as

Republic of the PhilippinesDepartment of Health

OFFICE OF THE SECRETARY

March 11, 2020

DEPARTMENT MEMORANDUMNo. 2020-_ DIS

TO: ALL UNDERSECRETARIES AND ASSISTANT SECRETARIES;DIRECTORS OF BUREAUS AND CENTERS FOR HEALTHDEVELOPMENT, MINISTER OF HEALTH - BANGSAMOROAUTONOMOUS REGION __IN_ MUSLIM__ MINDANAO,EXECUTIVE DIRECTORS OF SPECIALTY HOSPITALS ANDNATIONAL NUTRITION COUNCIL, CHIEFS OF MEDICALCENTERS, HOSPITALS, SANITARIA, AND INSTITUTES,PRESIDENT _OF THE PHILIPPINE HEALTH INSURANCECORPORATION; DIRECTORS OF PHILIPPINE NATIONALAIDS COUNCIL AND TREATMENT AND REHABILITATIONCENTERS AND ALL OTHERS CONCERNED

SUBJECT: Prioritization of Contact Tracing for Confirmed CoronavirusDisease 2019 (COVID-19) Cases

I. BACKGROUND

After a cluster of pneumonia cases of unknown etiology was reported in Wuhan City,Hubei Province of China last December 31, 2019, Chinese health authorities preliminarilyidentified the cause ofthis viral pneumonia as a newor noveltype of coronavirus (2019-nCoV).

With an increasing number of cases spreading to various territories and confirmedhuman-to-human transmission, the World Health Organization declared the outbreak as aPublic Health Emergency of International Concern (PHEIC) last January 30, 2020.

In view of the confirmation of local transmission of COVID-19 in the country, theDepartment of Health (DOH), hereby issues the following guidelines in conducting immediatecontact tracing for individuals with high risk and vulnerability to control local transmission.

This issuance is an enhancement of the Department Memorandum No. 2020-0068 datedFebruary 3, 2020 entitled “Interim Guidelines on Contact Tracing for Confirmed 2019 NovelCoronavirus Acute Respiratory Disease (2019-nCoV ARD Cases.”

A particular note on the general guidelines of the above mentioned memorandum is theSection A which enumerates the rationale of conducting contact tracing. These are:

1. Contact tracing shall be one ofthe major strategies to contain the outbreak in the earlystage where epidemiological evidence shows first and second generation transmissionof 2019-nCoV ARD.

Building 1, San Lazaro Compound, Rizal Avenue, Sta. Cruz, 1003 Manila Trunk Line 651-7800 focal 1108, 1111, 1112, 1113Direct Line: 711-9502; 711-9503 Fax: 743-1829 # URL: http://www.doh.gov.ph; e-mail: fduque@doh.gov.ph

2. Contact tracing and monitoring shall be considered on for the initial cases found atthe start of the outbreak. Contact tracing shall focus on the subset of the populationmost likely to be at risk of infections and in the network of transmission routes.

3. Contact tracing for the first 100 confirmed casesin the country shall be mandatory tocontain and limit the spread of infection.

I. IMPLEMENTING GUIDELINES

A. Criteria for the Prioritization of Contacts of COVID-19 Cases

A contact of a COVID-19 case is a person NOT presenting signs and symptoms oftheinfection, who has or may have been in contact with a COVID-19 case. The classification ofcontacts as high, medium or low-risk exposure is based on the associated risk of infection thatin turn determines the type of monitoring. The contact tracing team shall identify andcategorize the contacts based on thetable below.

Table 1. Categorization of contacts based on nature of exposure within 14 days

High Risk Medium Low

Health Workers who attended Travelled with (in e Individuals withto a laboratory confirmed airplane, follow the 4 history of travel toCOVID-19 case OR a health rows around) areas with reportedworker in a Laboratory facility A person who attended a communityprocessing COVID-19 social or religious transmission in thespecimens gathering where a last 14 daysHousehold contacts who lived confirmed case of COVID|@ Other individualswith a person whois a -19 was reported whoare notconfirmed COVID-19 case A hotel worker in a hotel categorized as highA person whois less than 1 where a laboratory or medium riskmeter from a laboratoryconfirmed COVID-19 case ina social or religious gatheringsAn office worker who hasclose engagement or businessencounter with a laboratoryconfirmed COVID-19 caseVisited the confirmed casewhere interaction was madeless than 1 meter distance fromeach other 4 days before onsetof illness and/or within the 14days from the onsetofillness

confirmed COVID-19case, was reportedA passenger in anenclosed transport where alaboratory confirmedCOVID-19 case, wasreported

1. All Persons Under Monitoring (PUMs) assessed as high risk for COVID-19 shall bethe focus of the contact tracing activity.

2. Medium and low risk individuals shall be endorsed by their respective RESUsto theprovincial and city government units for the monitoring of PUMs for a period of 14days. The engagementof the Barangay Health Emergency Response Teams (BHERTs)in contact tracing is important.

B. Roles and Responsibilities

1. The Epidemiology Bureau (EB) of the Department of Health shall be the overallBureau to oversee the contact tracing activity. This Bureau will consolidate all regionaldata pertaining to contact tracing and ensure that the contact tracing process is compliedwith by the different RESUs;

2. The Regional Epidemiology and Surveillance Unit (RESU) of the Centers for HealthDevelopment (CHD)shall take the lead in the contact tracing of individuals categorizedas high, while the medium to low risk will be monitored by the Local GovernmentUnit(LGU)upon proper coordination. The RESU shall be submitting their daily report oncontact tracing to the EB for consolidation:

a. Contact tracing teamThe role of the contact tracing team is to investigate, gather information onconfirmed cases and trace the contacts, locations of frequency and possibleexposures of people surrounding the case. Contact tracers investigate contactsexposure to the confirmed case, (now labelled as the index case on the chain oftransmission) categorize the contacts exposure, screen the initial health status ofcontact, answer questions and educate contact on use of thermometers, monitoringprocess, quarantine policy and education about COVID-19. The team shall putremarks as “closed” in their report when all contacts identified were seen and/orinterviewed by phone orface to face.

b. A contact monitering staff (BHERTS) from the LGU shall be assigned toundertake the following:i. Monitor Persons Under Monitoring (PUMs) monitor body temperature

twice a day (7AM and 3PM) andfor any signs and/or symptoms of COVID-19. This information will be entered in the COVID-19 Contact MonitoringTool (see Annex A). The BHERTs provides the Municipal Health Office(M/CHO) of daily report at 3 in the afternoon. The MHOreports thisinformation their Provincial Epidemiology and Surveillance Unit (PESU) by4PM. While the City Epidemiology and Surveillance Unit (CESU)to theirCity Health Office. The PESU and CESUin turn reports every 5 in theafternoon to the RESU.

ii. Any signs and symptoms during the course of the quarantine has to beassessed by the MHO/CHO usingthe current algorithm fortriage of patientswith possible COVID-19 infection.

iii. |The contact monitoring staff shall strictly follow the infection prevention andcontrol measures (see Annex B) to ensure they are protected.

3. The Infeetion Prevention and Control Committee (IPCC) of the hospital shallcategorize further the risk of health workers based on the WHO Health WorkersExposure Risk Assessment and Managementin the Context of COVID-19 Virus (SeeAnnex C).

C. Flow of Notification and Reporting

DOH-Emergency Operations Center (EOC)

Research Institutefor Tropical

Medicine (RITM)Releases (+) LabResult of a COVID-19 case

D. Contract Tracing Flow

DOH-EB

Referring Hosp

RESU i} Regional bpDirector

(RD)FAsst.RD

Local Chief Executive(Province’City/Municipality)

PESU/CESU

Local Health Authorities

Forstrict compliance.

their complete addresses (e.g. Person Under Investigation (PUI)and PUMs)and indexcase itinerary in and outside oftheir

region

‘ EB feedbacks within 24 hours to concerned RESU of :#°* contacts of index case who have transferred to another #**""'*. : region : .: Pusevereneurnn rae sARSORCCD DOES SDEDDEDRE DDE DDEREESEOBSOR

¥v

RITM DOH-EB RESUDetermines what Conducts the contact tracing process either through:

Releases (+) =] region case is from fom-|a. face-to-face interview of key informant to gather:Lab Result of and coordinates with 1. initial info ofthe case

a COVID-19 appropriate RESU 2. list of close contacts of a case

case 4 b, Conducts Phone interview ofali contacts of the case: «

: :Bo pence eeneenenseesersenssesusscusernnaesnsterseuseverssresend 6

., t RESU reports to EB within 24 hours all individuals traced with e

FRANCISCO T. DU! Ii, MD, MScSecretary of Health

Annex A. Signs and Symptoms Log Form

Confirmed Case ID:

Close Contact Name:

Date of Last Exposure:

Date:

Date of Voluntary Quarantine Period Ends*:

Region:

SymptomDate Date Date Date Date Date Date Date Date Date Date

AM|PM AM|PM AM|PM AM|PM AM|PM AM|PM AM|PM AM|PM AM|PM

No Symptom

Fever (temp.)

Cough

Sore Throat

Took Antivirals

Pneumonia

Diarrhea

Other Symptoms1.2.3.

Sought Consult

RYN

10.11.

12.

13.

Annex B. Infection prevention and control measures while contact tracing

Bring portable alcohol-based handrub(at least 60% strength)Always perform hand hygiene before and after the interviewKeep and maintain at least one metre distance between you and the intervieweeChoose an appropriate interview location, make sureit is well ventilated and ensureprivacy and confidentiality. This could be outside ofthe interviewees house.If the interviewee appears to have respiratory symptoms provide a medical mask forthem to wear prior to conducting the interview. Explain to the interviewee thatthis isto help prevent any spread of germs. If the interviewee cannot tolerate a medicalmask, proceed to wear a medical mask and explain that you are wearing a mask toprotect yourself while conducting the interviewIf you are wearing a medical mask:

° DO NOT touch the mask once you have placed it on your face° DO NOT touch your face whilst conducting the interview

Avoid touching the environment surfaces unnecessarily, perform hand hygieneaftercontact with the surrounding environmentDO NOTeator drink when interviewing contacts, politely decline eating or drinkingany foodordrinks offeredOncethe interview is complete, verbally thank the interviewee and maintain a onemetre distanceDO NOTshake handsor physically touch the intervieweeIf you are wearing a mask perform hand hygiene before removing the mask; removethe mask from the back, moving it away from yourface; dispose of the mask in a binand perform hand hygiene. DO NOT reuse masks.If any equipmentis used, ensure it is cleaned using a detergent wipe (and dispose ofwipe)Perform hand hygiene

+

as essment ndmanagement inthe —

- Interimguidance :

4March.2020

ANNEX ¢C.

rs exposureriskcontext of Cc VID-19virus”

SH]oO oe

“ao =,ga,°3

Coronavirus disease {COVID-19) was first detected in Wuhan city, China in December 2019. On30 January 2020, the WHO Director General declared that the current outbreak constituted a PublicHealth Emergency of International Concern.

Current available evidence is that the COVID-19 virusis transmitted between people through closecontact and droplets. People most at risk of infection are those who are in contact with a COVID-19patient and/or who care for COVID-19 patients. This inevitably places health workersat a high risk ofinfection.

Target audience:This tool is to be used by health care facilities that have either cared for or admitted COVID-19patients. This form is to be completed for all health workers who have been exposed to a confirmedCOVID-19 patient in a health care facility. It is intended to be an operational tool used by health carefacilities once a COVID-19 patient has been identified within thefacility. This tool will help determinethe risk of COVID-19 virus infection of all HCWs who have been exposed to a COVID-19 patient andthen provides recommendations for appropriate management of these HCWs, according to theirinfection risk.

Objectives:1. Todetermine the risk categorization of each HCW after exposure to a COVID-19 patient (see below

Part 1: COVID-19 virus exposure risk assessment form for HCWs);2. To inform the management of the exposed HCWs based on risk (see below Part 2: Management

of health worker exposed to COViD-19 virus).

Part 1: COVID-19 virus assessment ofrisk of exposure for health workers in healthcare facilities

Protecting HCWs is of paramount importance to WHO. Understanding HCW exposure to COVID-19virus and how this translates into risk of infectionis critical for informing infection prevention andcontrol (IPC) recommendations. The data that will be captured using this data collection form andrisk assessment tool can be used to identify IPC breaches and define policy to mitigate health workerand nosocomial infection. As such, health carefacilities using the following risk assessmentareencouraged to share deidentified data with WHO to inform discussions about WHO guidance relatedto IPC. That is, any data shared with WHO should not include any personably identifiable information(Questions 2A, 2B and 2G).

A. Interviewer name:B. Interviewer date (DD/MM/YYYY): aaC. Interviewer phone number:D. Does the health worker have a history of staying oYes oONo

in the same household or classroom environmentwith a confirmed COVID-19 patient?E. Does the HCW have history oftraveling together oYes oONo

in close proximity (within 1 meter) with a confirmedCOVID-19 patient in any kind of conveyance?

ifthe HCW answersyes for questions 1 D — 2£ it is considered a community exposure to COVID-19virus and health workers should be managed as such, The management recommendations in Part 2:Management of health workers exposed to COVID-19 virus apply only to health care-relatedexposure.

A. Last namB. First name:C. Age

D. Sex: oO Male a Female O Prefer not to answer

E. City:F. Country:G. Contact details:

H. Type of health care personnel: 0 Medical doctordc Physician assistantou Registered nurse (or equivalent)Assistant nurse, nurse technician (or equivalent)o Radiology /x-ray techniciana Phlebotomistu OphthalmologistoO Physical therapistc Respiratory therapistO Nutritionist/dietitian0 MidwifeO Pharmacista Pharmacy technician or dispenser

-2-

0 Laboratory personnelo Admission/reception clerk0 Patient transportera Catering staffa Cleanerao Other (specify):

|. Health care facility unit type in which the healthworker works?

A. Date of health worker first exposure to confirmedCOVID-19 patient:

Tick alf that apply:O OutpatientOo EmergencyD Medical unitd Intensive care unito Cleaning serviceso LaboratoryoD Pharmacy0 Other, specify:

G Not known

B. Name ofhealth care facility where case receivedcare:C. Type of health care setting: Cc Hospital

O Outpatient clinic

o Primaryhealth centreco Home care for mild caseso Other:

D. City:E. Country:F. Multiple COVID-19 patients in health care facility aYes oNo oUnknown

Number of patients (approximate if exact numbernot known):

procedures (AGP) was performed on the patient?See below for examples

A.Did you provide direct care to a confirmed COVID-|aYes ONo o Unknown19 patient?B. Did you have face-to-face contact (within 1 oYes oNo D Unknownmeter) with a confirmed COVID-19 patient in ahealth care facility?C. Were you present when any aerosol generating oYes oONo GO Unknown

- If yes, what type of AGP procedure? O Tracheal intubation0 Nebulizer treatmentD Open airway suctioningo Collection of sputumoO TracheostomyO Bronchoscopyu Cardiopulmonary resuscitation (CPR)G Other, specify:

Date (DD/MM/YYYY):__ff

D. Did you have direct contact with the environmentwhere the confirmed COVID-19 patient was caredfor?E.g. bed, linen, medical equipment, bathroom etc.

oYes ONo oUnknown

E. Were you involved with health care interaction(s)(paid or unpaid) in another health care facilityduring the period above?

a Other health care facility (public or private)a Ambulanceo Home careO No other health care facility

Exposure of health workers to COVID-19 virusIf the health worker responds ‘Yes’ to any of the Questions 4A — 4C, the health worker should beconsidered as being exposed to COVID-19 virus

For the following questions, please quantify the frequency you wore PPE, as recommende:‘Always, as recommended’ should be considered wearing the PPE when indicated more than 95% ofthetime; ‘Mostof the time’ should be considered 50% or more but not 100%; ‘occasionally’ should beconsidered 20% to under 50% and ‘Rarely’ should be considered less than 20%.

A. During the period of a health care interactionwith a COVID-19 patient, did you wear personalprotective equipment {PPE}?

o Yes oONo

If yes, for each item of PPE below,indicatehow often you usedit:1. Single gloves O Always, as recommended

0 Mostofthe time (50% or more but not 100%)u Occasionally 20% to under 50%)o Rarely (less than 20% ofthe time)

2. Medical mask co Always, as recommendeda Most ofthe timeU OccasionallyoO Rarely

3. Face shield or goggles/protective glasses oO Always, as recommended© Mostof the time6 OccasionallyoO Rarely

4, Disposable gown o Always, as recommended0G Most ofthe time0 Occasionallyo Rarely

B. During the period of health care interaction withthe COVID-19 patient, did you remove and replaceyour PPE according to protocol (e.g. when medicalmask became wet, disposed the wet PPE in thewastebin, performed hand hygiene, etc)?

G Always, as recommended0 Most ofthe timeO Occasionallyo Rarely

C. During the period of health care interaction withthe COVID-19 case, did you perform hand hygienebefore and after touching the COVID-19 patient?NB: Irrespective of wearing gloves

oO Always, as recommended0 Mostofthe timeD Occasionallyo Rarely

D. During the period of health care interaction withthe COVID-19 case, did you perform hand hygiene

c Always, as recommendedU Most of the time

-4-

before and after any clean or aseptic procedure wasperformed (e.g. inserting: peripheric vascularcatheter, urinary catheter, intubation, etc.)?

0 Occasionallyo Rarely

E. During the period of health care interaction withthe COVID-19 case, did you perform hand hygieneafter exposure to body fluid?

2 Always, as recommendedc Most of the time0 Occasionallyo Rarely

F. During the period of health care interaction withthe COVID-19 case, did you perform hand hygieneafter touching the COVID-19 patient’s surroundings(bed, door handle, etc}?Note: this is irrespective of wearing gloves

0 Always, as recommended© Most ofthe time0 OccasionallyO Rarely

G. During the period ofhealth care interaction withthe COVID-19 case, were high touch surfacesdecontaminated frequently (at least three timesdaily)?

D Always, as recommendedD Most ofthe timeO Occasionallyo Rarely

For the following questions, please quantify the frequency you wore PPE, as recommende‘Always, as recommended’ should be considered wearing the PPE when indicated more than 95% of thetime; ‘Most of the time’ should be considered 50% or more but not 100%; ‘occasionally’ should beconsidered 20% to under 50% and ‘Rarely’ should be considered less than 20%.

A. During aerosol generating procedures on a D Yes BDNo

COVID-19 patient, did you wear personal protectiveequipment (PPE}?

- If yes, for each item of PPE below,indicatehow often you used it:

- 1. Single gloves O Always, as recommended0 Most ofthe time0 OccasionallyO Rarely

- 2..N95 mask {or equivalent respirator) 0 Always, as recommended0 Most ofthe timeG Occasionallyo Rarely

- 3, Face shield or goggles/protective glasses|0 Always, as recommended0 Most ofthe timea Occasionallyo Rarely

- 4, Disposable gown O Always, as recommendedO Most ofthe timeDB Occasionallyo Rarely

- 5. Waterproof apron & Always, as recommendeda Most of the timeD Occasionallyo Rarely

B. During aerosol generating procedures on theCOVID-19 patient, did you remove and replace yourPPE according to protocol (e.g. when medical maskbecame wet, disposed the wet PPE in the waste bin,performed hand hygiene, etc)?

D Always, as recommendedG Most of the timeQ OccasionallyOo Rarely

C. During aerosol generating procedures on theCOVID-19 case, did you perform hand hygienebefore and after touching the COVID-19 patient?NB: Irrespective of wearing gloves

cu Always, as recommended0 Most ofthe timeD OccasionallyG Rarely

D. During aerosol generating procedures on theCOVID-19 case, did you perform hand hygienebefore and after any clean or aseptic procedure wasperformed (e.g. inserting: peripheric vascularcatheter, urinary catheter, intubation, etc.)?

0 Always, as recommendedCG Most ofthe timeG OccasionallyO Rarely

E. During aerosol generating procedures on theCOVID-19 case, did you perform hand hygiene aftertouching the COVID-19 patient’s surroundings (bed,door handle, etc)?Note: This is irrespective of wearing gloves

0 Always, as recommendedG Most of the timeO Occasionally0 Rarely

F. During aerosol generating procedures on theCOVID-19 case, were high touch surfacesdecontaminated frequently (at least three timesdaily)?

O Always, as recommended0 Most ofthe time0 Occasionallyo Rarely

A. During the period of a health care interactionwith a COVID-19 infected patient, did you have anyepisode of accident with biological fluid/respiratorysecretions?See below for examples

0 Yes ONo

- If yes, which type of accident? a Splash of biological fluid/respiratory secretions inthe mucous membrane of eyes0 Splash of biological fluid/respiratory secretions inthe mucous membrane of mouth/nose0 Splash of biological fluid/respiratory secretions onnon-intact skin

0 Puncture/sharp accident with any materialcontaminated with biological fluid/respiratorysecretions

ra

Risk categorization of health workers exposed to COVID-19 virus

High risk for COVID-19 infectionThe health worker did not respond ‘Always, as recommended’ to Questions:

5A1—-—5G, 6A ~6FAND/OR responded ‘Yes’ to 7A.

All other health workers shoud be considered low risk for COVID-19 virus infection.

Part 2: Management of health workers exposed to COVID-19 virus

The management of health workers exposed to COVID-19 virus will vary according to the Riskcategorization of health workers exposed to COVID-19 virus, as determined in Part 1.

Recommendations for health workers with high risk for infection:

Stop all health care interaction with patients for a period of 14 days after the last day ofexposure to a confirmed COVID-19 patient;Be tested for COVID-19 virus infection;Quarantine for 14 days in a designated setting.*

Health care facilities should:Provide psychosocial support to HCW during quarantine, or duration ofillness ifHCW becomes a confirmed COVID-19 case;Provide compensation for the period of quarantine and for the duration ofiliness (if not onamonthly salary) or contract extension for duration of quarantine/illness;Refresher infection prevention and control training for the health care facility staff, includingHCWsat high risk for infection once he/she returns to workat the end of the 14-day period.

Recommendations for health workers with low risk for COVID-19 infection:

Self-monitor temperature and respiratory symptoms daily for 14 days after the last day ofexposure to a COVID-19 patient. HCWs should be advisedtocall health care facility if he/shedevelop any symptoms suggestive of COVID-19;Reinforce contact and droplet precautions when caringforall patients with acute respiratoryillness? and standard precautions to take care ofall patients;Reinforce airborne precautions for aerosol generating procedures on all suspect andconfirmed COVID-19 patients;

1 WHO Considerations for quarantine of individuals in the context of containment for coronavirus disease{COVID-19): Interim guidance 28 February 2020 (https:

uarantine-of-individuals-in-the-context-of-containment-for-coronavirus-disease-(covid-19).2 WHO Infection prevention and control during health care when novel coronavirus (nCoV) infection is

www.who.int/publications-detail/considerations-for-

suspected: Interim guidance 25 January 2020 (https://www.who.int/publications-detail/infection-prevention-and-control-during-heaith-care-when-novel-coronavirus- -infection-is-suspected-20200125).

- Reinforce the rational, correct and consistent use of persona! protective equipment whenexposed to confirmed COVID-19 patients;?

- Apply WHO's “My 5 Moments for Hand Hygiene” before touching a patient, before any cleanor aseptic procedure, after exposure to body fluid, after touching a patient, and after touchingpatient’s surroundings;*

- Practice respiratory etiquette at all times.

© World Health Organization 2020.All rights reserved.This is a draft. The content of this document is not final, and the text may be subject torevisions before publication. The document may not be reviewed, abstracted, quoted,reproduced, transmitted, distributed, translated or adapted, in part or in whole, in any formor by any meanswithout the permission of the World Health Organization.

WHO reference number: WHO/2019-nCov/HCW_risk_assessment/2020.1

3 WHO Infection prevention and control during health care when novel coronavirus (nCoV) infection issuspected: Interim guidance 25 January 2020 (https://www.who.int/publications-detail/infection-prevention-

and-control-during-health-care-when-novel-coronavirus-(ncov)-infection-is-suspected-20200125).4 WHO guidelines on hand hygiene in health care: first global patient safety challenge — clean careis safer care.Geneva: World Health Organization; 2009 (https://apps.who.int/iris/handle/10665/44102).

-8-