Hospitals and care centers for COVID-19 have contributed to a significant proportion of confirmed cases in India. Enabling proper infection control measures at all care centers (from fever clinics to district hospitals and quarantine centers) are critical in controlling the spread of infection.
Infections are opportunistic and even microorganisms with low virulence can cause major infections in people visiting the hospital who may already by immunocompromised. According to the World Health Organisation, at any given time over 1.4 million people across the globe suffer from hospital-acquired infection (HAI). HAIs account for 2 million cases and about 80,000 deaths a year. The risk of fast spreading HAIs together with the virulence of SARS-CoV2 can wipe out our entire healthcare system.
SARS-CoV-2, the virus that causes COVID-19 is a respiratory pathogen and has a dose-dependent infection rate. This means that anyone at a hospital or visiting a hospital caring for COVID19 has a recognized risk of getting infected.
Reduce patient-healthworker interaction
Hence as much as possible patients should be discouraged from coming to the hospital. Alternatives to face-to-face triaging should be explored and doctors can offer home visits in case the patient requires minor procedures. While caring for a patient assume that every person is potentially infected or colonized with a pathogen that could be transmitted.
If a patient must come to the hospital, ensure a physical barrier or a teller window between the patients and the doctors.
Unless hospitalization is necessary; suspected patients with respiratory symptoms should be placed in quarantine centers while enabling virtual rounds of doctors and remote active monitoring of clinical symptoms.
As far as possible, have dedicated and trained healthcare professionals work in COVID-19 wards. Staffing plans for the hospitals should be created keeping that in mind.
Reduce patient-patient interaction
When hospitalization is necessary, place patients (suspected and confirmed) preferably in single room wards with a door and dedicated washroom. In non-availability of rooms; confirmed cases can be cohorted with other confirmed cases. Suspected cases should strictly not be cohorted.
Reduce patient-visitor interactions
Strictly limit the number of visitors that can come inside the hospital premise and issue time-cards to the visitors instructing them to spend no more than 30 minutes inside the hospital.
Require all visitors to download the AarogyaSetu app to enable contact tracing.
Do not let visitors without a mask to enter the hospital. Every visitor should have their faces covered when inside the hospital.
As far as possible allow no visitors for confirmed patients.
Reduce patient-environment interactions
Carry out any aerosol-generating procedures such as swabbing or open-air suctioning in either patient's room or a dedicated procedure room.
Install physical barriers wherever possible; eg guiding the confirmed patients to procedure rooms; between patient beds in isolation wards.
Those in quarantine be placed in adequately ventilated, spacious single rooms, with attached toilet (hand hygiene and toilet facilities). If single rooms are notavailable, beds should be placed at least 1 meter apart;
Suitable environmental infection controls, such as adequate air ventilation, filtration systems and waste management protocols;
Maintenance of social distancing (more than 1 meter) of the persons quarantined;
Accommodation with an appropriate level of comfort, including:
a. Food, water and hygiene provisions;
b. Protection for baggage and other possessions;
c. Appropriate medical treatment for existing conditions;
d. Communication in a language that they can understand explaining: their rights; provisions that will be made available to them; how long they will need to stay; what will happen if they get sick; contact information of their local embassy or consular support;
e. Assistance for quarantined travellers, isolated or subject to medical examinations or other procedures for public health purposes;
f. Assistance with communication with family members outside the quarantine facility;
g. If possible, access to the internet, news and entertainment;
h. Psychosocial support; and
i. Special considerations for older individuals and individuals with co-morbid conditions, due to their increased risk for severe COVID-19 disease.
Possible quarantine settings are hotels, dormitories, other facilities catering to groups, or the home of the contact. Regardless of the setting, an assessment must ensure that the appropriate conditions for safe and effective quarantine are being met.
When home quarantine is chosen, the person should occupy a well-ventilated single room, or if a single room is not possible, maintain a distance of at least 1 meter from other household members, minimizing the use of shared spaces and cutlery and ensuring that shared spaces (kitchen, bathroom) are well ventilated.
The following infection prevention and control measures should be used to ensure a safe environment for quarantined persons.
a. Any person in quarantine who develops febrile illness or respiratory symptoms, at any point during the quarantine period, should be treated and managed as a suspect COVID-19 case;
b. Apply standard precautions for all persons quarantined and quarantine personnel:
Perform hand hygiene frequently, particularly after contact with respiratory secretions, before eating and after using the toilet. Hand hygiene includes either cleaning hands with soap and water or with an alcohol-based hand rub. Alcohol-based hand rubs are preferred if hands are not visibly soiled; wash hands with soap and water when they are visibly soiled;
Ensure that all persons quarantined are practicing respiratory hygiene, and are aware of the importance of covering their nose and mouth with a flexed elbow or paper tissue when coughing or sneezing and disposing immediately of the tissue and performing hand hygiene;
Refrain from touching mouth and nose;
Administrative controls and policies for IPC within quarantine facilities include, but may not be limited to:
a. establishing sustainable IPC infrastructures (design of facility) and activities;
b. educating persons quarantined and quarantine personnel about IPC;
c. all personnel working in the quarantine facility need to have training on standard precautions before the quarantine measures are implemented.
d. The same advice on standard precautions should be given to all quarantined persons on arrival.
e. Both personnel and quarantined persons should understand the importance of promptly seeking medical care if they develop symptoms;
f. Developing policies on the early recognition and referral of a suspect COVID-19 case.
a. Environmental cleaning and disinfection procedures must be followed consistently and correctly.
b. Cleaning personnel need to be educated and protected from COVID-19 infection and ensure that environmental surfaces are regularly and thoroughly cleaned throughout the quarantine period:
Clean and disinfect frequently touched surfaces such as bedside tables, bedframes, and other bedroom furniture daily with regular household disinfectant containing a diluted bleach solution (1-part bleach to 99 parts water). For surfaces that do not tolerate bleach, 70% ethanol can be used;
Clean and disinfect bathroom and toilet surfaces at least once daily with regular household disinfectant containing a diluted bleach solution (1-part bleach to 99 parts water);
Clean clothes, bedclothes, bath and hand towels, etc., using regular laundry soap and water or machine wash at 60–90 °C with common laundry detergent and dry thoroughly;
Countries should consider measures to ensure that waste is disposed of in a sanitary landfill, and not in an unmonitored open area;
Cleaning personnel should wear disposable gloves when cleaning or handling surfaces, clothing or linen soiled with body fluids, and should perform hand hygiene before and after removing gloves.
i. Daily follow-up of persons quarantined should be conducted within the quarantine facility for the duration of the quarantine and should include daily body temperature and symptom screening.
ii. Groups of persons at higher risk of infection and severe disease may require additional surveillance for chronic conditions or specific medical treatments.
iii. Consideration should be given to the resources, personnel and rest period of staff at quarantine facilities. This is particularly important in the context of an ongoing outbreak, during which limited public health resources may be better prioritised towards health care facilities and case-detection activities.
iv. Laboratory testing of a respiratory sample from quarantined persons, irrespective of symptoms, is advised at the end of the quarantine period.