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MANAGEMENT OF COVID 19 PATIENTS IN HOME ISLOATION

Department of Health & Family Welfare,

Govt. of West Bengal

Swasthya Bhawan 03.11.20

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Strengthening care and support for Covid Patients in Home isolation

Objectives:

Each COVID patient in Home Isolation under coverage of a Doctor with whom she/he can

communicate.

Basic testing facilities of the ULB made available for necessary monitoring (preferably with

mechanism of sample collection).

The family members/contacts provided with appropriate guidance on testing and precautionary

measures as per guidelines.

Timely shifting of the patient(s) based on the alert generated by the local covering doctor.

Epidemiology:

As per current available evidence:

The causative virus (SARS-CoV-2) has a zoonotic source closely related to bat-origin SARS-like corona

virus.

An enveloped RNA beta corona virus related to the Severe Acute Respiratory Syndrome (SARS) virus

The virus has been shown to use the Angiotensin-Converting Enzyme 2 (ACE2) receptor in different

organs (like lungs, GI tract, Naso- & Oropharynx) for entry to the cell

Source of infection: The persons infected with the novel coronavirus (COVID 19)

Modes of Contact: Direct person-to-person transmission: mainly through respiratory droplets in proximity

when the infected person coughs, sneezes, or talks

Infested surface/ fomites: If a person touches such a surface and then touches his or

her eyes, nose, or mouth

Mean incubation period 4 - 6 days: Varies from 2 - 14 days

Mean Infective Period 8 days: Varies from 7 - 10 days

Viral Particle Shedding about up to 14 days: Depends on severity of illness RT-PCR test may be positive during Viral Particle Shedding

Viral Particle or RNA Shedding phase is not infective to others

No Need for Repeat Testing to prove Negative, unless Severe or Immunocompromised

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Testing Protocol:

Whom to Test

A. patient with acute respiratory illness (fever and at least one sign/symptom of respiratory disease, e.g.,

cough, shortness of breath), or any history suggestive of COVID 19 and a history of travel to or residence in a

location reporting community transmission of COVID-19 disease during the 14 days prior to symptom onset;

OR

B. A patient with any acute respiratory illness or any history suggestive of COVID-19 and having been in

contact with a confirmed or probable COVID-19 case in the last 14 days prior to symptom onset;

OR

C. A patient with severe acute respiratory illness (fever and at least one sign/symptom of respiratory disease,

e.g., cough, shortness of breath; and requiring hospitalization) and in the absence of an alternative diagnosis

that fully explains the clinical presentation.

When to Test

1) Between 5- 10 days of Contact with positive patient

2) First day of onset of symptom suggestive of COVID 19.

Modalities of Testing

1) Rapid Antigen Test

2) RT-PCR

3) Trunaat

4) CBNAAT

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Clinical Presentation

The presenting symptoms may be as follows:

Signs and Symptoms at Admission Proportion

Fever 99

Fatigue 70

Dry cough 59

Anorexia 40

Myalgia or arthalgia 35

Shortness of breath 31

Sputum production 27

Smell or Taste disorder / Anosmia 19

Sore Throat 13.9

Headache 13.6

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Nausea, Vomiting 13

Diarrhoea 10

Abdominal pain 9

Rhinorrhoea 2.3

Conjunctival congestion 0.8

Clinicians have to be vigilant about extra-pulmonary manifestations of COVID 19 infection

Clinical spectrum:

Presenting features:

Mild disease

Patients with uncomplicated upper respiratory tract infection, may have mild symptoms such as fever,

cough, sore throat, nasal congestion, malaise, headache Without evidence of breathlessness or Hypoxia

(normal saturation).

Moderate disease

Pneumonia with no signs of severe disease

Adolescent or adult with presence of clinical features of dyspnea and or hypoxia, fever, cough, including

SpO2

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Child with presence of clinical features of dyspnea and or hypoxia, fever, cough, including SpO2 30 breaths/min,

severe respiratory distress, SpO2 50 years

2. Diabetes mellitus

3. Hypertension

4. Chronic Lung disease

5. Chronic Kidney disease

6. Chronic Liver disease

7. Cardiovascular disease

8. Cerebrovascular disease

9. Severe Obesity (BMI ≥40)

10. Cancer

11. HIV

12. Immunosuppressive Drugs

Where to treat?

Cases Treatment at

Suspected Mild Case Home isolation

Suspected Moderate / Severe Case (SARI) SARI ward

Test Confirmed Mild Case Home isolation/ Safe Home

Test Confirmed Moderate / Severe Case AND

Test Confirmed Mild Case with High Risk*

Designated Covid ward/

CCU/ HDU

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Eligibility criteria for home isolation

1. Mild symptomatic cases and pre-symptomatic or asymptomatic laboratory confirmed cases as

clinically assigned by the treating physician can opt for home isolation

2. Such patients should have adequate facility (preferably separate room and toilet) at their

residence for self-isolation and also for quarantine of the family contacts

3. Each patient must be under one qualified Doctor, who is available for Teleconsultation,

Medical Care and Guidance 24x7

4. A care giver should be available at their residence to provide care on 24 x 7 basis

5. Care giver and all close contacts of such cases should take Ivermectin prophylaxis

as per protocol and as prescribed by the treating medical officer

6. The patient will agree to monitor his health. For further follow up by surveillance teams, patient

and the care giver will regularly inform his health status to the District Surveillance Team.

7. The patient will give an undertaking of self-isolation (Annexure) and will follow the guidelines

Admission criteria for Safe Home

1. Home isolation not suitable for him

2. No caretaker at home

3. Higher age group (>50 yrs ) plus one Risk Factor

4. Two risk factor irrespective of age.

Following parameters should be observed at Home

1. Temperature

2. SpO2 (By Pulse Oximeter)

3. Blood Pressure

4. Sensorium (conscious, drowsy or stupor)

5. Pulse

6. Urine Output (approx.)

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Investigations for Home Isolated cases: If possible

1. Complete Hemogram: Common abnormalities are Leucopenia with Absolute Lymphocytopenia

2. X-Ray Chest PA view (if Possible)

3. LFT

4. Serum Creatinine

5. Blood Glucose Level

6. ECG: (if possible)

7. CRP

Treatment

Tab Ivermectin12 mg once daily for 5 days PLUS Cap/ Tab Doxycycline 100 mg twice a day for 7

days (Take Ivermectin with a fatty meal like half a cup of milk or half a tea-spoon of butter).

Or

Tab HCQs for mild cases with high risk factors.

Dose: 400 one tab twice daily on D1 then 400 daily for 4 days.

Tab Paracetamol for fever

Tab Vitamin C 500 mg twice daily*

Tab Zinc 50 mg per day*

Vitamin D360000 IU weekly*

Supportive treatment for cough, diarrhea etc.

Features for progression from mild disease to moderate disease

Clinical Suspicion:

1. Difficulty in breathing

2. Persistent pain or pressure in the chest

Go by clinical parameters if laboratory service not available

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3. Mental confusion or inability to arouse

4. Developing bluish discolorations of lips/ face

5. SpO2 < 94% at Room Air (For Obstructive Airway Diseases: SpO2 < 90% at Room Air)

6. Stupor, Drowsiness or Confusion

7. SBP 100/min

Laboratory Markers/ parameters

10. Chest X-Ray showing Bilateral infiltrate (predominantly lower zones & periphery)/ Ground glass

opacity

11. ST-T changes in ECG or high cardiac markers suggestive of Myocarditis (Trop-T positive)

12. Exacerbation of Co-morbid Laboratory parameters

13. Neutrophil : Lymphocyte Ratio ≥3.13

14. Development of Acute Kidney Injury

15. Raised Bilirubin or Liver Enzymes

When to discontinue home isolation

Patient under home isolation will end home isolation

1. After 17 days from Onset of Symptoms (10+7) where afebrile for 10 days

2. After 17 days from the date of sampling for pre-symptomatic or asymptomatic cases.

There is no need for repeat testing after the home isolation period is over

Follow up

First follow up visit within 14 days or when needed

Look for common Post-COVID complications: -Pulmonary complication -Cardiac Complication -Renal Complication -Impaired blood glucose -Psychological issues

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Follow up advice to patients: -Nutritious diet, adequate sleep and rest -Avoid smoking and consumption of alcohol -Continue use of mask, hand & respiratory hygiene, physical distancing -Regular medications as advised after discharge and also for managing comorbidities -New onset of confusion, focal weakness etc if present, contact nearby hospital/ physician

Ivermectin

Doses:

For Treatment in mild-moderate cases: Tab Ivermectin12 mg once daily for 5 days PLUS Cap/ Tab

Doxycycline 100 mg twice a day for 7 days

Take Ivermectin with a fatty meal (say, half a cup of milk or half a tea-spoon of butter). Use in mild and

moderate cases only.

For prophylaxis:

Tab Ivermectin 12 Mg once daily on Day 1, Day 7 and followed by 12 mg once every 30 days. Take

Ivermectin with a fatty meal.

Side effects: It is usually well tolerated. Decreased leukocyte count (3%), eosinophilia (3%), and

increased haemoglobin (1%) have been reported with the use of systemic Ivermectin.

Caution: Hepatic impairment, allergic disorders, HIV infection. Avoid in Pregnancy and children

below 2 years. (Monitor LFT, hypersensitivity reaction etc)

Advice To The Patient During Home Isolation

-Mandatory use of Mask -Absolute rest -Monitoring of SpO2 and Temperature, at least four times daily

Advice To The Family Members

1. Use of Mask by caregiver when going near the patient 2. To stay at home mandatorily for a stipulated period as advised by doctor 3. Test for COVID-19 as soon as any member becomes symptomatic 4. Test for COVID-19 of asymptomatic family members who has High Risk and who are Close Contacts of the patient on Day-5 – Day-10

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Hydroxychloroquine

For treatment: Tab. Hydroxychloroquine 400 mg BD on Day 1, followed by 400 mg OD for 4Days

Contraindications: Children below 15 years, QTcin ECG >500 msec, Retinopathy, Drug Interactions,

Myasthenia Gravis, Porphyria, Epilepsy, G6PD deficiency, pregnancy, lactation.

If initial QTc> 450 msec perform basic biochemistry and ECG daily. Avoid Quinolones and Macrolides with

Hydroxychloroquine, if possible. Monitor QTc closely if these are needed

Way Forward:

Expansion of the resource pool establishing active coordination with the state health infrastructure and

ULBs at appropriate level.

HCQ Prophylaxis

Asymptomatic household contacts of laboratory confirmed

cases:

400 mg twice a day on Day 1, followed

by 400 mg once weekly for next 3 weeks;

to be taken with meals.

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Annexure:1

UNDERTAKING ON SELF-ISOLATION

I

…………………………………………………………………………………………………………………

S/W of

………………………………………………………………………………………………………….,

Resident

of…………………………………………………………………………………………………being

diagnosed as a confirmed/suspect case of COVID-19, do hereby voluntarily undertake to maintain strict

self- isolation at all times for the prescribed period. During this period, I shall monitor my health and those

around me and interact with the assigned surveillance team/ with the call center (1800313444222), in case I

suffer from any deteriorating symptoms or any of my close family contacts develops any symptoms

consistent with COVID-19. I have been explained in detail about the precautions that I need to follow while

I am under self-isolation. I am liable to be acted on under the prescribed law for any non-adherence to self-

isolation protocol.

Signature: Date: Contact Number:

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Annexure:2

বাড়ীেত থাকা কািভড-১৯ রাগীর জন সহািয়কা

১) কািভড ১৯ হেলও কখন বাড়ীেত ( হাম আইেসােলশন-এ) থাকা যােব ?

িন িলিখত শত িল পরূণ করেল কািভড-১৯ প জ টভ ব / ব রা হাম আইেসােলশন –এ থাকেত পারেবন :-

রােগর ল ণ :- অ ক অথবা কান ক নই এমন ে বাড়ীেত থাকা যেত পাের । এ ব াপাের আপনার

িচিকৎসকই িস া নেবন।

িচিকৎসক – রাগীেক বাধ তামূলক ভােব কান িচিকৎসেকর ত াবধােন থাকেত হেব িযিন েয়াজেন রাগীেক

টিলেফান / টিলেমিডিসেনর মাধ েম পিরেষবা দেবন।

বািড়েত থাকার ব ব া :- রাগীর জন আলাদা ঘর ও বাথ ম ( শৗচাগার) থাকেত হেব । পিরবােরর অন দর জন

যন আলাদা ঘর ও বাথ ম ( শৗচাগার) থােক ।

রাগীর দখােশানার ব ব া :- ২৪ ঘ া রাগীর দখােশানার জন বািড়র কাউেক থাকেত হেব। িতিন া ব ব ার

সে িনয়িমত যাগােযাগ রাখেবন।

স িতপ :– রাগী বাড়ীেত থাকার ( হাম আইেসােলশন –এর) িনয়মকাননু মেন চলার স িতপ জমা দেবন ও

িনেজর শারীিরক সুিবেধ অসিুবেধর ব াপাের িনয়িমত ভােব িচিকৎসেকর সে যাগােযাগ রাখেবন।

২) কািভড ১৯ হেল কখন বাড়ীেত ( হাম আইেসােলশন-এ) থাকা যােব না ?

য সম রাগীর িন িলিখত ঝঁুিক িলর মেধ দুই বা তার বশী ঝঁুিক আেছ, তােঁদর হাম আইেসােলশন এ রাখা যােব না –

Age more than 50 years (৫০ বছেরর বশী বয়স) Chronic Lung Diseases (দীঘিদন ফুসফুেসর/ াসকে র রােগ আ া ) Chronic Liver Disease (দীঘিদন িলভােরর রােগ আ া ) Chronic Kidney Disease (দীঘিদন িকডিনর রােগ আ া ) Hypertension (হাই াড সার/ উ র চাপ) Cardiovascular Disease ( দেরাগ/ হােটর রাগ) Cerebrovascular Disease ( ন াক ইত ািদ) Diabetes ( াড সুগার) HIV (এইচ আই িভ আ া ) Cancers (ক া ার/ ককট রাগ) On Immunosuppressive drugs ( রাগ িতেরাধ মতা কমায় এরকম ওষধু িনয়িমত খান)

৩) হাম আইেসােলশন -এ থাকা রাগীেক িক িক করেত হেব?

সবসময় মা ব বহার করেত হেব স ণূ িব ােম থাকেত হেব িদেন কমপে ৪ বার থােমািমটার এর সাহােয তাপমা া ও পাল্স অ িমটার এর সাহােয অ েজেনর মা া

(SpO2) দখেত হেব িত ৪ িদেন একবার নু নতম র পরী া িল করােত হেব

৪) হাম আইেসােলশন-এ থাকা রাগীর পিরবার – পিরজনেদর িক করেত হেব?

সবসময় মা ব বহার করেত হেব ল ণ দখা িদেল কািভড-১৯ এর পরী া করেত হেব পিরবােরর কান সদেস র বিশ ঝঁুিক (high risk factor) থাকেল অথবা রাগীর খুব কাছাকািছ থাকা ল ণ হীন ব র

ে ও ( রাগীর সে কাছাকািছ থাকার শষ িদন থেক ) ৫ থেক ১০ িদেনর মেধ কািভড-১৯ এর পরী া করেত হেব

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৫) কখন জ রী িভি েত িচিকৎসেকর সে যাগােযাগ করেবন?

িচিকৎসেকর সাহায /হাসপাতােল ভিত েয়াজন হেব ,যিদ -

শরীেরর অ েজেনর মা া – ৯৫% এর কম (SpO2 ৯৪% বা তার কম) হয় াসক হয় বেুক ব থা বা চাপ ভাব হয় রাগীর ঝিমেয় থাকা ভাব বা ভল বকা দখা যায় িখচঁিন হয় অথবা কথাবাতা জিড়েয় যায় মুখ, ঠাটঁ হঠাৎ কের নীলেচ হেয় যায় ল ণ দেখ বা পরী ার িরেপাট দেখ যিদ িচিকৎসক পরামশ দন।

৬) হাম আইেসােলশন-এ কতিদন থাকেত হেব?

রাগীর হাম আইেসােলশন শষ হেব ------

ক) উপসগ আর হওয়ার িদন থেক ১৭ িদন পের ( যখােন কমপে ১০ িদন র নই)

খ) উপসগহীন রাগীর ে কািভড পরী ার িদন থেক ১৭ িদন পের

হাম আইেসােলশন শষ হওয়ার পর আবার কািভড পরী া করার কান েয়াজন নই

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Annexure: 3

Model Prescription DR. XYZ MBBS Mr. ABCD EFGH Gender: Male Age: 38 yrs Date: DD/MM/YY C/O Fever since Mild cough, anosmia No SOB NO H/O T2DM NO H/O HTN COVID 19 POSITIVE ON DD/MM/YY BY RT PCR

Adv:

Strict Home isolation for 17 days since onset of symptom. Tab PARACETAMOL 650: one tab Thrice daily or SOS Cap IVERMECTIN 12mg: one cap once daily for 5 days with fatty

meal Tab/ Cap DOXYCYCLINE 100 mg: One tab/ cap twice daily for 7

days Cap VITAMIN C 500 mg: one cap twice daily for 28 days Tab ZINC ACETATE 50 mg: one tab once daily for 28 days Cap VITAMIN D3 60000 IU: one cap once in a week for 4 weeks

Monitor SPO2, Pulse, Temperature, BP at least twice daily or preferably 6 hourly.

Nutritious diet

Look for warning symptoms/ parameters and inform urgent:

o Difficulty in breathing

o Persistent pain or pressure in the chest

o Mental confusion or inability to arouse

o Developing bluish discolorations of lips/ face

o SpO2 < 94% at Room Air (For Obstructive Airway Diseases: SpO2 < 90% at

Room Air)

o Stupor, Drowsiness or Confusion

o SBP

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Annexure: 4

Discharge from Home Isolation

This is to certify that ................................................. , who tested positive for SARS-CoV2

(Covid-19), was advised home isolation for the period from ................... to ......................

Since the stipulated period of his/her isolation has been over and he/she is free from

symptoms of Covid-19, he/she is now being released from home isolation in accordance

with the National Guidelines for home isolation and discharge of Covid-19 cases.

As per standard guidelines, he/she does not require any further test for Covid-19.

Place & date: Sig. with seal

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Annexure: 5

Cleaning Of Toilets

• Toilet seat/pot, commode: To be cleaned with 1% Sodium Hypochlorite solution

• Toilet floor, tap & other areas: To be cleaned with soap water

Preparing 1% Sodium Hypochlorite Solution

• Add 15 grams of Bleaching Powder in 1 liter water

• To be kept in a covered container

• To be used within 24 hours of preparation