Case Management

Standard Operating Procedure

Version 3.1

Date: 15 June 2020

Table of Contents

Acronyms ................................................................................................................................. 3

Purpose .................................................................................................................................... 4

Responsibilities ........................................................................................................................ 4

Scope ........................................................................................................................................ 4

Introduction ............................................................................................................................. 5

COVID-19 Screening and Triage ............................................................................................... 6

Management of COVID-19 in designated locations outside of health facilities ....................... 8

Referral Guide for Patients Suspected or Confirmed ............................................................. 10

Transportation and Patient Handover ................................................................................... 10

Management of Mild Cases ................................................................................................... 11

Management of Severe COVID-19 ......................................................................................... 11

Management of Critical COVID-19 ......................................................................................... 12

Special Populations ................................................................................................................ 17

Monitoring of Patients ........................................................................................................... 18

Discharge and Deisolation Criteria ......................................................................................... 18

Drugs and Information ........................................................................................................... 18

Guidance on Surgical and Medical Procedures during COVID-19 .......................................... 22

Annexes/Additional Resources .............................................................................................. 23

Acronyms

BMI Body Mass Index COVID-19 Novel Coronavirus 2019 disease ENT Ear Nose and Throat HIV Human Immunodeficiency Virus HR Heart rate ICU Intensive Care Unit IPC Infection Prevention and Control LOC Level of consciousness MoHSS Ministry of Health and Social Services PPE Personal Protective Equipment RR Respiratory rate RT-PCR Reverse transcription polymerase chain reaction RTI Respiratory tract infection

Purpose

This Standard Operating Procedure (SOP) is a guide to the workflow for the Case Management Pillar of the National Covid19 Response in Namibia. This guide is complementary to the National Response Plan on Covid19 in Namibia. This guide is for use by all health care workers in both state and all private institutions in Namibia. It replaces all current and previous COVID-19 guidance. It provides guidance on timely, effective and safe supportive management of patients with suspected and confirmed COVID-19 at community and health facility level (clinic, health centre, hospital) for both private and public facilities. This SOP is being constantly updated as new information is available and providers should always ensure that they are using the most up to date guideline version.

New in this SOP version 3.0

1. Updated guidance on isolation. 2. Added information highlighting Namibia is not currently recommending self-isolation at

home. 3. Added Remdesivir dosing table

Responsibilities

The goal in clinical management of cases is to reduce morbidity and mortality and minimise transmission to uninfected contacts. Triaging patients and early identification of patients who are severely or critically ill and require hospital or ICU admission will be essential in reducing morbidity and mortality.

Scope

The procedures are applicable at national, regional, district (health facility) and community level.

Introduction

The goal in clinical management of cases is to reduce morbidity and mortality and minimise transmission to uninfected contacts. Triaging patients and early identification of patients who are severely or critically ill and require hospital or ICU admission will be essential in reducing morbidity and mortality. Patients with confirmed COVID-19 who need hospitalization can be managed at either state or private hospitals depending on where the patient presented. This is to minimize referrals which further expose more healthcare workers to COVID-19. According to WHO, about 81% of patients with COVID-19 may have mild disease; 14% of patients will have severe disease that requires oxygen therapy or other inpatient interventions; and about 5% have critical disease that requires mechanical ventilation.

Figure 1: Presentation of Covid-19 disease

5% CRITICAL

14% SEVERE

81% MILD DISEASE

High Risk Populations

Age above 65 years old Cardiovascular disease Diabetes mellitus Poorly controlled hypertension Immune deficiency states HIV, CD4 cell count <200 cell/mL or unknown CD4 Pre-existing pulmonary disease Chronic kidney disease Obesity (BMI≥30) Mild Disease Criteria

Adults SpO2 >93% Respiratory rate <30 breaths per minute HR <120 Children 5-12 Respiratory rate < 30HR <130 Severe and Critical Severe – Requires oxygen SpO2 ≤93% Respiratory rate ≥25 breaths per minute HR ≥130 Critical – Requires ventilatory support Present with severe respiratory distress to failure Multi-organ failure Children < I year – RR > 50bpm 1 -3 years – RR > 40bpm > 5years – RR > 30bpm Oxygen saturation < 90% Altered LOC Feeding difficulty Moderate to severe dehydration

ALWAYS WEAR APPROPRIATE PPE

COVID-19 Screening and Triage

Triage should follow one of the following three flow diagrams depending on whether Namibia continues to only have sporadic or cluster transmission, whether community transmission is occurring, and whether the case is identified in the community. While Namibia aims to contain the outbreak and isolate cases within a hospital setting, thresholds have been set to triage cases according to need. Both clinical condition and facility isolation capacity will determine whether or not a suspect case will be admitted to an isolation unit within a health facility or admitted to a designated isolation unit outside a health facility. Threshold 1: When more than 60% of the health facility bed capacity dedicated to COVID-19 is still available and care for other conditions can still occur. • Then, all cases will be managed in isolation units at COVID19-designated health facility. Threshold 2: When more than 60% of the health facility bed capacity dedicated to COVID-19 are used up by the COVID19 confirmed and/or suspect cases and/or there is a major disruption of essential medical services. • Isolation in health facility should be for severe COVID19 confirmed or suspect cases, and those at higher risk of developing severe disease or complications due to co-morbidities. • Isolation in other designated COVID19 non-health care facility sites (e.g. Guest houses, isolation tents) for non-severe COVID19 confirmed or suspect cases

Namibia is currently using this strategy Threshold 3: When the health facilities and other designated isolation sites are overwhelmed. • Isolation in health facility should be for severe COVID19 confirmed or suspect cases. • Isolation in other designated COVID19 non-health care facility sites (e.g. Guest Houses or tents) for non-severe COVID19 confirmed or suspect cases at higher risk of developing severe disease or complications due to comorbidities who need closer monitoring. • Isolation at home for COVID19 confirmed or suspect cases at low risk of developing complications, live in home that have space and amenities for home isolation (based on checklist) and do not have high-risk individuals in their households. COVID-19 Screening and Triage process at the health facility COVID-19 triage aims to recognize patients with acute respiratory infection (ARI) at first point of contact with the health care system in order to identify severe symptoms to allow for rapid action, rule-out other common causes of symptoms which could mimic COVID, ascertain whether suspect case definition is met, and protect other patients and staff from potential exposure to COVID-19. At presentation to a facility, any individual with symptoms of acute respiratory infection (flu-like symptoms such as fever, cough, difficulty in breathing, muscle ache, running nose, sneezing, and sore throat) should be directed to a designated area away from other patients. A small team of health care workers should be assigned to staff the triage area and be provided with PPE per IPC standards.

Figure 2: Triage and Screening at health facilities

No

No

Yes

Yes to at least 1

No to ALL

Wash or sanitize hands Take temperature using and infrared thermometer

LOW RISK TO COVID 19

Direct to facility for further

management

In the last 14 days, 1. Have you had contact with a known or probable COVID19 Case? 2. Have you travelled out of the country? 3. Have you had any 2 or more of the following: fever or temperature

T>37.5°C, cough, shortness of breath, weakness, muscle aches, chills, vomiting or diarrhoea, headache, chest pain, new loss of taste or smell?

Provide a medical mask to the patient and direct to designated triage area

Danger signs Stabilize Administer oxygen in a

designated isolation area

Collect samples for; • COVID 19 • Other infectious diseases

High risk for development of serious illness or

complications

Admit for isolation Prioritize for admission in

isolation ward in hospital with critical care capability

Admit for Isolation Admit for isolation in hospital or other

designated facility

Danger signs Rapid breathing: >30per min(adult/child>5y) >40 per min (child 1-5 yrs.) >50 per min (child < 1y) • Difficulty in breathing

and/or chest indrawing • Persistent high fever

for 3 or more days • Disorientation,

seizures or convulsions • Lethargy (excessive

weakness or tiredness) • Sunken eyes or other

signs of severe dehydration

• Inability to eat or drink

Patient enters health facility grounds

SUSPECT CASE

Yes

Management of COVID-19 in designated locations outside of health facilities

Cases may come to the attention of district surveillance teams, or other community members. The number of confirmed COVID-19 non-severe cases may overwhelm the health facilities capacity to isolate (thresholds 2 and 3 above). As a part of the plan for surge capacity, other designated facilities can be used for diagnostic evaluation and treatment of COVID-19. There is a need for a plan to identify and support secondary isolation sites such as community facilities (e.g. Guest house, hotel or tent). These sites may be used to manage non-severe, non-high-risk cases, and could be turned into health facility overflow sites for higher-risk patients currently with mild disease should the need arise. Potential sites will be designated by the National Case Management Committee or the Regional/District Task Force for COVID.

Guiding principles for other COVID-19 designated isolation sites.

The designated site should meet the following minimum requirements;

1. Proximity to a health facility with readily available transport 2. Ability to monitor case progression i.e. Human resources in a recommended ratio 3. Transport plan in case of disease progression 4. Access to running water, toilets and bathrooms 5. Provision of food 6. Security personnel 7. Psychosocial support for the patients

Figure 3: Management of Confirmed Covid-19

Oxygen + Ventilatory Support

Admit to nearest hospital.

Manage as SEVERE disease

Admit to nearest hospital with ICU

services

Manage as CRITICAL disease

Deisolation and Discharge Criteria

• There are no medical indications for admission. • The patient’s symptoms have improved or resolved. (Note: full recovery can take several weeks, especially

in severe cases. It is not necessary for every symptom to have completely resolved prior to discharge, only that there has been improvement).

• The patient has two consecutive negative combined nasopharyngeal and oropharyngeal RT-PCR tests performed at least 24-48 hours apart.

Assess Patient (Remember Always Use PPE)

MANAGEMENT OF CONFIRMED COVID-19 CASE

Oxygen Only

CRITICAL DISEASE*

Patient Requires Oxygen

Send Patient to a designated Isolation facility In your district

NO

MILD DISEASE* SEVERE DISEASE*

Referral Guide for Patients Suspected or Confirmed

COVID-19 is a highly infectious disease thus it is best managed at local facilities if adequate care is available. Minimizing movement of the patient will ensure that few health care workers and other support staff are potentially exposed to the virus. There are however instances when there are no options but to refer the patient to the next level. Familiarize yourself with the medical response teams in your districts. Please see below for guidance.

Type Level of Care Guide

Mild Disease

(See management of mild disease)

Primary level

Can be managed at specific isolating facilities in your districts or at home

Seek guidance from local consultants if patient is a high risk (See table on classification)

Refer to next level if patient develops shortness of breath and or reduced oxygen saturation <93% in room air.

Before referral to an isolation facility with oxygen services always call the facility first. This will ensure that they prepare.

Call the medical response team in your district or region to arrange for safe referral.

Severe

(See management of severe disease)

District level

Facility needs isolation rooms and oxygen supply

Refer to Intermediate Hospital if patient deteriorates despite provision of oxygen and other support services. This patient will need ICU services.

Before referral, call first to get more guidance.

Transportation and Patient Handover

If the patient requires transportation it is important to follow recommended channels as stipulated by the MOHSS. The Regional Case Management chair should be aware of the transportation of such patients, inquire to confirm location and direction well in advance. The guidelines below are aimed at reducing contamination:

• Ensure that the vehicle partition is closed or sealed throughout the incident to avoid exposure to the driver.

• Consider the removal of non-essential equipment from the vehicle or moving non-essential equipment to a closed compartment in provided clear plastic bags prior to loading the patient in the vehicle.

• Avoid opening cupboards and compartments unless essential, if equipment is likely to be required then remove from the cupboard prior to loading patient.

• Air conditioning/ ventilation on vehicles, MUST be set to extract and NOT recirculate the air within the vehicle.

• Family members and relatives of these patients must be asked to remain at home and not attend the hospital as they will likely not be allowed in (Liaise with the Surveillance team).

• Only essential persons are to travel to hospital with the patient. e.g. career for vulnerable adult or a parent/ guardian for a child. (they should also be given a surgical mask to wear or travel in the ambulance).

• Patients should only take essential items with them e.g. phone, money, keys and medication.

• These should be in normal patient bag and sealed and then in a clear plastic bag. • Pre-alert: Crews are required to notify the receiving unit through the set channel of

communication to the fact that they are transporting a possible COVID-19 patient to ensure the receiving unit can prepare for arrival and patient isolation. The receiving unit will advise the crew where the patient should be brought.

• On arrival the driver is to inform the receiving unit of their arrival prior to off-loading the patient.

Management of Mild Cases

• In Namibia all confirmed mild COVID-19 cases are managed at designated isolation facility identified by the MoHSS.

• Currently self-isolation at home is not recommended. Patients with COVID-19 can be de-isolated provided they meet ALL of the following criteria:

1. There are no medical indications for admission. 2. The patient’s symptoms have improved or resolved. (Note: full recovery can take several

weeks,especially in severe cases. It is not necessary for every symptom to have completely resolved prior to discharge, only that there has been improvement).

3. The patient has two consecutive negative combined nasopharyngeal and oropharyngeal RT-PCR tests performed at least 24-48 hours apart.

Management of Severe COVID-19

Patients with severe COVID-19 require urgent care with oxygen therapy. These patients will require hospitalization. Evaluations for hospitalized patients

Recommended daily labs: • FBC with differential • Complete metabolic panel • CPK • CRP (first 2 weeks of hospitalization)

Recommended every other day (if in ICU or elevated check daily):

• PT/PTT/fibrinogen • D-dimer

For acute kidney injury (creatinine >0.3 above baseline): • Urinalysis and spot urine protein: creatinine

When macrophage activation syndrome (MAS) or cytokine storm / secondary haemophagocytic lymphohistocytosis (sHLH) suspected:

• ESR If elevated LFTs:

• HBV serologies (sAb, cAb, sAg) • HCV antibody, unless positive in past • HIV

For risk stratification: • LDH (repeat daily if elevated) • Troponin (repeat q2-3d if elevated) • Baseline ECG (Qtc monitoring)

If clinically indicated: • Blood cultures (2 sets) if bacteria suspected • B-HCG for women of childbearing age

Radiology: • Portable CXR at admission • If CXR not available, ultrasound may be used • PA/lateral only if low suspicion for COVID-19 and

result would change management • Non-contrast CT is of limited utility and should only

be considered if it is likely to change management

Following IPC/PPE guidelines: • SARS-COV-2 test, if not already performed • Other respiratory viral tests not recommended • Routine sputum for bacterial gram stain and

culture, Legionella/Strep pneumo urinary antigen not recommended

Oxygen therapy and monitoring

• Give supplemental oxygen therapy immediately to patients with SARI and respiratory distress, hypoxaemia or shock and target SpO2 92-96%. Goal respiratory rate <24 breaths per minute

• Closely monitor patients with COVID-19 for signs of clinical deterioration, such as rapidly progressive respiratory failure and sepsis and respond immediately with supportive care interventions.

• Application of timely, effective and safe supportive therapies is the cornerstone of therapy for patients that develop severe manifestations of COVID-19.

• Understand the patient’s co-morbid condition(s) to tailor the management of critical illness. • Monitor for drug-drug interactions. • Use conservative fluid management in patients with SARI when there is no evidence of

shock. Aerosol generating procedures

• All aerosol generating procedures (AGP) should be performed cautiously and avoided if possible. All AGP require the healthcare provider to don N95 mask and face shield or googles as well as gloves and gown.

• Only essential AGP should be performed for patients with respiratory illness and only those healthcare providers who are needed to perform the procedure should be present in the immediate vicinity.

• Aerosol-generating procedures include, but are not limited to: o Intubation, extubation and related procedures such as manual ventilation and open

suctioning o Tracheotomy/tracheostomy procedures (insertion/open suctioning/decannulation) o Bronchoscopy or BAL o Non-invasive ventilation (NIV) such as bi-level positive airway pressure (BiPAP) and

continuous positive airway pressure ventilation (CPAP) o High-flow nasal oxygen (HFNO), also called high-flow nasal cannula (HFNC) o Induction of sputum o Medication administration via continuous nebulizer

Treatment of co-infections

• Routine empiric antibiotics are not recommended if COVID-19 confirmed and patient with peripheral/bilateral infiltrates on CXR.

• Empiric antibiotics can be given if COVID-19 not yet established and patient with lobar infiltrate on CXR and/or ICU care.

• Empiric therapy should be de-escalated based on microbiology results and clinical judgment. If started, usual course is 5 days.

• Recommend ceftriaxone 1 gm IV qd + doxycycline 100 mg po bid (azithromycin is alternative to doxycycline); ICU/sepsis: consider MRSA / multi-drug resistance coverage (alternative is amoxicillin/clavulanate or ampicillin/sulbactam)

• Due to low rates of coinfection reported, we do not recommend starting oseltamavir on most patients with COVID-19

Management of Critical COVID-19

COVID 19 Airway Standard Operation Procedures Objective: To establish an airway safely and timeously without compromising patient’s clinical condition whilst the health care worker adheres to the National IPC Guidelines to limit transmission.

These guidelines are intended for the following cadres:

• Trained & skilled medical practitioners designated to intubate critically ill patients indicated for mechanical ventilatory support in ICU

• Team members of a designated COVID Airway Team in a Unit (i.e Intensive Care, High Care, Emergency Unit, Isolation Centre or Theatre)

• Emergency Medical Services (trained paramedics, rapid response team members trained in managing COVID19 airway skills & techniques whilst adhering to IPC guidelines)

Clinical criteria for intubation:

• Persistent hypoxaemic respiratory failure (PaO2 < 60mmHg) despite non-invasive ventilatory support

• Low level of consciousness (Glasgow Coma Scale >8) • SpO2<85% • PaO2/FiO2< 200mmHg or SpO2/FiO2<315 • Lactate >3.0 mmol

Currently in Namibia, we recommend the following stepwise approach. Non- invasive ventilatory support: Supplementary oxygen via oxygen delivery devices> high flow nasal oxygen (HFNO)>Continuous positive airway pressure (CPAP)> mechanical ventilation.

Oxygen via O2 delivery devices

High flow nasal oxygen

Continous positive airway

pressure

Mechanical Ventilation

v1.3 April 2020Collaboration between Safe Airway Society + RNS ASCAR @SafeAirway + @RnsAscar

Acute Respiratory Distress Syndrome (ARDS)

• Recognize severe hypoxemic respiratory failure when a patient with respiratory distress is failing standard oxygen therapy and prepare to provide advanced oxygen/ventilatory support.

• Endotracheal intubation should be performed by a trained and experienced provider using airborne precautions.

• Rapid sequence intubation is appropriate after an airway assessment that identifies no signs of difficult intubation.

• Happy hypoxic patient – Oxygen mask or plastic bag with PEEP • Avoid intubation if saturation is more than 70%, unless decreased LOC or aggressively

hypoxic and septic shock. • Avoid high PEEP, aim for PEEP of 5 – 10 cmH20. • Early use of muscle relaxants improves outcome.

For intubated patients with ARDS use lung-protective ventilation strategies

• Aim for an initial tidal volume of 6mg/kg.16 Tidal volume up to 8 ml/kg predicted body weight is allowed if undesirable side effects occur (e.g. dyssynchrony, pH <7.15).

• Use lower inspiratory pressures (plateau pressure <30 cmH2O).16 • Hypercapnia is permitted if meeting the pH goal of 7.30-7.45. • Application of prone ventilation >12 hours a day is strongly recommended for patients with pressures.

• In patients with moderate or severe ARDS, moderately higher PEEP instead of lower PEEP is 16 targets.

• In patients with moderate-severe ARDS (PaO2/FiO2 <150), neuromuscular blockade by continuous infusion should not be routinely used.

• Risk factors for ARDS in COVID patients o Age >65 o Higher temperature at time of admission >39°C o Presenting with dyspnoea o Co-morbid disease (hypertension, diabetes) o Lymphopenia o Neutrophilia o Higher LDH o Higher D-dimer

Septic Shock

• Recognize septic shock in adults when infection is suspected or confirmed AND vasopressors are needed to maintain mean arterial pressure (MAP) ≥ 65 mmHg AND lactate is ≥ 2 mmol/L, in absence of hypovolemia.

• Recognize septic shock in children with any hypotension (systolic blood pressure [SBP] < 5th centile or > 2 SD below normal for age) or two or more of the following:

o Altered mental state o Tachycardia or bradycardia (HR < 90 bpm or > 160 bpm in infants and HR < 70 bpm

or > 150 bpm in children) o Prolonged capillary refill (> 2 sec) or feeble pulses; tachypnoea; mottled or cold skin

or petechial or purpuric rash o Increased lactate; oliguria; hyperthermia or hypothermia.

Anticoagulation

About 20% to 55% of patients admitted to hospitals for COVID-19 have laboratory evidence of coagulopathy. Elevated d-dimer concentration is associated with poor clinical outcomes. COVID-19-associated coagulopathy appears to be prothrombotic. In the absence of a contraindication, patients admitted to the hospital should receive thromboembolism prophylaxis as per standard of care.

Administration

Standard Risk Patients (DVT prophylaxis)

Indications:

• Hospitalized with moderate severe and critical COVID-19

• For CrCl >30 mL/min: enoxaparin 40 mg SC once daily

• For CrCl 15-30 mL/min: 40 mg SC once daily o For high risk of bleeding or <50 kg, use 30

mg SC once daily • For CrCl <15 mL/min: enoxaparin 30 mg SC once

daily

Intermediate Risk Patients (Increased DVT prophylaxis)

Indications:

• Inflammatory features present, such as rapidly climbing D-dimer, CRP, or Ferritin

• For CrCl >30 mL/min: enoxaparin 40 mg SC once daily

• For CrCl 15-30 mL/min: 40 mg SC once daily o For high risk of bleeding or <50 kg, use 30

mg SC once daily • For CrCl <15 mL/min: enoxaparin 30 mg SC once

daily

High Risk Patients (Therapeutic Anticoagulation)

Indications:

• Patients with rapidly climbing D-Dimer (>1000 ng/mL) with or without clinical evidence of thrombosis including but not limited to:

o Frequent clotting of vascular access sites o Clinical exam of vascular beds, paying

attention to poorly perfused extremities or punctate lesions similar to cardioembolic disease. Many COVID patients have demonstrated ischemic features in hands and feet

o Troponin elevation disproportionate to shock or hypoxia

o Clinical syndrome consistent with cardiogenic shock (Cool, clammy extremities) that is not due to hypovolemic or haemorrhagic shock

o Hypoxia or hypercarbia not otherwise explained by underlying process

o Clinical features consistent with sub-massive pulmonary embolism, where confirmatory imaging cannot be obtained

• Thrombosis confirmed by imaging • Comorbidities warranting full dose anticoagulation

(e.g. atrial fibrillation)

• Therapeutic Heparin is preferable to LMWH. • High heparin dosing may be required due to the

degree of inflammation during SARS-CoV-2 infection. • Initial dose in patients with documented thrombosis

should be 18 units/kg/hr.

Special Populations

Children

• Children have similar rates of contracting COVID-19. They however tend to present with milder symptoms and have very low fatality.

• Children are likely to shed the virus even though they have mild symptoms • There have however, been reports of ARDS and organ failure described in those who are <

12 months • Observational data is showing that children with malnutrition are at an increased risk of

developing severe to critical forms of COVID-19. Pregnant women with COVID-19

• Considering asymptomatic transmission of COVID-19 may be possible in pregnant or recently pregnant women, as with the general population all women with epidemiologic history of contact should be carefully monitored.

• Pregnant women with a suspected, probable or confirmed COVID-19 infection, including women who may need to spend time in isolation with obstetric, foetal medicine and neonatal care, as well as mental health and psychosocial support, with readiness to care for maternal and neonatal complications.

• Currently no evidence that pregnant women present with increased risk of severe illness or fetal compromise.

• Pregnant and recently pregnant women who have recovered from COVID-19 should be enabled and encouraged to attend routine antenatal or postpartum care as appropriate.

Infants and Mothers with COVID-19

• Infants born to mothers with suspected, probable or confirmed COVID-19 infection, should be fed according to standard infant feeding guidelines, while applying necessary precautions for IPC.

• As with all confirmed or suspected COVID-19 cases, symptomatic mothers who are breastfeeding or practicing skin-to-skin contact or kangaroo mother care should practice respiratory hygiene, including during feeding (for example, use of a medical mask when near a child if with respiratory symptoms), perform hand hygiene before and after contact with the child, and routinely clean and disinfect surfaces which the symptomatic mother has been in contact with.

• Breastfeeding counselling, basic psychosocial support and practical feeding support should be provided to all pregnant women and mothers with infants and young children, whether they or their infants and young children have suspected or confirmed COVID-19.

• In situations when severe illness in a mother due to COVID-19 or other complications prevent her from caring for her infant or prevent her from continuing direct breastfeeding, mothers should be encouraged and supported to express milk, and safely provide breastmilk to the infant, while applying appropriate IPC measures.

Monitoring of Patients

Patients may continue to be PCR positive after clinical resolution, although for how long such virus is viable (and thus infectious) remains to be determined. Repeat nasopharyngeal and oropharyngeal swabs should be only be sent once the patient’s fever (if present) has resolved, clinical improvement has been noted, and a minimum of 7 days has passed since the initial positive test. Samples should be sent every 2 days until two consecutive negative RT-PCR tests have been documented.

Discharge and Deisolation Criteria

Patients with COVID-19 can be discharged home provided the meet ALL the following criteria:

1. There are no medical indications for admission. 2. The patient’s symptoms have improved or resolved. (Note: full recovery can take several

weeks, especially in severe cases. It is not necessary for every symptom to have completely resolved prior to discharge, only that there has been improvement).

3. The patient has two consecutive negative combined nasopharyngeal and oropharyngeal RT-PCR tests performed at least 24-48 hours apart.

Patients with mild disease who were managed at home from the outset can be deisolated using the same criteria.

After discharge, patients should be called after 7 days by a healthcare provider to assess clinical improvement. The importance of infection control and counselling on warning symptoms (new onset dyspnoea, worsening dyspnoea, dizziness, and mental status changes such as confusion) should be provided.

Drugs and Information

At present, no drug has been proven to be safe and effective for treating COVID-19. There are insufficient data to recommend either for or against the use of any antiviral therapy in patients with COVID-19 who have mild, moderate, severe or critical illness. Currently there is no evidence for any drug to be used for pre-exposure prophylaxis or post-exposure prophylaxis for COVID-19. As more data are available, this guidance will be updated. Use of any experimental drug is done is not covered in this guide and should be done in consultation with experts and the National Program.

DO Repeat RT PCR once: 7 days after initial positive test AND Fever resolved AND Symptoms improving or resolved DO this until 2 consecutive Negative RT PCR tests 48hrs apart.

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ata

in h

uman

s ex

ists

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IVIG

IV

IG re

mai

ns o

n cr

itical

nat

iona

l sho

rtage

. Th

ere

is in

suffi

cien

t evid

ence

to re

com

men

d th

e us

e of

IVIG

for C

OVI

D 19

out

side

of la

bele

d in

dica

tions

.

Lopi

navi

r/rito

navi

r (K

alet

ra)®1

3,14

Lopi

navir

inhi

bits

the

prot

ease

act

ivity

of c

oron

aviru

s in

SAR

S. T

wo re

trosp

ectiv

e m

atch

ed c

ohor

ts o

f lop

inav

ir/rit

onav

ir (u

sed

in c

ombi

natio

n wi

th ri

bavir

in a

nd c

ortic

oste

roid

s) in

SAR

S de

mon

stra

ted

a po

tent

ial r

ole

in c

linica

l out

com

es, e

spec

ially

whe

n us

ed in

the

early

sta

ges

of

dise

ases

. Due

to ri

sk o

f adv

erse

eve

nts

and

drug

-dru

g in

tera

ctio

ns, a

long

with

lack

of d

ata

in S

ARS-

CoV-

2 at

pre

sent

tim

e, n

ot c

urre

ntly

reco

mm

ende

d.

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zoxa

nide

15

Disp

lays

inhi

bito

ry a

ctivi

ty a

gain

st th

e vir

us in

vitr

o ho

weve

r no

clini

cal d

ata

in h

uman

s ex

ists

.

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ltam

ivir

SARS

-CoV

-2 d

oes

NOT

use

neur

amin

idas

e as

par

t of t

he v

iral r

eplic

atio

n cy

cle s

o os

elta

mivi

r is

unlik

ely

to b

e of

ther

apeu

tic v

alue

.

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virin

Ro

le u

ncle

ar, d

oses

requ

ired

for o

ptim

al a

ntivi

ral a

ctivi

ty o

ften

exce

ed li

mit

of p

atie

nt to

lera

bility

. Ri

sk o

f tox

icity

out

weig

hs p

oten

tial c

linica

l be

nefit

.

Zinc

Th

ere

are

no c

linica

l dat

a su

gges

ting

zinc

impr

oves

out

com

es in

pat

ient

s wi

th C

OVI

D-1

9.

Remdesivir

Remdesivir is a nucleotide analogue pro-drug which inhibits RNA-dependent RNA polymerase. Remdesivir is a parenteral agent.

Although Remdesivir has shown to have promise as a potential agent to treat COVID-19, at this time it is not available in Namibia.

Remdesivir Dosing

AGENT DOSAGE REMARKS MAIN TOXICITIES

Remdesivir

Adults: 200 mg IV loading dose followed by 100 mg IV daily for 5 to 10 days

Infants, Children, and Adolescents:

<40 kg: IV: 5 mg/kg/dose as a single dose on day 1, followed by 2.5 mg/kg/dose once daily for 5 to 10 days

≥40 kg: IV: 200 mg as a single dose on day 1, followed by 100 mg IV daily for 5 to 10 days

Avoid use in patients with CrCl≤30 mL/minute; formulation contains the excipient cyclodextrin, which may accumulate in patients with kidney impairment

Pregnancy data lacking

No known significant drug interactions

Nausea, vomiting

Prolonged prothrombin time

LFT abnormalities

Corticosteroids

Data on the use of corticosteroids for novel coronavirus infections are quite variable with mixed results and little clarity on appropriate dosing or timing. In SARS-CoV, any steroid therapy was associated with increased need for ICU admission or mortality, although lower mortality and shorter hospitalization was seen among critical cases and pulse steroids did appear to result in lower oxygen requirements and better radiographic outcomes compared to non-pulsed steroids. In MERS-CoV, however, steroid therapy was evaluated both by dose and duration and no effect was seen on mortality; however, increased time to viral clearance was observed. One study of SARS-CoV-2 suggests, delayed use of steroids may increase risk of death in the ICU. In another COVID-19 cohort, the use of methylprednisolone in patients who developed ARDS was associated with decreased risk of death; short courses of low-moderate dose steroids have also been recommended in critically ill patients. Given these mixed data, and the potential for steroid therapy to worsen disease severity and lead to secondary infections, routine use of steroids is not recommended at this time.

Corticosteroids should not be withheld if there is medical indication (i.e. adrenal insufficiency, COPD exacerbation).

For the management of mechanically ventilated patients without ARDS, corticosteroids are not thought to be beneficial and may increase risk of mortality.

For the management of mechanically ventilated patients with ARDS, there is a potential role for corticosteroid therapy and should be considered on a case-by-case basis.

Non-Steroidal Anti-inflammatory Drugs (NSAIDs)

No evidence exists to support its use in mitigating the inflammatory response associated with COVID-19. There have been concerns voiced regarding clinical worsening of COVID-19 in patients taking ibuprofen but these are unsubstantiated at this time. At this time, insufficient evidence exists to specifically avoid NSAIDs in all COVID patients, but we do recommend avoiding in patients with pre-existing kidney disease or those with developing sepsis to avoid renal injury.

Guidance on Surgical and Medical Procedures during COVID-19

Elective surgeries may be performed as previous however the following should be noted:

1. COVID-19 testing within a facility should be conducted according to National guidance

2. Personal protective equipment: a. Facilities must have adequate PPE, including

supplies for potential second wave of COVID-19 cases

3. Case prioritization and scheduling: a. Facilities should establish a prioritization

committee consisting of surgery, anaesthesia and nursing leadership to develop prioritization strategy

b. Strategy should include phased opening of operating rooms

Flow Chart on Handling Elective Surgical Procedures

Patient booked for elective Surgery?

No

Screen patient for symptoms for COVID-19

Delay or cancel case and send for swab for COVID-19

Is the procedure high risk?

Proceed with surgery under standard IPC

measures

Do swab for COVID-19

No

Yes

Yes

Symptoms of COVID or RTI

Negative Results

Positive results

Cancel Cases and follow COVID-19 Management of

confirmed cases

High Risk Procedures: Upper airway procedures Gastroscopy ENT Endoscopy Colonoscopy Cardiothoracic Dental Maxillofacial

Annexes/Additional Resources

1. Other MoHSS SOPs - https://bit.ly/NamCOVID Departmental SOPs such as Paeditric, Dental and EMS The SOPs will be added as they are available.

2. WHO guidelines 3. CDC Covid-19 guidelines 4. Demonstration videos on airway management:

COVID 19 Intubation Demonstration: https://www.thegurneyroom.com/covid/intubation-approach An example of a COVID Airway Response Team interanest.org Airway Management in SARS Cov-2 Positive Patients https://www.youtube.com/watch?v=iIGAmdyZr4Y