalRecommenda onsBasedonGeneralPrinciplesofCri calCare …………………. 37

Infec onControlinCOVID-19pa ents ………………………………………………………………………………….. 38 Screeningandtriage …………………………………………………………………………………………………… 38 Collec onofspecimensforlaboratorydiagnosis ………………………………………………………… 39 Symptoma ctreatmentandmonitoring …………………………………………………………………….. 40 Managingcough ………………………………………………………………………………………………………… 40 Managingfever …………………………………………………………………………………………………………. 40

Managingbreathlessness ……………………………………………………………………………………………… 41 End-of-life treatments for managing breathlessness for pa ents aged 18 years and over .. 42 Managinganxiety,deliriumandagita on ………………………………………………………………………………. 43 ManagementofsevereCOVID-19:treatmentofco-infec ons ………………………………………………… 43 Preven onofcomplica ons ………………………………………………………………………………………………….. 43

CareofCri callyIllPa entswithCOVID-19 …………………………………………………………………………….. 45 GuidelinesforadultsandchildrenwithsevereasthmaduringtheCOVID-19 ……………………………. 45 COVID-19poten alanaesthe cdruglist ………………………………………………………………………………… 46 DischargecriteriaforconfirmedCOVID-19cases ……………………………………………………………………. 49 References ……………………………………………………………………………………………………………………….. 52

Introduc on

COVID-19 is an acute respiratory illness caused by a novel human corona virus (SARS-CoV-2, called COVID-19 virus), which causes higher mortality in people aged ≥60 years and in people with underlying medical condi ons such as cardiovascular disease, chronic respiratory disease, diabetes and cancer.

Epidemiology1,2

Since the first reported case in China, COVID-19 pandemic has exploded largely. As of 31st May 2020:

>6.2 million 373,697 deaths

>180 countries

Affected by COVID-19

Total recovered

599,867 206,555 171,883 196,958 N/A 157,507 91,852 68,355 165,200 67,208 127,973 118,848 42,727 48,879 61,871

Cases of COVID-19 have been reported worldwide

Reported globally

Reported cases and deaths by country2

Country

USA Brazil Russia Spain
UK
Italy India France Germany Peru Turkey Iran Chile Canada Mexico

Total cases

1,837,170 514,849 405,843 286,509 274,762 232,997 190,609 188,882 183,494 164,476 163,942 151,466 99,688 90,947 87,512

Total deaths

106,195 29,314 4,693 27,127 38,489 33,415 5,408 28,802 8,605 4,506 4,540 7,797 1,054 7,295 9,779

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Risk groups

People of all ages are at a risk for infec on. However, probability for fatal disease is higher in individuals aged more than 65 years and those living in a nursing home or those on long-term care facility.1

Hypertension

Cardiovascular disease

Obesity

Renal disease

Clinical Presenta on1

Highest risk for COVID-19

Cancer

Diabetes

Chronic respiratory disease

Ÿ Es matedincuba onperiodofCOVID-19is14days.
Ÿ Spectrum of infec on ranges from symptoma c to severe pneumonia with acute respiratory

distress syndrome (ARDS).

Most common symptoms as observed in 1,482 hospitalized pa ents with confirmed COVID-19 in the United States include:

Cough (86%)

Fever or chills (85%)

Shortness of breath (80%)

Diarrhea (27%)

Nausea (24%)

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Lboratory findings

Ÿ Leukopenia

Ÿ Lymphopenia

Ÿ Elevatedlevelsofaminotransferase,C-reac veprotein,D-dimer,ferri n, and lactate dehydrogenase.
X-ray, Computed tomography (CT)

Ÿ ChestX-rayrevealsbilateralmul -focalopaci es.

Ÿ CTofchestrevealsbilateralperipheralground-glassopaci es.
Roles and responsibili es of health care workers during COVID-194

Du es of HCWs

. 1 Follow occupa onal safety and health procedures.

. 2 Avoid exposing others to health and safety risks.

. 3 Treat pa ents with respect, compassion and dignity.

. 4 Maintain pa ent confiden ality.
Swi ly follow established public health repor ng procedures of suspected and confirmed cases.
Provide accurate infec on preven on and control and public health informa on.
Put on, use, take off and dispose off personal protec ve equipment properly.

8 Self-monitor for signs of illness.

Report to their immediate supervisor any situa on that presents a serious danger to life or health.

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Guidelines for physicians5

Preparing your prac ce or health system for COVID-195

Follow occupa onal safety and health procedures.

Communicate the updates and your plan for managing COVID-19 with your staff and pa ents.

Set up screening measures and guidance on using personal protec ve

equipment (PPE) for your staff.

Take measures to ensure people with suspected COVID-19 symptoms remain separated from the rest of your pa ents.

Protec ng yourself and your employees from the effects of COVID-195

Measures recommended by CDC to minimize the spread of infec on:

Ÿ FollowPPEguidelines.

Ÿ ScreeneveryoneforsymptomsofCOVID-19beforetheyenteryourhealthcarefacility.

Ÿ Implement comprehensive source control for all to prevent transmission from asymptoma c and pre-symptoma c individuals.

Ÿ Screen for fever and symptoms before every shi in areas with heightened community transmission.

Ÿ Establishrepor ngwithinhealthcarefacili esandtopublichealthauthori es.

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Priori zing urgent and emergency visits5

Delay all elec ve ambulatory provider visits

Reschedule elec ve and non-urgent admissions

Delay inpa ent and outpa ent elec ve surgical and procedural cases

Urge pa ents to postpone rou ne dental and eye care visits

Following these ac ons can preserve protec ve equipment and pa ent care supplies, ensure staff and pa ent safety.

Con ngency planning

Con ngency planning within the primary care se ng6

Establish a triage system at the entrance of facility.

Establish dedicated teams for receiving and managing non-COVID-19 pa ents.

Establish dedicated teams for receiving and managing COVID-19

pa ents.

Include back-up teams in case staff members get sick.

Establish clear procedures for any staff member developing

COVID-19-related symptoms.

Facilitate increased number of incoming calls from pa ents who have to be referred

to appropriate services.

Separate these hotlines from normal healthcare advice services

Ensure that sufficient materials are available for swabbing pa ents who have acute respiratory infec ons

and/or influenza-like illness

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Con ngency planning within the hospital se ng6

Outpa ent facili es6

Reschedule non-urgent outpa ent visits as necessary

Inpa ent facili es6

Dedicate facili es to manage suspected COVID-19 cases

Set up separate loca on for laboratory tes ng

Cohort COVID-19 pa ents

Separate mild cases and keep them in one loca on within the hospital

Concentrate severe cases to one loca on

Repurpose non-intensive care unit wards as intensive care units (ICU)

Reach out to out-pa ents who may be at a higher risk of COVID-19 such as elderly and those with medical co-morbidi es; provide specific advice and support in rela on to their medical condi on

Op mizing the use of PPE

Use surgical masks if the supply of FFP 2/3 respirators is limited

Reserve FFP2/FF3 respirators for airborne-genera ng procedures

Use the same FFP2/FFP3 respirator when performing the same

ac vity (e.g. swabbing) (up to 4 hours if not damaged, soiled or

contaminated)

Other measures

Dedicate staff members to the care of COVID-19 pa ents

Appoint designated staff members to tes ng

Enable rapid registering, appropriate training and realloca on of

medical support staff to frontline roles

Voluntary recruitment of inac ve healthcare workers

Ÿ Cancelallnon-essen alac vi es(butreviewregularly). Ÿ Limit the number of visitors to COVID-19 pa ents.
Ÿ Reducethemovingofpa entsinthehospital.
Ÿ Triagepa entsbasedonven la oncapacity.

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Disinfec on of environments in healthcare se ng7

SARS-CoV-2 virus is transmi ed by contact with contaminated fomites. Therefore, to reduce the risk of infec on through fomites, it is essen al to establish procedures for the correct disinfec on of environments.

Authorized disinfectant products

Ÿ Sodiumhypochlorite.8
Ÿ Alcohol-based disinfectants (ethanol, propan-2-ol, propan1-ol) in concentra ons

of 70-80% with one minute exposure me.7

Cleaning op ons for healthcare se ngs a er the management of a suspected or confirmed case of COVID-197

Healthcare se ng areas (pa ent rooms, wai ng areas, procedure rooms, resuscita on rooms) should be first ven lated

well.

Rooms where aerosol genera ng procedures (AGP) have been performed (bag- valve ven la on, intuba on, administra on of nebulised medicines, bronchoscopy, etc.) need to be ven lated with fresh air for 1–3 hours, if they are not func oning under nega ve pressure.

Ven la on

High-efficiency par culate air (HEPA) filtra on should be used in buildings where windows

cannotbeopened.

Place temporary HEPA filters over the vents and exhausts in the rooms housing COVID- 19 pa ents or use a portable HEPA air filtra on system placed in close proximity to these pa ents.

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Cleaning op ons for healthcare se ngs7

Surfaces

Ÿ Neutral detergent AND
Ÿ Virucidal disinfectant OR
Ÿ 0.05% sodium hypochlorite OR Ÿ 70% ethanol

Tex les

Toilets

Ÿ Virucidal disinfectant OR Ÿ 0.1% sodium hypochlorite

Ÿ Hot-water cycle (90°C) AND

Ÿ Regular laundry detergent

Ÿ Alterna ve: lower temperature cycle
+ bleach or other laundry products
Cleaning equipment
Ÿ Single-use disposable OR
Ÿ Non-disposable disinfected with: Virucidal
disinfectant OR 0.1% sodium hypochlorite
PPE for cleaning staff
Ÿ Surgical mask
Ÿ Disposable long-sleeved water-resistant gown
Ÿ Gloves
Ÿ FFP2 or 3 when cleaning facili es where AGP have been performed
Waste management
Ÿ Infec ous clinical waste category B (UN3291)

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Infec on preven on and control

Communica ng with pa ents and minimizing risk8

Explain to the pa ent:

Key symptoms of COVID-19: cough, fever, breathlessness, anxiety, delirium and also fa gue, muscle aches and headache.

That if the symptoms are mild they are likely to feel much be er in a week.

Who to contact if their symptoms get worse.

That they should follow the guidelines on self-isola on and protec ng

vulnerable people.

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General infec on preven on and control measures9

Implement physical distancing among staff, visitors and pa ents.

Create a separate area in the emergency department for managing pa ents

with respiratory symptoms in order to spare PPE.

Avoid emergency intuba on as much as possible. Plans should be made

well in advance for pa ents requiring intuba on for mechanical ven la on.

Create a separate area in the emergency department for swabbing suspected cases.

Use Telephone or telemedicine in order to reduce the number of

people who come in contact with the healthcare workers.

Develop policies for priori zing availability of equipments for the administra on of oxygen.

Ensuring triage, early recogni on, and source control10

1 Assess all pa ents

Encourage HCWs to have a high level of clinical suspicion.

Establish a well-equipped triage sta on at the entrance to the facility.

Ins tute the use of screening ques onnaires according to the updated case defini on.

Post signs in public areas reminding symptoma c pa ents to alert HCWs.

STEP

2 Allow for early recogni on

STEP

3 with suspected disease in

STEP

at admission

of possible COVID-19 Immediately isolate pa ents

an area separate from other pa ents (source control).

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Personal protec ve equipment11

Ra onal use of PPE

The PPE are to be used on the basis of risk profile of the health care workers. Ra onal use of PPE for Outpa ent Department:

Help desk/Registra on counter

Doctors chamber

Pre- anesthe c check-up clinic

Pharmacy counter

Chamber of Dental/ ENT doctors/ Ophthalmology doctors

Sanitary staff

Risk: Mild risk

Ÿ Triple layer medical mask Ÿ Latex examina on gloves

Risk: Mild risk

Ÿ Triple layer medical mask Ÿ Latex examina on gloves

Risk: Moderate risk

Ÿ N-95 mask
Ÿ Goggles
Ÿ Latex examina on gloves

Risk: Mild risk

Ÿ Triple layer medical mask Ÿ Latex examina on gloves

Risk: Moderate risk

Ÿ N-95 mask
Ÿ Goggles
Ÿ Latex examina on Ÿ Gloves
Ÿ Face shield

Risk: Mild risk

Ÿ Triple layer medical mask Ÿ Latex examina on gloves

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Ra onal use of PPE for In-pa ent Department in Non-COVID treatment areas of a hospital which has a COVID block:11

Ward/individual rooms

ICU/ Cri cal care

Cri cal care (Non-COVID)

Labor room

Opera on Theater

Sanitary staff

Risk: Mild risk

Ÿ Triple layer medical mask Ÿ Latex examina on gloves

Risk: Mild risk

Ÿ Triple layer medical mask Ÿ Latex examina on gloves

Risk: Low risk

Ÿ Triple layer medical mask Ÿ Latex examina on gloves

Risk: Moderate risk

Ÿ Triple Layer medical mask Ÿ Face shield
Ÿ Sterile latex gloves
Ÿ N-95 mask

Risk: Moderate risk

Ÿ Triple layer medical mask

Ÿ Face shield (where
feasible)

Ÿ Sterile latex gloves

Ÿ Goggles
Risk: Low risk
Ÿ Triple layer medical mask Ÿ Latex examina on gloves

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Ra onal use of PPE for Emergency Department in Non-COVID treatment areas of a hospital which has a COVID block:11

Emergency Department

A ending emergency cases

A ending to severely ill pa ents while performing aerosol genera ng procedure

Triple Layer medical mask Latex examina on gloves

Full complement of PPE (N-95 mask, coverall, goggle, Nitrile examina on gloves, shoe cover)

Ra onal use of PPE for Other Suppor ve/ Ancillary Services11

Rou ne Laboratory

Risk: Mild risk (tes ng of rou ne non-respiratory samples)
Ÿ Triple layer medical mask Ÿ Latex examina on gloves

CSSD/Laundry

Risk: Mild risk

Ÿ Triple layer medical mask Ÿ Latex examina on gloves

Rou ne Laboratory

Risk: Moderate risk (tes ng of respiratory samples)
Ÿ N-95 mask
Ÿ Latex examina on gloves

Radiodiagnosis, Blood bank, etc.
Risk: Mild risk
Ÿ Triple layer medical mask Ÿ Latex examina on gloves

Other suppor ve services including Kitchen
Risk: Low risk
Ÿ Face cover

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Pre-hospital (Ambulance) Services11

Transpor ng pa ents not on any assisted ven la on

Low-risk

Ÿ Triple layer medical mask

Ÿ Latex examina on gloves

Ambulance transfer to designated hospital

Management of SARI pa ent

High-risk

Ÿ Full complement of PPE (N-95 mask, coverall, goggle, latex examina on gloves, shoe cover)

Driving the ambulance

Low-risk

Ÿ Triple layer medical mask

Ÿ Latex examina on gloves

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Donning and Doffing of PPE12

Sequence for Pu ng on Personal Protec ve Equipment (PPE)

The type of PPE used will vary based on the level of precau ons required, such as standard and contact, droplet or airborne infec on isola on precau ons. The procedure for pu ng on and removing PPE should be tailored to the specific type of PPE.

1. GOWN

Ÿ Fully cover torso from neck to knees, arms to end of wrists, and wrap around the back

Ÿ Fasten in back of neck and waist
2. MASK OR RESPIRATOR

Ÿ Secure es or elas c bands at middle of head and neck

Ÿ Fit flexible band to nose bridge

Ÿ Fit snug to face and below chin

Ÿ Fit-check respirator
3. GOGGLES OR FACE SHIELD
Ÿ Place over face and eyes and adjust to fit
4. GLOVES
Ÿ Extend to cover wrist of isola on gown
Use Safe Work Prac ces to Protect Yourself and Limit The Spread Of Contamina on
Ÿ Keep hands away from face
Ÿ Limit surfaces touched
Ÿ Change gloves when torn or heavily contaminated Ÿ Perform hand hygiene

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How to safely remove Personal Protec ve Equipment (PPE)

There are a variety of ways to safely remove PPE without contamina ng your clothing, skin, or mucous membranes with poten ally infec ous materials. Here is one example. Remove all PPE before exi ng the pa ent room except a respirator, if worn. Remove the respirator a er leaving the pa ent room and closing the door. Remove PPE in the following sequence:

1. GLOVES

Ÿ Outside of gloves are contaminated!

Ÿ If your hands get contaminated during glove removal,
immediately wash your hands or use an alcohol-
based hand sani zer

Ÿ Using a gloved hand, grasp the palm area of the
other gloved hand and peel off first glove

Ÿ Hold removed glove in gloved hand

Ÿ Slide fingers of ungloved hand under remaining glove
at wrist and peel off second glove over first glove

Ÿ Discard gloves in a waste container
2. GOGGLES OR FACE SHIELD

Ÿ Outside of goggles or face shield are contaminated!

Ÿ If your hands get contaminated during goggle or face shield removal, immediately wash your hands or use an alcohol-based hand sani zer

Ÿ Remove goggles or face shield from the back by li ing head band or ear pieces

Ÿ If the item is reusable, place in designated receptacle for reprocessing. Otherwise, discard in a waste container
3. GOWN

Ÿ Gown front and sleeves are contaminated!

Ÿ If your hands get contaminated during gown
removal, immediately wash your hands or use an
alcohol-based hand sani zer

Ÿ Unfasten gown es, taking care that sleeves
don’t contact your body when reaching for es

Ÿ Pull gown away from neck and shoulders,
touching inside of gown only

Ÿ Turn gown inside out

Ÿ Fold or roll into a bundle and discard in a waste
container

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How to safely remove Personal Protec ve Equipment (PPE)

4. MASK OR RESPIRATOR

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

Ÿ If your hands get contaminated during mask/respirator removal, immediately wash your hands or use an alcohol-based hand sani zer

Ÿ Grasp bo om es or elas cs of the mask/respirator, then the ones at the top, and remove without touching the front

Ÿ Discard in a waste container
5. WASH HANDS OR USE AN ALCOHOL- BASED HAND SANITIZER IMMEDIATELY AFTER REMOVING ALL PPE
Perform hand hygiene between steps if hands become contaminated and immediately a er removing all ppe

How long do corona viruses live on surfaces?3

Surface

Metal
Glass Ceramics Paper
Wood
Plas cs Stainless Steel Cardboard Aluminum Copper Food/Water

Examples

Doorknobs, Jewelry, Silverware Drinking glasses, Mirrors, Windows Dishes, Po ery, Mugs
Newspaper, Magazines

Furniture, Decking
Milk bo les, Bus seats, Elevator bu ons Refrigerators, Pots/pans, Sinks, Water bo les Shipping boxes
Soda cans, Tinfoil, Water bo les
Pennies, Teake les, Cookware
Doesn’t seem to spread through food, and has not

Days or Hours

5 Days
Up to 5 Days
5 Days
Up to 5 Days
4 Days
2-3 Days
2-3 Days
1 Day
2-8 Hours
4 Hours
been found in water.

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Sugges ons for the use of PPE in ICU and in OPD36,37

In ICU

Full complement of PPE is required which consists of:

Ÿ Gloves

Ÿ Coverall

Ÿ Goggles

Ÿ N-95 masks

Ÿ Shoe covers

Ÿ Face shield

Ÿ Triple layer
medical mask

In OPD

Ac vity

Physical examina on of pa ent with respiratory symptoms

Physical examina on of pa ents without respiratory symptoms

Type of PPE

Ÿ Medical mask Ÿ Gown
Ÿ Gloves
Ÿ Eye protec on

PPE according to standard precau ons and risk assessment.

Applying standard precau ons for all pa ents10

Standard precau ons include:

Ÿ Hand and respiratory hygiene

Ÿ Use of appropriate personal protec ve equipment
(PPE)

Ÿ Injec on safety prac ces

Ÿ Safe waste management

Ÿ Proper linens

Ÿ Environmental cleaning

Ÿ Steriliza on of pa ent-care equipment

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HCWs should follow WHO’s My 5 Moments for Hand Hygiene

approach10,13

This approach recommends health-care workers to clean their hands in the following 5 moments

1 AFTER TOUCHING A

RESIDENT

4 AFTER TOUCHING A

RESIDENT

5AFTER TOUCHING RESIDENTS SURROUNDINGS

Implemen ng empiric addi onal precau ons10,14

Contact and droplet precau ons

All pa ents’ beds should be placed at least 1 meter apart.

Provide proper ven la on: adequate ven la on for general ward

rooms is considered to be 60 L/s per pa ent.

Use either single-use and disposable

or dedicated equipment.

HCWs should wear goggles, face shield, long-sleeved gown

and gloves.

If equipment needs to be shared among pa ents,

clean and disinfect it between use.

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Airborne precau ons for aerosol-genera ng procedures10,14

Ÿ Aerosol-genera ng procedures should be performed in an adequately ven lated room, with air flow of at least 160 L/s per pa ent or in nega ve- pressure rooms with at least 12 air changes per hour.

Ÿ Always perform the seal check before pu ng on a disposable par culate respirator.

Ÿ If gowns are not fluid-resistant, HCWs should use a waterproof apron for procedures
expected to create high volumes of fluid that might penetrate the gown.
The ABCs for ba ling against COVID-1915
Ÿ The pa ents and public can be advised to adopt the following ABCs in order to stay strong and avoid health problems during the COVID-19 pandemic.

. A Alertness, A en on and Apprecia on

. B Be posi ve (Corona nega ve), Books Reading, Be Bold.

. G Generosity, Gra tude, God (Surrender). Gargles

. H Humanity, Health Tips, Hot Water

C Compassion, Care, Crea vity, I Calm and Counselling. Cau on

. D Disciplined Behaviour. Drugs. J Devo on. Donate
Exercise: Yoga. Pranayam.

. E Educate: social distancing, K
mask, hand washing. E que e and Hygiene

. F Fight Fear. Follow Friends. L Finance Handling and Forgive

Immunity Enhancer (Medical, Ayush including Ayurveda and Homeopathy, Yoga).

Jovial

Kindness

Love. Light. Listen Carefully.

People.

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. M Medica ons. Medita on. Music. T

. N New Skill Development. Non U
Violence.

. O Op mis c V

. P Prayer and Pa ence. Preserve W
Nature

. Q Quaran ne X

. R Responsible Behavior Y

. S Spirituality, Serenity. Self Z Dependence. Steam Inhala on.
Sani za on.

Trust in GOD. Time is Healer

Unleash Your Poten al.

Vegetarian Diet. No Vices (No Smoking-No Alcohol)

Win. We will win over Corona.

x don’t hurt. x no nega ve. X Factor to win Corona is Immunity

(Remember) You are not alone

Zeal. Zest. Zen. Medita on.

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General guidelines for hospitals16

Out Pa ent Department (OPD) Guidelines16

Preferably, one person should be allowed to accompany

each pa ent to OPD.

Minimize visi ng persons to OPD area.

Visitors should take care of hand hygiene and should

use PPE

OPD areas should display informa ve posters about hygiene & protec on.

How to resume outpa ent prac ces?

Fever clinic

Air flow

Anybody with an acute febrile illness needs to be seen in a place where protec on is available. Protec on for the doctor in terms of mask, face shield and protec on of the pa ent in terms of a face mask.

Pa ent should call before a ending the physician. Physician should talk to the pa ent and ascertain that he doesn’t have an acute fever.

If they have fever they need to be seen in Fever clinic where the doctor and pa ent have appropriate precau on so that there is no transmission.

Ÿ The air flow in the room where a physician is consul ng a pa ent should be from the doctor towards the pa ent. The direc on of the airflow of AC and fan should be from the doctor to the pa ent.

Ÿ Pa ent should be masked. For healthcare workers a surgical mask is more than enough. An N-95 mask is not necessary in OP prac ce because there is no genera on of aerosols.

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Sugges ons for Physical examina on

Ÿ Maintain 2 meters distance between yourself and the pa ent.

Ÿ When doing physical examina on make sure that mask is put on
and also put some eye protec on such as goggles or face cover.

Ÿ Be sure to quickly finish your physical exam.

Ÿ Make sure the pa ent is not talking or giving history during the physical exam.
In-Pa ent Department (IPD) & Hospital Staff Guidelines16

Staff should immediately contact the doctor if they suspect COVID-19 in any

pa ent.

Staff should immediately contact the doctor if they suspect COVID-19 in any of their colleague.

Prompt detec on, isola on of poten ally infec ous pa ents.

A endants’ Guidelines15

Assign staff as primary contact to a end rela ves over phone with

recording facility.

Sterilize the equipment likely which are likely to be contaminated before reuse in other pa ents.

Frequently monitor admi ed pa ents for developments of any symptom.

Nursing homes should immediately contact their local health department if a pa ent is suspected of having COVID-19.

ü Preferably a single selected Pa ent Care Companion should be for admi ed pa ent.

ü There should not be change of persons to avoid more persons being exposed to possible hospital borne infec on.

ü Teach a endants about Distancing, hand hygiene & Personal Protec ve measures for their protec on.

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Pharmacy Guidelines16

Ÿ The necessary medica ons, injec ons & emergency disposables should be ready in adequate quan ty.

Ÿ Do not replace, subs tute & reuse the products.

Ÿ Distancing, hand hygiene & Personal Protec ve measures.
Considera ons for quaran ne of individuals in context of COVID-1917

The quaran ne of persons is the restric on of ac vi es of or the separa on of persons who are not ill but who may been exposed to an infec ous agent or disease.

Quaran ne of persons17

Authori es must provide people with clear, up-to-date, transparent and consistent guidelines, and with reliable informa on about quaran ne measures.

When to use quaran ne17

Isola on

Isola on is the separa on of ill or infected persons from others to prevent the spread of infec on or contamina on

Ÿ WHO recommends that contacts of pa ents with laboratory-confirmed COVID-19 be quaran ned for 14 days from the last me they were exposed to the pa ent.

Ÿ Person who are involved in any of the following from 2 days before and up to 14 days a er the onset of symptoms in the pa ent needs to be quaran ned.

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Quaran ned persons need to be provided with health care; financial, social and psychosocial support; and basic needs, including food, water, and other essen als.

Having face-to-face contact with
a COVID-19 pa ent within 1 meter and for >15 minutes

Providing direct care for pa ents with COVID-19 disease without using proper PPE

Staying in the same close environment as a COVID-19 pa ent

Travelling in close proximity with (within 1 m separa on from) a COVID-19 pa ent

Ensuring an appropriate se ng and adequate provisions17

Quaran ne must be placed in adequately ven lated, spacious single rooms. If single rooms are not available, beds should be placed at least 1 meter apart. Following provisions must be made:

Ÿ Provision of food, water, and hygiene facili es

Ÿ Protec on for baggage and other possessions

Ÿ Appropriate medical treatment for exis ng condi ons

Ÿ Communica on in a language that those who are quaran ned can understand

Ÿ Explana on of rights, services that will be made available, how long they will need to stay and what will happen if they get sick

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Immuniza on ac vi es during the COVID-1918

Ÿ Immuniza on should be priori zed for the preven on of communicable diseases and safeguarded for con nuity during the COVID-19 pandemic, where feasible.

Ÿ Vaccine preventable disease (VPD) surveillance should be maintained and reinforced to enable early detec on and management of VPD cases.

Ÿ Mass vaccina on campaigns should be temporarily suspended. COVID-19, countries need to design strategies for catch-up vaccina on for the period post COVID-19 outbreak.

Ÿ Where feasible, influenza vaccina on of health workers, older adults, and pregnant women is advised.
Guidelines for safe and adequate blood supply during COVID-19
Mi ga ng the poten al risk of transmission through the transfusion of blood and blood components19
Respiratory viruses have never been reported to be transmi ed through blood or blood components; therefore any poten al risk of transmission by transfusion of blood collected from asymptoma c individuals is theore cal. However, in order to mi gate the risk following precau ons should be taken:

Ÿ Donor educa on

Ÿ Self-deferral or deferral of at-risk donors

Ÿ Quaran ne of blood components

Ÿ Screening of dona ons using laboratory test

Ÿ Pathogen reduc on

Ÿ Poten al donors should be educated about the need to self-defer based on risk factors for COVID-19.

Ÿ Persons who donate should inform the blood centre immediately if they develop a respiratory illness within 28 days of dona on.

Ÿ Develop a system for donors to report post-dona on illness consistent with COVID-19.

Ÿ A haemovigilance system should be in place to capture any possible cases of transmission
through blood and components.

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Who should refrain from dona ng blood? (For at least 28 days)19

Persons who have fully recovered from confirmed COVID-19

those with possible direct exposure to COVID-19 from a confirmed case

Those who have travelled from areas with ongoing community transmission

Mi ga ng the impact of reduced availability of blood donors19

Blood dona on numbers should be closely monitored in order to pre-empt any decline in donor

a endance, specially for components with short shelf life, such as platelets.

Communica on strategy is needed to address donor anxiety, which

results due to lack of awareness, misinforma on or fear of becoming infected during blood

Systems should be in place to enable re-entry of infected donors a er recovery (usually

28 days a er full recovery).

Containment strategies may limit the ability of donors. Strategies to overcome this may

include rapid switching of sites for blood collec ons where feasible.

Importa on of blood and components from unaffected areas of the

country or another unaffected country is a poten al solu on if there are insufficient local stocks.

dona on.

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COVID-19 Treatment Guidelines

Prophylaxis for COVID-19

Pre-exposure prophylaxis (PrEP)20

At present, no agent given before an exposure (i.e. , as PrEP) is known to be effec ve in preven ng SARS-CoV-2 infec on. Clinical trials using hydroxychloroquine, chloroquine, or HIV protease inhibitors as PrEP are in development or underway.

Advisory on the use of hydroxy-chloroquine as prophylaxis for SARS- CoV-2 infec on21

The Na onal Task force for COVID-19 cons tuted by Indian Council of Medical Research recommends the use of hydroxyl-chloroquine for prophylaxis of SARS-CoV-2 infec on for high risk popula on.

Asymptoma c household contacts of laboratory confirmed cases.

Dose:21

Asymptoma c Healthcare Workers

Asymptoma c household contacts of laboratory confirmed cases.

Asymptoma c 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.

400 mg twice a day on Day 1, followed by 400 mg once weekly for next 3 weeks; to be taken with meals.

Who should use hydroxy-chloroquine for prophylaxis of SARS-CoV-2 infec on?

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Who should not be prescribed Hydroxychloroquine?21,22

Combina on Therapy22

Hydroxychloroquine

Ÿ Has mul organ failure. This is due to cardiac concerns with severe COVID-19 and HCQ or CQ use.

Ÿ Has a QTc >500 ms at baseline, documented cardiomyopathy, or myocardi s.

Ÿ If HCQ or CQ treatment is ini ated in a pa ent with elevated QTc at baseline (>450 ms in men; >470 ms in women), clinicians should obtain a follow-up electrocardiogram daily for the first 48 to 72 hours.

Ÿ If QTc increases to >500 ms, clinicians should discon nue HCQ or CQ treatment.

Ÿ Children under 15 years of age.

Ÿ Person with known case of re nopathy, known hypersensi vity to hydroxychloroquine, 4-aminoquinoline compounds.
Azithromycin

Should not be prescribed solely for COVID-19. Combina on therapy has the known risk of addi ve QT increase without benefit.

Drug interac ons22

Hydroxychloroquine

Concomitant drug

Digoxin

Effects of drug interac on

Increased serum digoxin levels

Recommenda ons

Serum digoxin levels should be closely monitored

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Hydroxychloroquine

Hydroxychloroquine Hydroxychloroquine Hydroxychloroquine

Hydroxychloroquine

Antacids and kaolin

Cime dine

Insulin and other an diabe c drugs

Arrhythmogenic drugs

Ampicillin

Cyclosporine Mefloquine Praziquantel

Tamoxifen

An epilep cs

Reduces absorp on of hydroxychloroquine sulfate

Inhibits the metabolism of hydroxychloroquine sulfate, increasing its plasma level

Hydroxychloroquine sulfate may enhance the effects of a hypoglycemic treatment

Increased risk of inducing ventricular arrhythmias

Reduces the bioavailability of ampicillin

Sudden increase in serum cyclosporine level

May increase the risk of convulsions

Reduces the bioavailability of praziquantel

Known to induce re nal toxicity

Ac vity of an epilep c drugs might be impaired

An interval of at least 4 hours between intake of these agents and hydroxychloroquine sulfate should be observed

Concomitant use of cime dine should be avoided

Decrease in doses of insulin or other an diabe c drugs may be required

–

An interval of at least two hours between intake of ampicillin and hydroxychloroquine sulfate should be observed

Close monitoring of serum cyclosporine level is recommended

–

Concomitant use of hydroxychloroquine sulfate is not recommended

–

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Use in pregnancy22

Ÿ In humans, hydroxychloroquine sulfate exposure during pregnancy, have shown no increase in the rate of birth defects or spontaneous abor ons when used at recommended doses for prophylaxis and treatment of malaria.

Ÿ The individual benefit-risk balance should be reviewed before prescribing hydroxychloroquine sulfate in pregnant women.
Considera ons for certain concomitant medica on in pa ents with COVID-1923

ACE Inhibitors and ARBs

HMG-CoA Reductase Inhibitors (Sta ns)

Nonsteroidal An -Inlammatory Drugs (NSAIDs):

Ÿ The use of ACE inhibitors or ARBs for the treatment of COVID-19 outside of the se ng of a clinical trial is not recommended.

Ÿ Persons with COVID-19 who are prescribed ACE inhibitors or ARBs for cardiovascular disease should con nue these medica ons.

Ÿ Use of sta ns for the treatment of COVID-19 outside of the se ng of a clinical trial is not recommended.

Ÿ Persons with COVID-19 who are prescribed sta n therapy for the treatment or preven on of cardiovascular disease should con nue these medica ons.

Ÿ Persons with COVID-19 who are taking NSAIDs for a co- morbid condi on should con nue therapy.

Ÿ There should be no difference in the use of an pyre c strategies between pa ents with or without COVID-19

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For Cri cally Ill Pa ents with COVID-19

Ÿ Use of systemic cor costeroids for the treatment of mechanically ven lated pa ents with COVID-19 is not recommended.

Ÿ Use of low-dose cor costeroid therapy is recommended over no cor costeroids for adults with COVID-19 and refractory shock.

Cor costeroids

For Hospitalized, Non-Cri cally Ill Pa ents with COVID-19

Ÿ Use of systemic cor costeroids for the treatment of pa ents with COVID- 19 is not recommended unless they are in ICU.

For Pa ents on Chronic Cor costeroids

Ÿ Oral cor costeroid therapy used prior to COVID-19 diagnosis for another underlying condi on should not be discon nued.

Ÿ Inhaled cor costeroids used daily for pa ents with asthma and COPD should not be discon nued in pa ents with COVID-19.

Guidelines when a suspect/confirmed COVID-19 HCW is iden fied24

Immediately put on a facemask and inform supervisor and Hospital Infec on Control Commi ee (HICC)

HCW should be Isolated and referred to COVID-19 designeted hospital

He/she should be immediately taken off the roster

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Other HCWs that might have been exposed to the suspect HCW should be put under queatan ne for 14 days

All close contacts of the confirmed case should be put on Hydroxychloroquine chemoprophylaxis for a period of 7 weeks

All health facili es (HCF) must have a staffing plan in place including a con ngency plan

Infec on Control in COVID-19 pa ents25

Pa ents with COVID-19 can be grouped into the following illness categories:25

Asymptoma c or Presymptoma c Infec on

Individuals who test posi ve for SARS-CoV-2 but have no symptoms.

Mild Illness

Individuals who have any
of various signs and symptoms without shortness of

breath, dyspnea, or abnormal imaging.

Moderate Illness

Individuals who have evidence of lower respiratory disease by clinical assessment or imaging and a satura on of oxygen (SaO )

>93% on room air at sea level

Severe Illness

Individuals who have respiratory frequency >30 breaths per minute, SaO ≤93% on room air at sea level, ra o of arterial par al pressure of

oxygen to frac on of inspired oxygen (PaO /FiO) <300, or lung inzltrates >50%

Cri cal Illness

Individuals who have respiratory failure, sep c shock, and/or mul ple organ

dysfunc on

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Asymptoma c or Presymptoma c Infec on25

Asymptoma c infec on can occur, although the percentage of pa ents who remain truly asymptoma c for the course of their infec on is unknown. Some asymptoma c individuals may present with objec ve radiographic findings consistent with COVID-19 pneumonia.

He can discon nue isola on 7 days a er the date of his first

posi ve SARS-CoV-2 test

Mild Illness25

Pa ents can be managed in an ambulatory se ng or at home through telemedicine or remote visits.

Severe Illness25

These pa ents should be placed in airborne infec on isola on rooms (AIIRs), if possible.

Pa ents should be closely Monitored as in some pa ents the clinical course

may rapidly progress

Administer oxygen therapy immediately using nasal cannula or high-flow oxygen.

He should contact his health care provider for further guidance

No specific laboratory evalua ons are indicated in otherwise healthy pa ents with mild COVID-19 disease.

Follow other recommenda ons as for moderate

illness.

If a persons test posi ve for SARS-CoV-2 and he is asymptoma c

He should self isolate for 7 days

If he remains asymptoma c

If he becomes symptoma c

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Moderate Illness26

Pa ents with moderate COVID-19 should be admi ed to a health care

facility for close observa on

Cri cal Illness25

If bacterial pneumonia or sepsis is strongly suspected.

Administer empiric an bio c treatment for community-acquired pneumonia

If there is no evidence of bacterial infec on, de-escalate or stop an bio cs.

Successful clinical management of a pa ent with COVID-19 depends on a en on to the primary process leading to the ICU admission.

Oxygena on and Ven la on26

For adults with COVID-19 who are receiving supplemental oxygen:26

Closely monitor for worsening respiratory status

Early intuba on should be performed by an experienced prac oner in a controlled se ng.

For adults with COVID-19 and acute hypoxemic respiratory failure despite conven onal oxygen therapy:26

Use high-flow nasal cannula (HFNC) oxygen over noninvasive posi ve pressure ven la on (NIPPV).

For mechanically ven lated adults with COVID-19 and ARDS:26

Low dal volume (Vt) ven la on (Vt 4–8 mL/kg of predicted body weight) is recommended over higher dal volumes
(Vt >8 mL/kg) (AI).

Plateau pressures of <30 cm H2O should be targeted.

Rou ne use of inhaled nitric oxide is not recommended.

Conserva ve fluid strategy is recommended over liberal fluid technology.

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For mechanically ven lated adults with COVID-19 and moderate-to- severe ARDS:26

Use of a >higher posi ve end-expiratory pressure (PEEP) strategy is recommended over a lower PEEP strategy (BII).

Prone ven la on for 12 to 16 hours per day is recommended over no prone ven la on

In the event of persistent ven lator dyssynchrony, using a con nuous neuromuscular blocking agents (NMBA) infusion is recommended for up to 48 hours as long as pa ent anxiety and pain can be adequately monitored and controlled.

For mechanically ven lated adults with COVID-19, severe ARDS, and hypoxemia:26

Recommenda ons

Hemodynamics27

For adults with COVID-19 and shock

For the acute resuscita on of adults with COVID-19 and shock

Recruitment maneuvers should be used rather than not using recruitment maneuvers.

Trial of inhaled pulmonary vasodilator as a rescue therapy is recommended

Staircase [incremental posi ve end-expiratory pressure (PEEP)] recruitment maneuvers should not be used

If no rapid improvement in oxygena on is observed, the treatment should be tapered off

Ÿ Fluid responsiveness should be assessed using dynamic parameters, skin temperature, capillary refilling me, and/or lactate rather than sta c parameters.

Ÿ Buffered/balanced crystalloids are recommended over unbalanced crystalloids.

Ÿ Ini al use of albumin for resuscita on is NOT recommended

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Addi onal recommenda ons based on general principles of cri cal care27

What is recommended?

Norepinephrine should be used as the first-choice vasopressor.

Vasopressin (up to 0.03 U/min) or epinephrine can be added to norepinephrine to raise mean arterial pressure to target.

Dopamine can be used as an alterna ve vasopressor agent norepinephrine only in certain pa ents.

Pa ents who require vasopressors should have an arterial catheter placed as soon as prac cal.

What is not recommended?

Use of hydroxyethyl starches for intravascular volume replacement in pa ents with sepsis or sep c shock.

Use of low-dose dopamine for renal protec on

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Infec on control in COVID-19 pa ents

Screening and triage28

Screen and isolate all pa ents with suspected COVID-19 at the first point of contact with the health care system. Consider COVID-19 as a possible e ology of pa ents with acute respiratory illness under certain condi ons.

Pneumonia

Adult with pneumonia but no signs of severe pneumonia and no need for supplemental oxygen.

Child with non-severe pneumonia who has cough or difficulty breathing + fast breathing

Severe pneumonia

Adult: fever or suspected respiratory infec on, plus one of the following: respiratory rate > 30 breaths/min; severe respiratory distress; or SpO2 ≤ 93% on room air .

Child with cough or difficulty in breathing, plus at least one of the following: central cyanosis or SpO2 <90%; severe respiratory distress; signs of pneumonia with a general danger sign: inability to breas eed or drink, lethargy or unconsciousness, or convulsions.

Acute respiratory distress syndrome

Onset: within 1 week of a known clinical insult

Chest imaging:

bilateral opaci es, not fully explained by volume overload, lobar or lung collapse, or nodules.

Oxygena on impairment in adults and children: Mild, moderate and severe ARDS.

Sep c shock

Adults: persis ng hypotension despite volume resuscita on, requiring vasopressors to maintain MAP ≥ 65 mmHg and serum lactate level > 2 mmol/L.

Children: Any hypotension or two or three of the following: altered mental state, tachycardia or bradycardia, prolonged capillary refill or feeble pulse, tachypnoea, mo led or cool skin or petechial or purpuric rash, increased lactate, oliguria, hyperthermia or hypothermia.

Clinical syndromes associated with COVID-19

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Collec on of specimens for laboratory diagnosis29

General guidelines:

Do’s

Ÿ Collect blood cultures for bacteria that cause pneumonia and sepsis, ideally before an microbial therapy.

Ÿ In a clinically recovered pa ent, two nega ve tests, at least 24 hours apart, is recommended for hospital discharge

Ÿ Use appropriate PPE for specimen collec on
In a clinically recovered pa ent, two nega ve tests, at least 24 hours apart, is recommended for hospital discharge

Ÿ When collec ng URT samples, use viral swabs (sterile Dacron or rayon, not co on) and viral transport media.

Ÿ Do not sample the nostrils or tonsils

Ÿ Do not delay an microbial therapy to collect blood cultures

Don’ts

Sites for collec on of specimen for COVID-19 virus tes ng by RT-PCR and bacterial stains/cultures:29

Collec on
of specimens

Preferred

where clinical suspicion remains and URT specimens are nega ve

Collect specimens from the upper respiratory tract

Collect specimens from the lower respiratory tract

Nasopharyngeal Oropharyngeal

Expectorated sputum

Endotracheal aspirate

Bronchoalveolar lavage in ven lated pa ent

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Symptoma c treatment and monitoring30

Managing Cough30

Ini al management

Use simple measures first, such as a teaspoon of honey (for pa ents aged over 1 year).

First choice: Only if cough is distressing

Codeine linctus or codeine phosphate tablets: 15 mg to 30 mg every 4 hours as required, up to 4 doses in 24 hours.

If necessary, increase dose to a maximum of 30 mg to 60 mg 4 mes a day.

Managing fever30

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Second choice: Only if cough is distressing

Morphine sulfate oral solu on:

Ÿ 2.5 mg to 5 mg when required every 4 hours

Ÿ Increase up to 5 mg to 10 mg every 4 hours as required

Ÿ If the pa ent is already taking regular morphine increase the regular dose by a third.
Other sugges ons
Encourage pa ents with cough to avoid lying on their back because this makes coughing ineffec ve

Fever is most common 5 days a er exposure to the infec on.

Advise pa ents to drink fluids regularly to avoid dehydra on.

Do not use an pyre cs with the sole aim of reducing body temperature

Advise pa ents to take paracetamol or ibuprofen if they have fever and other symptoms that an pyre cs would help treat

An pyre cs for managing fever in adults and children:30

For adults
(18 years and over)

Managing breathlessness: 30

Paracetamol

Ibuprofen

0.5 g to 1 g every 4 to 6 hours, maximum 4 g per day

400 mg three mes a day when required.

Suppor ve care

Ÿ Keeptheroomcool.

Ÿ Encourage relaxa on and breathing techniques and
changing body posi oning.

Ÿ Encourage pa ents who are self-isola ng alone, to improve air circula on by opening a window or door.

Ÿ Do not use a fan because this can spread infec on.

Ÿ When oxygen is available, consider a trial of oxygen therapy
and assess whether breathlessness improves.

Ÿ Iden fy and treat reversible causes of breathlessness, for example pulmonary oedema.

Ÿ Consider an opioid and benzodiazepine combina on for pa ents with COVID-19 who:

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End-of-life treatments for managing breathlessness for pa ents aged 18 years and over:30

Treatment

Already on opoids

Those who are unable to swallow

Morphine sulfate modified-release 5 mg twice a day, increased as necessary (maximum 30 mg daily).

Morphine sulfate immediate-release 5 mg to 10 mg every 2 to 4 hours as required.

One twel h of the 24-hour dose for pain, whichever is greater.

Parenteral treatment :

Morphine sulfate 1 mg to 2 mg subcutaneously every 2 to 4 hours as required, increasing the dose as necessary

Following benzodiazepines can be added if required:30

For breathlessness and anxiety

Lorazepam 0.5 mg sublingually when required (maximum 4 mg daily).

For breathlessness and anxiety

Midazolam 2.5 mg to 5 mg subcutaneously when required.

Morphine sulfate immediate-release 2.5 mg to 5 mg every 2 to 4 hours as required .

Opioid naive Or

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Managing anxiety, delirium and agita on:30

Treatments for managing anxiety, delirium and agita on in pa ents aged 18 years and older:30

Anxiety or agita on and able to swallow

Lorazepam tablets:

Lorazepam 0.5 mg to 1 mg 4 mes a day as required (maximum 4 mg in 24 hours).

Anxiety or agita on and unable to swallow

Midazolam injec on:

Midazolam 2.5 mg to 5 mg subcutaneously every 2 to 4 hours as required.

Delirium and able to swallow

Haloperidol orally:

Haloperidol 0.5 mg to 1 mg at night and every 2 hours when required.

Delirium and unable to swallow

Levomepromazine injec on:

Levomepromazine 12.5 mg to 25 mg subcutaneously as a star ng dose and then hourly as required

Management of severe COVID-19: treatment of co-infec ons29

Give empiric an microbials to treat all likely pathogens causing SARI and sepsis as soon as possible, within 1 hour of ini al assessment for pa ents with sepsis.

Empiric therapy should be de-escalated on the basis of microbiology results and clinical judgment.

Preven on of complica ons29

Reducing incidence of ven lator-associated pneumonia

Ÿ Oral intuba on is preferable to nasal intuba on in adolescents and adults

Ÿ Keep pa ent in semi-recumbent posi on (head of bed eleva on 30-45 ̊)

Ÿ Use a closed suc oning system; periodically drain and discard condensate in tubing

Ÿ Use a new ven lator circuit for each pa ent; once pa ent is ven lated, change circuit if it is soiled or damaged, but not rou nely .

Ÿ Change heat moisture exchanger when it malfunc ons, when soiled, or every 5-7 days.

Treatment

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Reducing incidence of venous thromboembolism

Reducing incidence of catheter-related bloodstream infec on

Reducing incidence of pressure ulcers

Reducing Reduce incidence of stress ulcers and gastrointes nal (GI) bleeding

Reducing incidence of ICU- related weakness

Ÿ Use pharmacological prophylaxis (low molecular-weight heparin [preferred if available] or heparin 5000 units subcutaneously twice daily) in adolescents and adults without contraindica ons.

Ÿ For those with contraindica ons, use mechanical prophylaxis (intermi ent pneuma c compression devices)

Ÿ Use a checklist with comple on verified by a real- me observer as reminder of each step needed for sterile inser on and as a daily reminder to remove catheter if no longer needed.

Ÿ Turn pa ent every 2 hours

Ÿ Give early enteral nutri on (within 24–48 hours of admission).

Ÿ Administer histamine-2 receptor blockers or proton-pump inhibitors in pa ents with risk factors for GI bleeding.

Ÿ Ac vely mobilize the pa ent early in the course of illness when safe to do so.

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Care of Cri cally Ill Pa ents with COVID-1931

Health care workers who are performing aerosol- genera ng procedures should use:

Endotracheal intuba on for pa ents with COVID- 19 should be done by health care providers with extensive airway management experience

Fit-tested respirators (N- 95 respirators) or powered air-purifying respirators rather than surgical masks.

intuba on should be achieved by video laryngoscopy.

Hemodynamic support31

Recommended 1st choice Vasopressor is norepinephrine

Pa ents who show evidence of persistent hypoperfusion should be prescribed dobutamine

Guidelines for adults and children with severe asthma during the COVID-1932,33

Do’s

Con nue the use of inhaled asthma controller medica ons in asthma cs during the COVID-19 epidemic

In acute asthma a acks, pa ents should take a short course of oral cor costeroids if instructed by their healthcare provider, to prevent serious consequences.

Biologic therapies should be used in severe asthma pa ents who qualify for them, in order to limit the need for OCS as much as possible

Use of pressurized metered dose inhaler (pMDI) via a spacer is the preferred treatment during severe a acks.

Pa ents with allergic rhini s should con nue to take their nasal cor costeroids, as prescribed by their clinician

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Infec on Control31

Don’ts

Do not stop the prescribed inhaled cor costeroid controller medica on (or prescribed oral cor costeroids) in people with asthma.

Do not use nebulisers for acute a acks, wherever possible, due to the increased risk of dissemina ng COVID-19

Spacers must not be shared at home

Suspend the rou ne spirometry tes ng to reduce the risk of viral transmission

COVID-19 poten al anaesthe c drug list34

Drugs used in anesthesia and cri cal care are under supply pressure due to the increased demand driven by the COVID-19 pandemic. The Associa on of Anaesthe sts and the Royal College of Anaesthe sts provides a brief overview of drugs that may not be used in regular prac ce:

Anaesthesia34

THIOPENTAL ISOFLURANE

Ÿ Dose: 3-5mg/kg adult

Ÿ Vasodilata on and
hypotension

Ÿ !!! Distal limb ischaemia with intraarterial injec on !!!

Ÿ Poorly obtunds laryngeal reflexes

Ÿ Contraindicatedinporphyria
ETOMIDATE

Ÿ Dose: 0.2-0.3mg/kg

Ÿ Rela ve cardiovascular
stability

Ÿ Suppresses adrenocor cal func on

Ÿ Involuntary movements

Ÿ Pain on injec on

Ÿ 1 MAC = 1.2% in adults

Ÿ Poten ates ac on of nondepolarising Neuromuscular blocking drugs

Ÿ Avoid for inhala onal induc on

HYPERBARIC 2% PRILOCAINE

Ÿ Saddle block: 10-20 mg (0.5- 1 mls)

Ÿ T10 block: 40-60 mg (2-3mls)
Ÿ No need for addi onal opioids
Ÿ Reduced risk of urinary reten on and

ongoing motor block
Ÿ Surgery for up approximately 60 minutes Ÿ Rela vely contraindicated in sickle cell

disease due
Ÿ to methaemoglobinaemia risk

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Neuromuscular blocking drugs:34

VECURONIUM SUXAMETHONIUM

Ÿ Dose: 0.08-0.1 mg/kg IV

Ÿ Onset: 3-5 min

Ÿ Dura on: 20-35 min

Ÿ Powder does not need to be refrigerated

Ÿ Can be reversed with sugammadex
PANCURONIUM

Ÿ Dose: 0.05-0.1 mg/kg

Ÿ Onset: 90-150 s

Ÿ Dura on: 65-100 minutes

Ÿ Causes increased heart rate, blood pressure and cardiac output
Analgesia:34

Ÿ Dose: 1-1.5 mg/kg

Ÿ Onset: 30 s

Ÿ Dura on: 3-5 minutes

Ÿ Suggested first line for RSI if no contraindica ons

Ÿ Causes transient hyperkalaemia

CLONIDINE PETHIDINE

Ÿ Dose: up to 150 mcg, trated to effect

Ÿ IV / PO

Ÿ Hypotension & reflex
tachycardia

Ÿ Can cause drowsiness

Ÿ 50-150 mg PO QDS

Ÿ 25-100 mg IV

Ÿ Avoid in pa ents on MAOIs

CLONIDINE TRAMADOL

Ÿ IV/PO/SC

Ÿ 1-10 mg IV trated to
effect

Ÿ 2 mg PO equivalent to 1mg IV

Ÿ Cau on in hepa c failure 47

Ÿ PO/IM /IV

Ÿ Dose: 50-100 mg 4-6
hourly

Ÿ Effec ve for postopera ve shivering

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DICLOFENAC PARECOXIB

Ÿ Dose: 75-150 mg PO/IM/PR in divided doses

Ÿ 25-75 mg IV

Ÿ Risk of renal impairment if
coadministered with ACEi

Ÿ Avoid in NSAID-sensi ve asthma cs
KETOROLAC

Ÿ IV/IM

Ÿ Dose: 10 mg loading

Ÿ 10-30 mg every 4-6 hours PRN

Ÿ Maximum dosage 90 mg/day

Ÿ Maximum dura on: 2 days

Ÿ Cau on as per NSAID use
Others:34

Ÿ IV/IM

Ÿ Dose: 40 mg loading

Ÿ 20-40 mg every 6-12 hours PRN

Ÿ Maximum 80 mg per day

Ÿ Maximum dura on: 3 days

IF NO VOLUMETRIC PUMP PHENYLEPHRINE

Ÿ Drips/min = [Volume (ml) x Drip factor] /

Ÿ Time (min)

Ÿ Drip factor is provided on
individual giving sets

Ÿ Example: 500 ml normal saline over 4

Ÿ hours via a standard giving set

Ÿ [500 x 20] / 240 = 42 drips/min

Ÿ Dose: 50-100 mcg boluses IV

Ÿ 10 mg vial diluted in 100 or 500 ml of normal saline

Ÿ Can be used as peripheral infusion (use local protocol)

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Discharge criteria for confirmed COVID-19 cases35

Dura on of SARS-CoV-2 virus shedding in bodily fluids of symptoma c pa ents:

SARS-CoV-2 virus can ini ally be detected 1-2 days prior to symptom onset in upper respiratory tract samples.

The virus can persist for 7-12 days in moderate cases and up to 2 weeks in severe cases.

In faeces, viral RNA has been detected in up to 30% of pa ents from day 5 a er onset and up to 4 to 5 weeks in moderate cases.

Among convalescent children virus shedding is prolonged a er mild infec ons: upto 22 days in respiratory tract samples and between 2 weeks and more than 1 month in faeces

Di“scharged pa ents should be advised to strictly follow personal hygiene precau ons in order to protect household contacts. This applies

to all convalescing pa ents, but par cularly to convalescent childre“n. 49

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Recommenda ons for the de-isola on of COVID-19 pa ents according to na onal bodies of countries:35

NCID Singapore

Afebrile ≥ 24 hours

Day of illness from onset ≥ 6 days

2 respiratory samples tested nega ve for SARS- CoV-2 by PCR in ≥ 24 hours

Alterna ve ae ology found (e.g. influenza, bacteraemia)

Not a close contact of a COVID-19 case

Does not require in-pa ent care for other reasons

Pa ents mee ng the following criteria can be discharged

Afebrile for >3 days

Nucleic acid tests nega ve for respiratory tract pathogen twice consecu vely (sampling interval ≥ 24 hours).

Where pulmonary imaging shows obvious absorp on of inflamma on

Those with Improved respiratory symptoms

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CDC USA

Nega ve rRT-PCR results from at least 2 consecu ve sets of nasopharyngeal and throat swabs collected ≥24 hours apart

Hospitalized COVID-19 Pa ents mee ng the following criteria can be discharged

Improvement in illness signs and symptoms.

Resolu on of fever, without use of an pyre c medica on

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References

1. Na onal Ins tute of Health. COVID-19 Treatment Guidelines – Overview. Available at h ps://www.covid19treatmentguidelines.nih.gov/introduc on/ Accessed on 31st May 2020.

2. Worldometer. COVID-19 Coronavirus pandemic. Available at h ps://www.worldometers.info/coronavirus/ Accessed on 31st May 2020.

3. Nazario B. How long do coronaviruses live on surfaces? WebMD. Available at h ps://img.webmd.com/dtmcms/live/webmd/consumer_assets/site_images/ar cle_thumbnails/features/covid_19/Coronavirus_Surfaces.pdf Accessed on 31st May 2020.

4. World Health Organiza on. Coronavirus disease (COVID-19) outbreak: rights,roles and responsibili es of health workers, including key considera ons for occupa onal safety and health. Available at h ps://www.who.int/publica ons-detail/coronavirus-disease-(covid-19)- outbreak-rights-roles-and-responsibili es-of-health-workers-including-key-considera ons-for-occupa onal-safety-and-health Accessed on Accessed on 31st May 2020.

5. American Medical Associa on. A physician’s guide to COVID-19. Available at h ps://www.ama-assn.org/system/files/2020-04/physicians- guide-covid-19.pdf Accessed on 31st May 2020.

6. European Centre for Disease Preven on and Control (EADC). Guidance for health system con ngency planning during widespread transmission of SARS-CoV-2 with high impact on healthcare services. Available at h ps://www.ecdc.europa.eu/sites/default/files/documents/COVID-19-guidance-health-systems-con ngency-planning.pdf Accessed on Accessed on 31st May 2020.

7. European Centre for Disease Preven on and Control (EADC). Disinfec on of environments in healthcare and non-healthcare se ngs poten ally contaminated with SARS-CoV-2. Available at h ps://www.ecdc.europa.eu/sites/default/files/documents/Environmental-persistence- of-SARS_CoV_2-virus-Op ons-for-cleaning2020-03-26_0.pdf Accessed on Accessed on 31st May 2020.

8. World Health Organiza on. Coronavirus disease (COVID-19). Infec on preven on and control during health care when novel coronavirus (nCoV) infec on is suspected. Available at h ps://www.who.int/publica ons-detail/infec on-preven on-and-control-during-health-care-when- novel-coronavirus-(ncov)-infec on-is-suspected-20200125 Accessed on 31st May 2020.

9. European Centre for Disease Preven on and Control (EADC). Infec on preven on and control and preparedness for COVID-19 in healthcare se ngs. Available at h ps://www.ecdc.europa.eu/sites/default/files/documents/Infec on-preven on-control-for-the-care-of-pa ents-with- 2019-nCoV-healthcare-se ngs_update-31-March-2020.pdf Accessed on Accessed on 31st May 2020.

10. World Health Organiza on. Infec on preven on and control during health care when COVID-19 is suspected. Available at h ps://www.who.int/publica ons-detail/infec on-preven on-and-control-during-health-care-when-novel-coronavirus-(ncov)-infec on-is- suspected-20200125 Accessed on 31st May 2020.

11. Ministry of Health and Family Welfare. Novel Coronavirus Disease 2019 (COVID-19): Addi onal guidelines on ra onal use of Personal Protec ve Equipment (se ng approach for Health func onaries working in non-COVID areas). Available at h ps://www.mohfw.gov.in/pdf/Addi onalguidelinesonra onaluseofPersonalProtec veEquipmentse ngapproachforHealthfunc onariesworking innonCOVIDareas.pdf Accessed on 31st May 2020.

12. Centers for Disease Control and Preven_on (CDC). Healthcare-associated Infec ons. Sequence for pu ng on personal protec ve equipment (PPE). Available at h ps://www.cdc.gov/hai/pdfs/ppe/PPE-Sequence.pdf Accessed on 31st May 2020.

13. World Health Organiza on. Clean Care is Safer Care. About SAVE LIVES: Clean Your Hands h ps://www.who.int/gpsc/5may/background/5moments/en/ Accessed on 31st May 2020.

14. Atkinson J, Char er Y, Pessoa-Silva CK, Jensen P, Li Y, Seto WH, editors. Natural ven la on for infec on control in health-care se ngs. Geneva: World Health Organiza on; 2009. Available at h ps://apps.who.int/iris/handle/10665/44167 Accessed on 31st May 2020.

15. Dr. Sudhir Shah. Navbharat Samay: Ravivar Samay. Come On! Let us adopt new ABCD to conquer Corona (ચાલો! નવી ABCD અપનાવીએ, કોરોના પર િવજય મેળવીએ). Available at h ps://epaper.navgujaratsamay.com/download/newspaper/2684767# Accessed on 31st May 2020.

16. Indian Medical Associa on. COVID-19 – Role of hospitals & healthcare professionals. Available at h ps://www.ima- india.org/ima/pdfdata/COVID-19-Guidelines-for-Hospitals-n-Doctors.pdf Accessed on 31st May 2020.

17. World Health Organiza on. Considera ons for quaran ne of individuals in the context of containment for coronavirus disease (COVID-19). Available at h ps://www.who.int/publica ons-detail/considera ons-for-quaran ne-of-individuals-in-the-context-of-containment-for- coronavirus-disease-(covid-19) Accessed on 31st May 2020.

18. World Health Organiza on. Guiding principles for immuniza on ac vi es during the COVID-19 pandemic: interim guidance. Available at h ps://apps.who.int/iris/handle/10665/331590 Accessed on 31st May 2020.

19. World Health Organiza on. Maintaining a safe and adequate blood supply during the pandemic outbreak of coronavirus disease (COVID-19). Available at h ps://www.who.int/publica ons-detail/maintaining-a-safe-and-adequate-blood-supply-during-the-pandemic-outbreak-of- coronavirus-disease-(covid-19) Accessed on 31st May 2020.

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20. Na onal Ins tutes of Health. COVID-19 Treatment Guidelines Panel. Coronavirus Disease 2019 (COVID-19) Treatment Guidelines. Persons at Risk for Infec on with SARS-CoV-2. Available at h ps://www.covid19treatmentguidelines.nih.gov/overview/prophylaxis/ Accessed on 31st May 2020.

21. Ministry of Health and Family Welfare. Advisory on the use of hydroxy-chloroquine as prophylaxis for SARS-C0V-2 infec on. Available at h ps://www.mohfw.gov.in/pdf/AdvisoryontheuseofHydroxychloroquinasprophylaxisforSARSCoV2infec on.pdf Accessed on 31st May 2020.

22. United Na ons Medical Directors (UNMD). Guidance for OFF LABEL use of Hydroxychloroquine (HCQ) and Chloroquine (CQ) for COVID- 19 infected pa ents. Available at h ps://www.un.org/sites/un2.un.org/files/guidance_for_off_label_use_of_hydroxychloroquine.pdf Accessed on 31st May 2020.

23. Na onal Ins tutes of Health. Considera ons for Certain Concomitant Medica ons in Pa ents with COVID-19. Available at h ps://www.covid19treatmentguidelines.nih.gov/concomitant-medica ons/ Accessed on 31st May 2020.

24. Ministry of Health & Family Welfare Directorate General of Health Services. Guidelines to be followed on detec on of suspect/confirmed COVID-19 case in a non-COVID Health Facility. Available at h ps://www.mohfw.gov.in/pdf/Guidelinestobefollowedondetec onofsuspectorconfirmedCOVID19case.pdf Accessed on 31st May 2020.

25. Na onal Ins tutes of Health. Management of Persons with COVID-19. Available at h ps://www.covid19treatmentguidelines.nih.gov/overview/management-of-covid-19/ Accessed on 31st May 2020.

26. Na onal Ins tutes of Health. Oxygena on and Ven la on. Available at h ps://www.covid19treatmentguidelines.nih.gov/cri cal- care/oxygena on-and-ven la on/ Accessed on 31st May 2020.

27. Na onal Ins tutes of Health. Hemodynamics. Available at h ps://www.covid19treatmentguidelines.nih.gov/cri cal-care/hemodynamics/ Accessed on 31st May 2020.

28. Ministry of Health & Family Welfare – Directorate General of Health Services. Revised guidelines on clinical management of COVID-19. Available at h ps://www.mohfw.gov.in/pdf/RevisedNa onalClinicalManagementGuidelineforCOVID1931032020.pdf Accessed on 31st May 2020.

29. World Health Organiza on (WHO). Clinical management of severe acute respiratory infec on (SARI) when COVID-19 disease is suspected. Available at h ps://www.who.int/publica ons-detail/clinical-management-of-severe-acute-respiratory-infec on-when-novel-coronavirus-(ncov)- infec on-is-suspected Accessed on 31st May 2020.

30. Na onal Ins tute for Health and Care Excellence (NICE). COVID-19 rapid guideline: managing symptoms (including at the end of life) in the community. Available at h ps://www.nice.org.uk/guidance/ng163/resources/covid19-rapid-guideline-managing-symptoms-including-at-the-end- of-life-in-the-community-pdf-66141899069893 Accessed on 31st May 2020.

31. Na onal Ins tutes of Health. Care of Cri cally Ill Pa ents with COVID-19. Available at h ps://www.covid19treatmentguidelines.nih.gov/cri cal-care/ Accessed on 31st May 2020.

32. Global Ini a ve for Asthma (GINA). Recommenda ons for inhaled asthma controller medica ons. Available at h ps://ginasthma.org/recommenda ons-for-inhaled-asthma-controller-medica ons/ Accessed on 31st May 2020.

33. Global Ini a ve for Asthma (GINA). COVID-19: GINA answers to frequently asked ques ons on asthma management. Available at h ps://ginasthma.org/covid-19-gina-answers-to-frequently-asked-ques ons-on-asthma-management/ Accessed on 31st May 2020.

34. The Associa on of Anaesthe sts and the Royal College of Anaesthe sts. COVID-19 poten al anaesthe c drug list. Available at h ps://sta c1.squarespace.com/sta c/5e6613a1dc75b87df82b78e1/t/5e999ad41f79016c41a07d9b/1587125084445/COVID- 19+POTENTIAL+ANAESTHETIC+DRUG+LIST Accessed on 31st May 2020.

35. European Centre for Disease Preven on and Control (EADC). Discharge criteria for confirmed COVID-19 cases – When is it safe to discharge COVID-19 cases from the hospital or end home isola on? Available at h ps://www.ecdc.europa.eu/sites/default/files/documents/COVID-19- Discharge-criteria.pdf Accessed on 31st May 2020.

36. Ministry of Health and Family Welfare. Novel Coronavirus Disease 2019 (COVID-19): guidelines on ra onal use of personal protec ve equipment. Available at h ps://www.mohfw.gov.in/pdf/Guidelinesonra onaluseofPersonalProtec veEquipment.pdf Accessed on 31st May 2020.

37. World Health Organiza on. Ra onal use of personal protec ve equipment (PPE) for coronavirus disease (COVID-19). Available at h ps://apps.who.int/iris/bitstream/handle/10665/331498/WHO-2019-nCoV-IPCPPE_use-2020.2-eng.pdf?sequence=1&isAllowed=y Accessed on Accessed on 31st May 2020.

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