Covid-19 Care Guidelines

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Personal protective equipment (PPE) for healthcare workers

Medical facilities have stringent requirements for the use of personal protective equipment (PPE) among healthcare workers who are directly dealing with patients and persons under investigation (PUI) for COVID-19. A protective layer of clothing is the primary protective barrier against transmission of infectious material, and it is a must for healthcare workers who are on the frontlines for treating COVID-19 patients. PPE is defined as “specialized clothing or equipment worn by an employee for protection against infectious materials.”[1]

Aside from frontliners, community members such as pharmacists and tellers who may be exposed may also wear face masks to reduce the risk of infection.[2] In Metro Manila and urban areas, supplies have been scarce, so people with no access to masks may make improvised coverings for their face, practice proper hand-washing and disinfecting at all times, and avoid contact with people through social distancing.

According to the CDC, there are basically three components of the PPE[3]:

Infographics about the components of the PPE.png

The proper use of PPE is extremely important to prevent incidences of transmission. First and foremost is preventing emissions from the respiratory tract (either through coughs or sneezes) from entering the body through its orifices (mouth, nose, eyes). This should be remembered when putting on and removing the PPE. Soiled PPE is particularly critical and difficult[4] because improper disposal of PPE with traces of droplets and minute particles may also lead to contact and transmission.

Applying and removing PPE should also be done before contact with the patient. The healthcare worker should pay attention to the space between gloves and gowns that can serve as a point of entry of the pathogen. The gown should be tucked into the gloves (leaving no gap in-between). Later, the long cuffs of gowns can be used in the removal of the gown and gloves as a single unit.[5]

Below are the steps in the proper use of PPE based on US CDC Guidelines for healthcare workers caring for patients with coronavirus disease (COVID-19)[6]:

  1. Put on PPE before patient contact in a sanitized room.
  2. Before putting on the PPE, perform hand hygiene using an alcohol-based sanitizer.
  3. Before putting on the PPE, check to ensure that all items are free from damage.
  4. Wear the gown first. This should be a clean and disposable material. The gown should fully cover the torso, have a comfortable fit, and have long sleeves. The opening in the back can be secured by the strings’ ties at the neck and waist part.
  5. Next in the sequence is the mask or respirator. In treating COVID-19, the N-95 mask has been identified as effective because of its sub-micron filter. It protects the nose and mouth by fully covering these areas to prevent fluid penetration and particles that are less than 5 microns in diameter. The N-95 has a flexible nosepiece and can be secured to the head with elastic ties for a snug fit.
  6. Goggles are also prescribed to shield the eyes. The goggles can provide a barrier of protection against minute particles that can enter the eye ducts and cause infection. Prescription glasses should not be used as a substitute for goggles.
  7. Last to be donned are the gloves. The gloves should fit the hand well and be made of appropriate materials like vinyl or latex. The gloves can be worn over the gown cuffs to secure them. It can also provide additional protection for the wearer’s skin.
  8. At all times, the healthcare worker should keep the gloved hands away from the face. He or she should also avoid adjusting the mask or the goggles in a contaminated zone.
  9. Once the gloves are torn they should be removed immediately and replaced with a new pair, but not before performing hand hygiene first. Workers should also limit touching surfaces and items.
  10. Removing the PPE should also be done in a clean and sanitized room. Untie the gown first then peel from the body carefully. The gown can be rolled up and then removed along with the gloves, careful not to touch the contaminated parts.
  11. The gown and gloves should be thrown immediately in the proper bin.
  12. The goggles can then be removed, and thrown also in the proper bin.
  13. Last to be removed is the mask, but this should be done in an area outside the anteroom, after the door has been closed.
  14. Lastly once all PPE is removed, practice hand hygiene immediately using soap and water and an alcohol-based sanitizer.

Basic protective measures against COVID-19 for the general public

The World Health Organization (WHO) reminds the public to be properly informed about the latest information on the COVID-19 outbreak. Information should be gathered from reliable sources such as the WHO and CDC websites. The public should also be wary about feeds appearing on social media sites or accepting such posts as factual unless the info is from verified sources.

Recovery rates from COVID-19 are considerably high among those already infected, but people should still take extra care of their health and their daily activities to avoid infection, especially during a quarantine or lockdown. The WHO has released to the general public the following basic guidelines against COVID-19[7]:

Frequent hand-washing: People should practice frequent and thorough hand washing using soap and water. Throughout the day, it is also important to sanitize the hand using an alcohol-based hand gel. This practice can help kill viruses found on one’s hands.

Maintain social distancing: A minimum distance of 3 feet (1 meter) between each person should be observed. The same distance should be considered when a person is in the same area as a person who is coughing or sneezing. When someone coughs or sneezes, they spray small liquid droplets from their nose or mouth, which may contain the virus. If one is too close, he or she can breathe in the droplets, including the COVID-19 virus if the person coughing has the disease.[8]

Avoid touching the eyes, nose and mouth: The eyes, nose, and mouth can be entry points of respiratory tract emissions that may include COVID-19 virus pathogens. As such, people should avoid touching these parts of the face using their hands, which are most susceptible to pick up viruses from contaminated surfaces.

Practice respiratory hygiene: Good respiratory hygiene must be observed everywhere, especially in enclosed spaces. This means covering the mouth and nose with a bent elbow or tissue when one coughs or sneezes. Used tissue should be disposed of immediately in a lined garbage bin.

Seek medical care early when experiencing symptoms: People experiencing symptoms such as cough, flu, or difficulty in breathing are advised to seek medical attention, depending on the severity of their symptoms. Those with mild symptoms should stay at home and go on a self-quarantine until they recover. For others who have prior travel history or exposure to potential COVID-19 patients, they should seek medical attention and notify the authorities immediately.

Stay informed and follow advice given by the authorities: People should also stay up to date with the latest developments about COVID-19. Aside from healthcare providers, local government units and public health authorities will be tasked to keep citizens updated about the latest developments. These agencies will be using social media and traditional print, TV, or radio to release information, so these should be prioritized instead of getting instant online feeds coming from dubious sources.

How to self-quarantine

People who have been exposed to COVID-19 are now mandated to isolate themselves to prevent possible infection of their family, friends, relatives, and neighbors. The self-quarantine period is advised for at least two weeks, which is the presumed incubation period of the virus.

The US Centers for Disease Control and Prevention has issued the following “House Rules” on self-quarantine, published by The New York Times[9]:

  1. If suffering from mild cough or colds, the patient should avoid going to the hospital because he or she might get infected by potentially positive patients.
  2. The patient should stay home unless he or she must see a doctor. He or she should stay in a designated room for his or her exclusive use and if possible with his or her own bathroom.
  3. If the patient needs to come out of the isolation room, he or she should wear a mask. If going out to see a doctor, the patient should wear a mask, and gloves if available.
  4. The patient should not share food, drinking glasses, eating utensils, towels, or bedding with anyone.
  5. Contact with the patient should be discouraged at all times, especially the elderly.
  6. The patient should not accept visitors. If it is unavoidable to make contact with others in the household inside closed quarters, a distance of one to two meters away from others must always be maintained.
  7. Proper hygiene should be practiced at all times. The patient should cover his or her mouth and nose with a tissue if he or she coughs or sneezes. Used tissue should be properly discarded after use in a lined trash bin.
  8. Hand-washing should be frequently done with soap and water for at least 20 seconds.
  9. The patient should avoid touching his or her eyes, nose and mouth. He or she should also avoid touching surfaces, and even pets.
  10. The patient should inform his caregivers to call a doctor immediately in case of severe symptoms. The medical staff should be informed about the risk of infection with COVID-19.

Supportive care for patients on self-quarantine

Family or loved ones of people who are in self-quarantine following exposure to the coronavirus are likewise advised to follow protocol and get factual knowledge on the proper care of their patient. They should also make sure that they are safe and protected from potential virus transmission since they are usually in the same household with the patient on self-quarantine.

Below are the US CDC guidelines for the supportive care of people on self-quarantine, also published by The New York Times[10]:

  1. Choose an isolation room with its own toilet for the patient on self-quarantine. Do not allow anyone to enter the room of the patient under self-quarantine.
  2. If the toilet is to be shared, the isolation room should be located close to the shared toilet.
  3. The patient should be in full protective gear when he or she moves out of the isolation area.
  4. Wait an hour after patient returns to the isolated room. Then disinfect the whole area of the shared toilet.
  5. Wear a protective suit that covers the eyes, face, and gloves. Use long sleeves so that the virus cannot enter through exposed skin. Ensure that the eyes are covered well and protected from droplets that can enter via eye ducts and cause infection.
  6. Caregivers should ensure the provision of supplies to the patient in quarantine. Supplies and food should be left outside the door for the patient to collect.
  7. The patient should use disposable paper plates, cups and utensils. These items should be discarded after use in a double garbage bag.
  8. Disinfect the door and the whole hallway, both floors and walls, with Lysol or 70% alcohol.
  9. Insulate the door by wrapping the door jambs with plastic wrap.
  10. The caregiver should also practice proper hand hygiene. Always wash hands with soap and water for at least 20 seconds. Use a sanitizer if there’s no access to soap and water.
  11. Call a doctor immediately if the patient develops symptoms or if they worsen. Make sure to tell the medical staff that the patient is at risk of infection with COVID-19.
  12. Stay in the loop by consulting newsletters, daily updates, and reliable information guides on the virus.

Risk assessment

The elderly sector has been identified as more susceptible to the COVID-19 virus, but this does not exempt the rest of the population from being carriers of the pathogen or from being infected through transmission from asymptomatic carriers. The WHO rates the risk assessment of COVID-19 as “very high” on a regional and global level,[11] so control of the pandemic is now prioritized across different countries through the imposition of community-wide and nationwide quarantine or lockdowns.

The risk of COVID-19 is now also being assessed based on specific factors, such as the severity of the patient’s condition, how it is transmitted between people, the characteristics of the virus, and the success rate of medical measures utilized to control the impact of the virus. There is no approved vaccine or prescription medicine against the virus to date, so healthcare providers can only resort to therapeutic care or experimental medications to alleviate or combat the disease’s symptoms.

Figure 1. A graph indicating the number of hospitalizations, ICU admissions, and fatalities classified by age groups from 12 February to 16 March 2020 in the United States as registered by its Centers for Disease Control and Prevention. Source: “Severe outcomes among patients with coronavirus disease 2019 (COVID-19) — United States,” https://www.cdc.gov/mmwr/volumes/69/wr/mm6912e2.htm.

With the COVID-19 virus exhibiting an exponential rate of increase as the outbreak expands, the risk of exposure is likewise expected to go up as the virus takes its course in an area. The documented cases in the Philippines show transmission between family members or those within a common community, then spreading further to other areas when an asymptomatic patient unwittingly introduces the pathogen into a locality.

At elevated risk of exposure are:

  • Residents and transients where there is ongoing community spread of the virus, with the level of risk dependent on the location[12]
  • Healthcare workers caring for patients with COVID-19
  • Close contacts with persons symptomatic of COVID-19
  • Travelers returning from locations abroad where community spread is ongoing, with the level of risk dependent on where they traveled.

At risk of severe illness are:

  • Older adults, with risk increasing by age[13]
  • People who have serious chronic medical conditions like:
    • Heart disease
    • Diabetes
    • Lung disease
    • High blood pressure

Doing your part by helping flatten the epidemic curve

The term “flattening the curve” has become a byword recently, with experts pointing to this strategy as the most effective in dealing with the COVID-19 virus. It refers to slowing down the natural course of the disease that is spread from an infected person to another. This can be achieved by isolating cases as well as suspected patients, and preventing further spread of the virus through community quarantine, social distancing, and urban lockdowns to break the chains of disease transmission. By doing so, governments and healthcare providers can be in a position to provide better treatment for infected patients with adequate medical facilities being equipped to handle cases.[14]

The flattening-the-curve model illustrates how community protective measures can reduce the daily number of cases and delay the peak of the outbreak, leading to improved healthcare system capacity. Without the protective measures, the R, or reproductive rate of the disease will be exponentially higher, and the outbreak may become uncontrollable once hospitals become inundated with a deluge of patients.


Under the quarantine, citizens are mandated to stay at home, while all modes of public transport are limited. However, provision for food and essential health services are regulated, while the presence of uniformed personnel to enforce quarantine procedures are heightened.[15]

The quarantine follows similar initiatives taken by other countries in their objective of lessening the spread and impact of the COVID-19 virus. Governments work closely with local and regional units, agencies, private partners, as well as public health partners, to respond to the massive public health threat of COVID-19.

A TALE OF 2 PROJECTIONS

Figure 4 (Left) is a graph depicting two epidemic curves modeled by Dr. Jomar Rabajante, who predicted that “based on my optimistic forecast, if the interventions such as the enhanced community quarantine aren’t that effective, the peak might happen mid-April, with around 2,500 active cases in Metro Manila” (red curve). In a second graph (not shown), Dr. Rabajante predicted that the epidemic would subside by the end of June when a total of 11,000 cases would have been reported in Metro Manila. Figure 5 (Right) Nationwide in scope, and with more daunting figures. Dr. Darwin Bandoy’s analysis points to a peak by the end of June, with a total of 245,000 cases. He believes that the epidemic will subside not earlier than October this year.

Source: “[ANALYSIS] Why Filipinos need to stay at home until June (or even longer),” Rappler, <nowiki>https://www.rappler.com/</nowiki> thought-leaders/255096-analysis-why-filipinos-need-stay-home-until-june-2020-or-longer.


Adam Kucharski, an infectious disease expert and author of the book The Rules of Contagion, stated that containment is widely regarded as the solution to controlling the virus globally, since it worked remarkably well for the earlier outbreak of SARS in 2003. Control should focus on isolating the cases and their potential contacts while avoiding disruption to the wider population. This method breaks the chains of transmission and ensures that no further transmission occurs.[16]


Figure 6. Differently shaped epidemic curves that depict the predicted impact that government countermeasures could have on critical care bed use in Britain. Note the the different estimated peaks in the UK, which is predicted to occur any time between late May through July. After figure 2 of Neil Ferguson et al., “Impact on non-pharmaceutical interventions (NPIs) to reduce COVID-19 mortality and healthcare demand,” Imperial College COVID-19 Response Team, https://www.imperial.ac.uk/media/imperial-college/medicine/sph/ide/gida-fellowships/Imperial-College-COVID19-NPI-modelling-16-03-2020.pdf.

Mathematical modeling predictions are pivotal in influencing government policies. A study (figure 6) led by mathematical epidemiology expert Neil Ferguson for the Imperial College of London influenced the pandemic response policies of both the UK and US governments by analyzing “the likely impact of multiple health measures on slowing and suppressing the spread of coronavirus.”[17]

The study predicted the sheer number of fatalities (510,000 Britons and 2.2 million Americans) that would occur if nothing urgent was done by both governments in controlling the epidemic curve.[18] Reflecting on the Chinese experience, the report stated that “Through the hospitalisation of all cases (not just those requiring hospital care), China in effect initiated a form of case isolation, reducing onward transmission from cases in the household and in other settings. At the same time, by implementing population-wide social distancing, the opportunity for onward transmission in all locations was rapidly reduced. Several studies have estimated that these interventions reduced R [reproduction rate] to below 1. In recent days, these measures have begun to be relaxed. Close monitoring of the situation in China in the coming weeks will therefore help to inform strategies in other countries.”[19]

These studies, which coincide with similar studies done abroad, point to the urgent need of Filipinos to help flatten its epidemic curve by slowing down infection rates through implementing population-wide social distancing, enforcing the rules of the lockdown, and practicing good personal hygiene.

By following government guidelines with regard to social distancing and strategies for flattening the curve, you can help break the spread of infection. You and all your friends and loved ones can help stem this infectious tide with your personal actions and sacrifice.

To Downward Trajectory

In early September, the OCTA research team—an independent and interdisciplinary research group composed most of UP faculty members and alumni—said the Philippines had already flattened the curve of coronavirus cases, with its reproductive rate sitting at 0.94 percent. The statistical measure, used to determine the “contagiousness” or rate of virus transmission, should ideally be one or less, as anything higher means there is still a significant community transmission. DOH cited the country’s improving case fatality and recovery rates, as well as ramped up healthcare system including boosted testing, tracing, and clinical management efforts. The agency, however, advised the public to remain vigilant and cautious, especially when the community quarantines are beginning to ease up. .[20] With the new and more contagious UK variant already in the Philippines, the country is very much vulnerable.

The New Normal

The social distancing programs of the government may eventually prove not to be enough to curb the rate of infection in your locality. Thus, since the increase of infection in the country in 2020, the government has implemented different levels of quarantines and lockdowns. Many of these restrictions have some of the following measures: cutting all transport into and out of your locality; shutting down of all public and private institutions such as schools, offices, and factories; the prohibition of operation of private vehicles and even public transportation in city streets; the imposition of entry and exit restrictions in neighborhoods and apartment complexes; obligatory isolation of people with fever or symptoms for monitoring by health authorities; and the deployment of police or military to ensure lockdown compliance.

The restrictions vary from cities to cities, but it would most likely depend on the population and rate of infections in the communities. Some signs of an impending total lockdown are the following: the successive doubling of reported infections in a day; infections that range in the thousands per day; or increasing fatality rates. In the event that your local government would take more stringent and even draconian measures, here are protocols derived from the lessons of the Wuhan lockdown that took effect on 23 January 2020. It can be recalled that this type of lockdown in China proved to be effective in slowing or stopping the spread of infection. Movements of your household will be monitored with only one person from each household allowed to exit or enter your residence every two or three days but only for essential purposes such as the purchase of medicine or food or consultation with a doctor. A temperature check will be performed upon exit or entry of your residence.[21]

Protocols for safe travel in possibly contaminated areas:

  1. Before leaving, create a containment zone immediately by your exit door.
  2. Leave fresh clothes, alcohol, or sanitizer in the containment zone.
  3. Before leaving, wear a face mask and eye goggles or visor.
  4. Take along a hand sanitizer or a spray bottle of 75% alcohol.
  5. If the errand requires a high touch area such as a grocery, wear gloves.
  6. Once outside, take care not to touch high-touch surfaces such as elevator buttons, handrails, bus rails, or wall surfaces.
  7. Sanitize immediately after coming into contact with surfaces.
  8. Remember not to touch the face, especially the eyes, nose, or mouth.
  9. When you get back home, disinfect your eye protection gear, clothes and throw them directly into the wash or into a sealed garbage bag.
  10. Dispose of mask and gloves into a sealed garbage bag.
  11. Wash hands with soap and water.
  12. Change into fresh clothes or shower immediately.
  13. Disinfect paper or plastic bags, groceries, and any packages from outside.
  14. Disinfect car keys, door handle and lock, and any mobile phones.
  15. Disinfect paper money or coins.

The health crisis altered practically all aspects of Filipinos’s way of life – the way they work, the manner we interact with people, and the methods we use in doing business, among others. The government urged Filipinos to adapt to the “new normal” by observing new systems of health protocols until the public health crisis is over. To move forward, we had to undergo the process of adaptation; that is, by adopting to the new systems, approaches, and a new way of doing things.[22]


References

  1. “Personal protective equipment,” US OSHA.gov, accessed 5 April 2020, https://www.osha.gov/SLTC/ personalprotectiveequipment/.
  2. “Guidance for the selection and use of personal protective equipment (PPE) in healthcare settings,” US Centers for Disease Control and Protection, accessed 5 April 2020. https://www.cdc.gov/hai/pdfs/ ppe/ppeslides6-29-04.pdf.
  3. Josh Farkas, “Personal protective equipment,” The Emcrit Internet Book of Critical Care, 2 March 2020, accessed 5 April 2020, https://emcrit.org/ibcc/covid19/#anti-bacterial_therapy.
  4. Farkas, Ibid; “Personal protective equipment.”
  5. Farkas, Ibid.
  6. “Guidance for the selection and use of personal protective equipment (PPE).”
  7. “Coronavirus disease (COVID-19) advice for the public,” World Health Organization, accessed 5 April 2020, https://www.who.int/emergencies/diseases/novel-coronavirus-2019/advice-for-public.
  8. “Coronavirus disease (COVID-19) advice.”
  9. Roni Caryn Rabin, “How to quarantine yourself,” The New York Times, 6 March 2020, accessed 5 April 2020, https://www.nytimes.com/2020/03/06/health/self-quarantine-coronavirus.html.
  10. Rabin, Ibid; “How to quarantine yourself.”
  11. “Coronavirus disease 2019 (COVID-19) situation report – 46,” World Health Organization, accessed 5 April 2020, https://www.who.int/docs/default-source/coronaviruse/situation-reports/20200306-sitrep-46-COVID-19.pdf?sfvrsn=96b04adf_2.
  12. “Coronavirus disease 2019 (COVID-19) situation summary,” US Centers for Disease Control and Prevention, 15 March 2020, accessed 5 April 2020, https://www.cdc.gov/coronavirus/2019-ncov/ cases-updates/summary.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fcoronavirus%2F2019-ncov%2Fsummary.html.
  13. “Coronavirus disease 2019 (COVID-19): If you are at higher risk,” US Centers for Disease Control and Prevention, 15 March 2020, accessed 5 April 2020, https://www.cdc.gov/coronavirus/2019-ncov/specific-groups/high-risk-complications.html.
  14. Siobhan Roberts, “Flattening the Coronavirus Curve,” The New York Times, 11 March 2020, accessed 5 April 2020, https://www.nytimes.com/2020/03/11/science/coronavirus-curve-mitigation-infection.html.
  15. Virgil Lopez, “Duterte orders Luzon-wide ‘enhanced community quarantine,’” GMA Network, 16 March 2020, accessed 5 April 2020, https://www.gmanetwork.com/news/news/nation/729875/duterte-orders-lockdown-of-entire-luzon-due-to-covid-19-threat/story/.
  16. Adam Kucharski, “How can we control the coronavirus pandemic?” TED.com, accessed 18 March 2020, https://www.ted.com/talks/adam_kucharski_how_can_we_control_the_coronavirus_pandemic#t-202680.
  17. Sabine L. van Elsland and Ryan O’Hare, “COVID-19: Imperial researchers model likely impact of public health measures,” Imperial College of London, 17 March 2020, accessed 5 April 2020, https://www. imperial.ac.uk/news/196234/covid19-imperial-researchers-model-likely-impact/.
  18. Neil Ferguson et al., “Impact on non-pharmaceutical interventions (NPIs) to reduce COVID-19 mortality and healthcare demand,” Imperial College COVID-19 Response Team, 16 March 2020, accessed 5 April 2020, https://www.imperial.ac.uk/media/imperial-college/medicine/sph/ide/gida-fellowships/Imperial-College-COVID19-NPI-modelling-16-03-2020.pdf.
  19. Neil Ferguson et al., “Impact on non-pharmaceutical interventions (NPIs) to reduce COVID-19 mortality and healthcare demand,” 14.
  20. ”More than a flattened curve, PH eyes ‘downward trajectory’ in COVID-19 cases — Duque”, 5 Oct 2020, accessed 3 March 2021, https:// https://www.cnnphilippines.com/news/2020/10/5/Philippines-COVID-downward-trajectory-flattening-curve-Duque.html.
  21. This community information was compiled from personal blog posts and tips posted by Wuhan residents in WeChat or other social messaging apps.
  22. Lade Jean Cabagani, “Adapt to new normal till pandemic is over, Pinoys urged, 31 December 2020, accessed 3 March 2021, <nowiki>https:// https://www.pna.gov.ph/articles/1126079/.

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