Neurosurgery Practice During Corona Virus Pandemic

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Neurosurgery and Neurology Practices

during the Novel COVID‑19 Pandemic:
Website:
A Consensus Statement from India
www.neurologyindia.com
Prakamya Gupta, Muthukumar N1, V Rajshekhar2, Manjari Tripathi3,
DOI:
10.4103/0028-3886.283130
Sanjeev Thomas4, Sunil Kumar Gupta5, Vivek Lal6, Pramod Pal7, Mathew Abraham8,
Sanjay Behari8, Vimal Paliwal9, Daljit Singh10, Sanjay Pandey10,
PMID:
Lakshmi Narasimhan11, Dwarakanath Srinivas12, Samhita Panda13, S S Kale14,
xxxx
P Sarat Chandra14
Division of Innovation and

Translational Research, Abstract:
ICMR, 10Department BACKGROUND: The COVID‑19 infection outbreak has aroused increasing attention and affected thousands
of Neurosurgery, GB of people nationwide. The long incubation period, high infectious rate, varied manifestation, and absence of
Pant, Departments effective treatment make it difficult to manage the disease transmission.
of 3Neurology and
OBJECTIVE: The intended goals are to encourage efficient management of neurological and neurosurgical
14
Neurosurgery, AIIMS,
patients, resource utilization, and protecting the healthcare provider during the COVID‑19 epidemic. Herein,
New Delhi, 1Department
we present a consensus statement from various centers in India
of Neurosurgery,
Devdoss Hospital, METHODOLOGY: In addition to the literature review, recommendations were included from neurologists and
Madurai, 2Department neurosurgeons from various centers in India.
of Neurological RESULTS: Every patient presenting for treatment should be treated as a potential asymptomatic infected
Sciences, CMC, case. Patients should be categorized based upon the priority as acute (require immediate treatment/surgery
Vellore, 11Department within 24 h), sub‑acute (requiring treatment within a maximum of 7–10 days), or chronic (requiring treatment
of Neurology, Institute within a month). Non‑essential elective surgeries and outpatient clinics should be avoided after informing the
of Neurology, Madras patient(s). There is a high risk of aerosol dispersion during intubation and certain neurosurgical procedures
Medical College, particularly those involving drills and endoscopes. These procedures should be performed wearing full
personal protective equipment. The workflow of the operating rooms should also be modified significantly.
Chennai,
Minor modifications in personal and professional lifestyles and routine training to use the PPE will ensure
Tamil Nadu, 4Department
efficient management of resources.
of Neurology, SCTIMST,
Trivandrum, Kerala, CONCLUSION: These recommendations could be used to mitigate the risks and reduce exposure to other
Departments of patients, public, and healthcare staff.
5
Neurosurgery and Key Words:
6
Neurology, PGIMER, COVID‑19, neurology, neurosurgery, protocols
Chandigarh, Departments
of 7Neurology and
Key Message:
12
Neurosurgery,
NIMHANS, Bengaluru, The following article provides some workflow paradigms specially of relevance for practice of neurosurgeons
Karnataka, Departments and neurologists during the COVID-19 pandemic.
of 8Neurosurgery and
“A
9
Neurology, SGPGI, ccording to Darwin’s Origin of Species, it is not health and life across the globe. By 10th April
Lucknow,
the most intellectual of the species that survives; 2020, nearly 1,645,428 cases of COVID‑19 were
Uttar Pradesh,
it is not the strongest that survives; but the species that confirmed worldwide and nearly 7347 cases were
13
Department of
Neurology, AIIMS, survives is the one that is able best to adapt and adjust reported from India. Despite prudent healthcare
Jodhpur, Rajasthan, India to the changing environment in which it finds itself.” measures taken by the Indian Government, the
projected impact of coronavirus infection falls
—Leon C Megginson, 1963 to 2%.[1] Therefore, it is pertinent to curtail the
infection, rationalize the use of resources, and
Address for
correspondence: Introduction and Background: The COVID‑19 manage the patient rush in the given scenario.
Dr. P Sarat Chandra, pandemic has raised significant threats to public
Professor and Head
Unit I, Department of This is an open access journal, and articles are distributed under the terms
How to cite this article: Gupta P, Muthukumar N,
Neurosurgery, of the Creative Commons Attribution‑NonCommercial‑ShareAlike 4.0
Rajshekhar V, Tripathi M, Thomas S, Gupta SK, et al.
CN Center, AIIMS, License, which allows others to remix, tweak, and build upon the work
non‑commercially, as long as appropriate credit is given and the new Neurosurgery and neurology practices during the
New Delhi ‑ 110 029, India. novel COVID-19 Pandemic: A consensus statement
creations are licensed under the identical terms.
E‑mail: saratpchandra3@ from India. Neurol India 0;0:0.
gmail.com For reprints contact: reprints@medknow.com
© 2020 Neurology India, Neurological Society of India | Published by Wolters Kluwer - Medknow 1
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Gupta, et al.: Neurosurgery and neurology practices during COVID‑19 pandemic
The symptoms vary with every patient. The typical “cytokine should be treated as a potential asymptomatic infected case.
storm” elicited depends on the immune dysregulation History regarding respiratory illness, international travel and/
rather than the peak viremia. This induces insufficient and a or, contact with COVID‑19 patients should be documented
late‑type I interferon (IFN) response which leads to aberrant in every case sheet separately. All patients, as well as their
proinflammatory cytokine secretion by alveolar macrophages attendants, should be screened for COVID‑19 before entering
and subsequent CD4, CD8 T cell dysfunction. There is a the emergency room. Any patients suspected of COVID‑19
marked increase of 14 cytokines in COVID‑19 patients and should be immediately isolated while emergency treatment
there are high levels of three cytokines (CXCL 10, CCL7, and is being administered. All doctors/nurses/paramedical
IL‑1 receptor antagonist) which are associated with increased staff are advised to wear surgical scrubs along with a
viral load, loss of lung function, lung injury, and a possibly plastic apron, face masks, and other protective equipment
fatal outcome.[2,3] as necessary while in the triage area. They should wear
PPE, N95 masks as well as a face visor while examining/
The typical clinical manifestation of COVID‑19 positive intubating suspected or proven COVID‑19 patients in the
patients are fever, cough, and dyspnea. However, several emergency. A dedicated operating room (OR) and the same
patients present with neurological symptoms, such as anesthesia machine should only be used for COVID‑19
vomiting, headache, dizziness, and delirium. Anosmia and positive cases for the duration of the epidemic. The risk of
ageusia can also be early symptoms.[2,3] The diagnosis and aerosol dispersion is maximum during intubation, hence it
severity of illness are based on the SARS‑CoV‑2 guidelines has been suggested that the whole face area may be covered
by WHO [Supplementary File 1]. The patients are categorized by a transparent sheet and the hands may be inserted under
into five levels of severity: mild illness, pneumonia, severe the sheet to intubate the patients, while the edges should be
pneumonia, acute respiratory distress syndrome (ARDS), and stuck to the surface. Alternatively, the use of a transparent
septic shock. A study by Gautret et al. have shown that combined Perspex square box has been suggested which is placed over
treatment with azithromycin and hydroxychloroquine the patient’s head and has two ports for the anesthesiologist
significantly reduces the viral load from the COVID‑19 to insert his/her arm so that the whole intubation may be
positive cases.[4] The COVID‑19 patients may be managed by performed inside the box. A preferred protocol is the use of
hydroxychloroquine or chloroquine or lopinavir/ritonavir or a separate room for intubation and then bringing the patient
combination of HCQ and lopinavir [Figure 1]. to the OR, so the risk is minimized to the surrounding health
personnel. Patients should be categorized based upon priority
The COVID‑19 pandemic has raised great challenges for (i) acute (requiring immediate treatment/surgery within
both neurologists and neurosurgeons worldwide.[5‑7] The 24 h.) (ii) sub‑acute (requiring treatment within a maximum
novel‑SARS‑CoV‑2 has been directly associated with acute of 7–10 days) or (iii) chronic (requiring treatment within a
hemorrhagic necrotizing encephalopathy[8] or may also cause month) [Figure 2 and Supplementary File 1]. The COVID‑19
central nervous system (CNS) infection together with systemic positive patients should be strictly managed according to the
inflammation.[9,10] Restricted clinical work has a great impact on WHO guidelines [Supplementary File 2].
patients’ mental and physical health and thus becomes even
more challenging to manage patients with CNS diseases.[11] The Acute cases
situation regarding COVID‑19 is rapidly evolving and dynamic. A pulmonary computed tomography (CT) scan and nucleic
Although timely policies have been laid down by the state and acid sequencing (RT‑PCR) of throat swab are recommended
central governments to facilitate objective decision‑making, in all cases, again subject to the National/Government
such directives will inevitably need to be adapted to this guidelines. However, these examinations may be canceled and
ever‑changing environment. The policies laid down by the a direct surgical intervention may be performed. The surgical
government and individual hospitals aim to provide efficient indications should be rigorously evaluated and surgical
resource management to tackle the sudden surge of patients, treatment should be preserved for patients with an emergency
management of patients which require immediate neurosurgical condition such as intracranial hemorrhage, significantly raised
intervention and engaging in neurosurgical research during the ICP, ruptured aneurysm. COVID‑19 positive or suspected
COVID‑19 outbreak. The infectivity period may start several cases should be operated in the dedicated OR. In acute
days before the person becomes symptomatic. They can spread stroke patients requiring mechanical thrombectomy at least,
the infection in the preclinical stage. This increases the risk of chest X‑ray should be done if not pulmonary CT scan while
healthcare providers. This paper aims to provide comprehensive shifting to the intervention room without causing a delay
recommendations for neurological and neurosurgical patient in procedure and intervention in COVID‑19 suspect cases
management, efficient resource management, and protecting should also be done in separate dedicated intervention room.
the healthcare provider during the COVID‑19 epidemic. In Pre‑op and Post‑op transfer from the ward to the OR and back
addition to a literature review, we have included the advice and should be done by the ward nurses in full personal protective
expertise from neurologists and neurosurgeons from various equipment (PPE) including a well‑fitting N95 mask, goggles
key centers. These recommendations aim to minimize infections or face shield, splash‑resistant gown, and boot covers. Double
to doctors, nurses, and paramedical staff of the neurology and surgical gloves are recommended for neurosurgeons to avoid
neurosurgery division and fight the novel coronavirus infection. cross‑infection due to glove rupture. Postoperatively the OR
should be fumigated after the case is completed. It is suggested
Recommendation for Patient Management (for details see that during the acute stage of the pandemic, elective surgeries
Supplements 1-3) should be postponed to the extent possible [Figure 1]. A recent
The incubation period of the n‑CoV‑SARS2 ranges from study from Wuhan, Hubei[13] showed that 34 patients who
3–14 days[12] henceforth, every patient presenting for treatment underwent elective surgeries during the incubation period
2 Neurology India | Volume 68 | Issue 2 | March-April 2020

Figure 1: (a) Flow chart of pre and postoperative patient management for patients with CNS disease during the COVID‑19 epidemic. CT: computed tomography. (b) Patients
prioritization and action required
of COVID‑19 infection developed pneumonia, 44% needed mortality e.g. Low‑grade glioma, arteriovenous malformation,
ICU care and the mortality rate was 20%. unruptured aneurysm, Pituitary apoplexy. Treatment decisions
need to be made on a case‑by‑case basis. Case prioritization
Sub‑acute cases should be done in consultation with a senior consultant. Risks
Although these cases do not require immediate intervention, for patients should be determined by weighing the risks of
however, if not treated can have significant morbidity and proceeding versus delaying surgery. Priority should be based
Neurology India | Volume 68 | Issue 2 | March-April 2020 3
Practising doctors/
Tertiary Care Centers Small and Medium Hospitals
small clinics
Substitute Advisable to
Team A Team B Team A Team B
Team collaborate with other
clinics or doctors to
Can alternate Quarantine
Quarantine form a partnership to
Week 1& 2 On Duty with Team A On Duty (Self
(Self Isolation) follow up patients
and Team B Isolation)
and continue patient
or members
care
could be
Quarantine stand by if Quarantine
Week 3&4 (Self On Duty any team On Duty
(Self Isolation)
Isolation) members fall
sick
Figure 2: A dedicated team comprising of neurosurgeon(s), anesthesiologist(s), nursing staff, paramedical staff performs all tasks for 14 days. The teams switch
coverage on a 14‑day cycle and 14 days of self‑quarantine. A back‑up or alternative team substitutes for any team member who shows signs of illness. In case a
particular team is contaminated, the substitute team will fill the gap. Contacts between the teams and/or overlapping are prohibited. Small and medium neurology
and neurosurgery super specialty hospitals are encouraged to collaborate and form teams. Each team should only rotate at one hospital (no cross‑covering) at a
given time
on both COVID‑19 associated and other risks, given the particulate air filter (HEPA)
competing risks that many neurosurgical emergencies may 4. Creating a set of new workflows e.g. coordination of staff,
come with. movement of surgical and anesthetic equipment, infection
prevention practices, etc.
Chronic cases 5. A comprehensive program for the use of PPE must be
Suspected or confirmed COVID‑19 cases should be treated enforced. These include separate donning and doffing
with more caution and conservative treatment should be given areas, use of N95 masks with surgical masks over them
priority. Non‑essential elective surgeries such as pituitary (double masks), use of clear instructions and direction
adenoma, (without visual deterioration) craniopharyngioma, panels in the operating rooms, and segregation of staff.
etc., should be postponed after informing the patient. For Training staff to use PPE competently is essential. In an
patients whose health condition is likely to deteriorate with more observational study, 90% of staff did not use the correct
than 1‑month delay and are keen to proceed with treatment can doffing sequence or technique or use the appropriate PPE.[23]
be done on the elective list as per prioritization. It is advisable Figure 3. Also enclosed is the YouTube link to a video of
to avoid admitting cases requiring elective postoperative ICU Donning and Doffing methods from AIIMS, New Delhi.
management. Routine patient follow‑up may be avoided or https://youtu.be/03Von0Beoh8
postponed. Among all procedures, endoscopic endonasal 6. The use of a powered air‑purifying respirator is
procedures and techniques like bone drilling are at the highest recommended (PAPR). They are likely to have a higher
risk due to aerosol dispersion.[14] Hence, it is important to
protective ratio than N95 respirators
carefully screen the patient before performing such procedures.
7. Following surgery, it is important to discard the canister of soda
lime to eliminate the negligible risk of circuit contamination
Creating COVID specific operating room protocols: Wong
8. Following the disposal of single‑use equipment, all
et al.[14] in their article described a systematic set of protocols
instruments should be sent for decontamination and sterile
they have taken at Singapore General hospital to streamline
re‑processing. Surfaces of all medical devices are cleaned
their surgical cases. Coronavirus disease (SARS‑CoV‑2) is likely
with wipes soaked in ammonium chloride. The OR then
going to stay for a prolonged period, even though we hope that
the pandemic will be controlled.[14‑22] These measures have to should be cleaned with sodium hypochlorite 1000 ppm
become part of the protocol similar to universal precautions and treated with hydrogen peroxide vaporization or
taken for other infectious diseases like HIV and viral hepatitis. ultraviolet‑C irradiation. Hypochlorite is affordable, has
Their strategies include a rapid onset, and has a large bactericidal spectrum with
1. Before the commencement of the procedure a “team no toxic residue. Ultraviolet‑C irradiation effectively
huddle” should take place so that each member of the team inactivates aerosolized viruses, bacteria, and fungi
understands the sequence of anesthesia and surgery as this 9. All staff should then shower and change into a clean set of
will ensure seamless teamwork with all the necessary drugs scrubs
and equipment in place before the commencement of the 10. All “high‑touch” equipment within the operating room
operating procedure e.g., anesthesia stations, laptops, cabinets, etc., should be
2. An OR with a negative pressure environment is ideal covered with disposable plastic sheets. Following surgery,
to reduce transmission of infection. However, a high these sheets are then disposed and the surfaces cleaned and
frequency of air changes (25/h) is also effective to rapidly OR fumigated
reduce the viral load in the OR 11. Names of all participating staff members are recorded
3. It would be desirable to have a separate OR with separate air to facilitate contact tracing. Since more time is required
duct flow for managing COVID cases. Each OR should have for decontamination, the turn‑around time for surgery is
its ventilation system with an integrated high‑efficiency naturally increased.

Gupta, et al.: Donning and

Neurosurgery andDoffing
neurology Sequence forCOVID‑19
practices during PPE pandemic
Donning Sequence Doffing Sequence
Remove all personal items

(e.g.watches/pen/jewellery) Outer Gloves
Hand Wash Hood
Cap Cover all/ Gown
Shoe Cover Shoe Cover
Hand rub Hand rub (Gloved hand)
Inner glove Goggles
Cover all/ Gown Mask (Surgical or N95)
Mask (Surgical or N95)

Cap
Goggles
Inner glove
Hood
Hand Wash
Outer Gloves
Figure 3: Donning and Doffing Sequence for Personal Protective Equipment (PPE)
Intra and postoperative patient management usually around 5 days (3–6 days), while IgG is detected at
Postoperative pulmonary CT scan and nucleic acid 14 days (10–18 days) after symptom onset. The positive rate
sequencing (RT‑PCR) of throat swab are recommended in was 85.4%, 92.7%, and 77.9%, respectively. In confirmed
all cases. All postoperative patients should be assumed to and probable cases, the positivity of IgM antibodies was
be suspected cases and quarantined for at least 2 weeks. 75.6% and 93.1%, respectively. The detection efficacy by
Postoperatively, a pulmonary CT and nucleic acid IgM ELISA was shown to be higher by the qPCR method by
sequencing (RT‑PCR) of throat swab should be repeated 5.5 days of symptom onset. The positive detection increased
three times in 2 weeks. If the tests are negative after significantly when combined ELISA and PCR were done as
2 weeks, the quarantine may be terminated and patients compared to a single PCR (98.6% vs 51.9%). A combination
may be shifted to the ward or an individual room. The of RT‑PCR with a CT scan of the chest again increased the
median duration of IgM and IgA antibody detection is sensitivity to 92%.[24]
As mentioned above, endonasal procedures are at high risk of Seniors doctors (age above 60) may avoid going to the hospital.
transmission. The use of debriders and drills within the nasal During this time, they are encouraged to work from home
cavity will produce a highly dangerous droplet aerosol. It is engaging in research activities i.e. writing research papers,
recommended to avoid sinus breach whenever possible and projects, or data analyses. The senior doctors may also
avoid the use of any instrument which causes aerosol droplets actively participate in taking classes for students over video
to form. Usage of drills/craniotomes is known to be associated conferencing. They can also be involved in patient consultations
with significant aerosol formation. Hence, all craniotomies via teleconsultations and also in virtual ward rounds using
should be done using Hudson’s brace and Gigli saw. During the mobile video conferencing methods. Similarly, pregnant and
usage of these instruments, the scrub nurse/assistant should potentially immunocompromised staff should not be involved
liberally irrigate the surgical site to prevent/reduce aerosol in the care of COVID patients. The above protocols are going
formation. If drills are used during spinal/cranial procedures, to place tremendous stress on the health infrastructure, but
they must be used at lower speeds and with liberal irrigation to a well‑laid out protocol is much more effective in the long
reduce the risk of aerosol contamination of the theatre milieu. run rather than risk the health personnel falling sick and
Transcranial procedures, on the other hand, are safer as there jeopardizing the entire hospital.
is no evidence at present that virus concentrates in either
blood or cerebrospinal fluid (CSF). Care must be provided to Identify the hotspots in the hospital
reserve surgery for urgent cases and minimize the length of It is important to have a team discussion through video
stay at the hospital (day case, single night stay). Each patient conferencing with the entire hospital administrative team to
ward should be divided into three categories i.e. COVID‑19 identify the potential hotspots. These include commonly (i) the
Positive, Suspected, and Negative area. Daily sterilization hospital canteen (ii) the cafeteria and the doctor’s lounge (iii) the
is recommended in each room. The doctors, nurses, and hospital reception and the patient waiting for areas (iv) hospital
paramedical staff must take strict third level protection before ambulances (v) emergency and outpatient’s department.
entering the room.
A recent study from Lombardy, Italy showed that the maximum
Efficient human resource management cross infections occurred while transporting the patients to the
The prevailing crisis may lead to a risk of PPE supply shortage, hospital in ambulances.[7] Similarly, intelligent modifications
and hence efficient human resource management is required to must be performed in patient waiting areas (allowing patients
curb the wastage of resources. The neurosurgeons should limit to sit only in alternate chairs, sanitizing the chairs after every
the outpatient clinic, surgeries of sub‑acute and chronic cases patient, compulsory wearing of masks by all patients in
to a maximum of 25%. This volume‑limiting approach will the hospital). Similarly, overcrowding should be avoided and
ensure the maximal availability of hospital supplies where the distancing must be maintained in the elevators. All canteens,
demand is high. Telemedicine consultations are now advised. cafeteria, and eateries should be closed during the active
The hospital management should now be encouraged to modify pandemic. The patients may be provided with room delivery
the OPD chambers by creating barriers e.g. transparent glass or take away counters. It is desirable to create a special COVID
barriers may be created between the doctor and the patient with team that can look into all these matters and reports actively
a communication facility through a mic. Physical examination to the administrators and doctors of the hospital.
should be performed in full protective gear especially oral,
endoscopic examination, etc., The entry of doctors and patients Protecting the healthcare provider, changing professional,
should also be separated into the OPD chamber. The neurology, and personal lifestyles
neurosurgery, and anesthesia departments are encouraged to The COVID‑19 virus is a high‑risk pathogen with high
form teams based on the expertise of members. Each team may transmissibility and infectivity. Consulting physicians,
include resident doctors, nurses, paramedical staff, attendants, resident doctors, and nurses are at significantly high risk of
etc., A designated team performs designated tasks to avoid infection (both symptomatic and asymptomatic) during patient
the frequency of contact within the team and the patient while care.[17] A recent study has shown that the COVID‑19 virus is
preserving efficacy, hospital supplies, and the quality of care. detectable up to 4 h on copper, up to 24 h on cardboard, and
The teams should have prefixed working hours and should not up to 2–3 days on plastic and stainless steel, and up to 3 h in
have any overlapping clinical time with each other. The teams aerosols.[18] It is recommended the use of hydroxychloroquine for
may initially rotate on a weekly cycle i.e. work for 1–2 weeks prophylaxis of COVID‑19 infection by asymptomatic healthcare
and stay in quarantine for 2 weeks. Later as the pandemic workers involved in the care of suspected or confirmed cases
reduces, this may accordingly reduce in duration. A stand by of COVID‑19[19‑22] [Supplementary File 3]. However, the risks of
the team should always be present so that if one team falls sick, hydroxychloroquine such as cardiac arrhythmias, etc., should be
the stand by the team can take over. The desperate measures taken into consideration while using these drugs for susceptible
require remodeling the hospital treatment system. During healthcare workers. Due to the epidemic, there is a risk of supply
this outbreak situation, small and medium neurosurgery shortages of PPE. Hospitals should keep an inventory of all
super‑specialty hospitals are encouraged to collaborate and available PPE and rationalize the use of PPE. All staff should
form teams.[16] Each team should only rotate at one hospital be routinely trained on the correct use of PPE and general
(no cross‑covering) at a given time. Collaborative teamwork hospital gear [Figure 4]. The physician needs to take different
will ensure the efficient and safe management of more patients precautionary measures while working:
at a given time. Tertiary care hospitals are encouraged to (i) While working in emergency and operating room
form a back‑up or alternative team substitutes for any team • Hospitals should ensure the availability of thermal
member who shows signs of illness. In case a particular team screening and/or rapid detection using COVID‑19
is contaminated, the substitute team will fill the gap [Figure 3]. Detection Kits

Figure 4: Suggested management paradigm for patients with COVID-19
• Ensure rapid and safe isolation of patients with also a valid option in hospitals that cannot afford electronic
symptoms of suspected COVID‑19 or other respiratory medical records.
infection (e.g. fever, cough) (iii) While taking routine patients rounds
• Install physical barriers (e.g. glass or plastic windows) • It is strongly recommended to wear head covers, shoe
at reception areas to limit close contact between triage covers, face‑masks (Respirator N95 or FFP2 standard
personnel and potentially infectious patients and FFP3, or equivalent), sterile standard gown, and eye
• It is suggested to wear hair covers, shoe covers, protection goggles or face shield
face‑masks (Respirator N95 or FFP2 standard and • Physicians/healthcare workers should stay in hospital in
FFP3, or equivalent[22]), sterile standard gown, double designated scrubs which may be left behind in the hospital
gloves (avoid rupture and cross infection), long‑sleeved • Hand hygiene is highly recommended after attending to
water‑resistant gown and eye protection (goggles or face each patient
shield, better if disposable). • The distance between each bed should be around 6 feet
(ii) While attending the OPDs for the general ward or the patients should be lodged in
• Ensure thermal screening and/or rapid detection using separate rooms to prevent cross‑infection
COVID‑19 Detection Kits and isolation of suspected cases • Since it may not possible to screen all the patients for
• Physicians should wear hair covers, hospital scrubs, gloves, COVID, all patients suspected of having infection should
face‑masks (Respirator N95 or FFP2 standard and FFP3, be lodged in separate rooms or cubicles. If positive, they
or equivalent), and eye protection (goggles or face shield, should be sent to the exclusive center of the hospital.
better if disposable)
• Hand hygiene is recommended using alcohol‑based hand General lifestyle modifications for physicians and
sanitizer with 60–95% alcohol after attending each patient. surgeons
If the hands are soiled, hands should be washed with soap Along‑with personal safety, the physicians should ensure strict
and water for at least 20 s precautions to avoid passing the infection to their families. The
• A special modification of the OPD infrastructure suggested nosocomial transmission can easily be mitigated with careful
e.g. creating a glass barrier between the patient and doctor vigilance and minor lifestyle modifications:
with separate entries between the patient and doctor
• Avoiding any paper reports or MRI films. It is important to While going to the hospital:
switch over to electronic medical records and visualizing • Always wear full sleeves gown/scrubs. The use of the
MRI and other imaging using a CD or through a hospital traditional white apron should be avoided as it does not
intranet server facility. Image sharing over social media is provide any protection to the physician
• Do not touch anything, assume that everything is Stigma against healthcare workers by the general public:
contaminated unless cleaned in your presence Recently in India, there have been a spate of isolated events,
• C a r r y o n l y o n e p e n , p h o n e , a n d w a t e r b o t t l e where some members of the general public have expressed
(disposable better) stigma against healthcare workers. The government has taken
• The packed food in a disposable bag. Avoid eating in groups prompt and stringent action against such erring members of
or hospital canteen society. However, in the long‑term, adequate education, and
• Avoid wearing watches, rings, bangles, and earrings awareness should be brought out in the general public through
• Hairs should be tied and covered with a head cap media regarding the low risk of contracting an infection from an
• Avoid taking lifts, touching stair railing, or lift buttons HCP, as the HCP themselves take much more precautions and
• Wear footwear that covers the foot fully. Plastic or rubber safety measures to prevent the spread of the disease and even
is easy to disinfect. Always wear shoe covers while providing patient care, adequate protective measures
• Clean your desk, doorknob, computer, workstation are taken by the HCP.
yourself, or in your presence
• Empty your bowel and bladder before you wear your PPE. Medicolegal implications and issuing medical certificates:
In crises, physicians should document their rationale for
In hospital: a particular decision in case of medico‑legal implications.
• Always attend to patients in full gear i.e. full gown, head Physicians should refrain from giving medical rest certificates
cap, mask, shoe cover, and gloves during this pandemic for more than 3–5 days unless deemed
• There has been a lot of debate regarding the availability necessary.
of such gear for everyone. A shortage of gear may be
minimized by ensuring that minimal staff takes rounds Conclusion
• Besides, the local facilities may be optimized to overcome
the gear shortage e.g., the hospital may employ tailors to The COVID pandemic has placed a tremendous burden on
create fabric gear for “non‑COVID” areas, which could be the entire human civilization. Most of us in this generation
washed and autoclaved. are witnessing a pandemic for the first time. It has brought
tremendous changes in the quality of life, challenges to the
While going home economy, stress, sickness, loss of loved ones, and suffering. It
• Call up home when you are starting from the hospital. is putting the entire medical fraternity through testing times.
Someone at home should keep the front door open (so that However, at the same time, it has provided an opportunity
you do not have to touch the calling bell or door handle). for significant learning. It is a great opportunity to promote
Take a head bath with a shampoo and body bath with soap indigenous production of medical devices such as ventilators,
• Decontaminate phone/wallet/car keys etc., using diagnostics (rapid diagnostic COVID kits), vaccines and active
alcohol‑based sanitizers pharmaceutical ingredients. The COVID pandemic will no
• Avoid carrying files/case records, stethoscope, or any other doubt change the world from the manner we perceive it. Once
office item to home the pandemic resolves, we should be ready to adapt to quantum
• Wash your clothes/put in warm water in detergent and changes in global functioning. It would only increase our
dry clothes in direct sunlight resolve to fight for our basic human rights‑ to remain healthy.
• At‑home physical distancing/less interaction with elderly From the neurosurgical and neurological perspective, we need
or premorbid family members explaining them the risk. to implement COVID safe protocols to ensure better safety for
patients and healthcare workers.
Mental Well‑Being of Healthcare Professionals: Often, the
mental health of healthcare professionals is often neglected Disclaimer: The paper is a consensus and does not in any way
as during the pandemic, the foremost goal is to treat patients override the National or State guidelines.
and save human lives. It thus becomes important for the team
leader to stay in touch with his/her team every day. Video Financial support and sponsorship
conferencing has emerged as a very useful modality to stay in Nil.
touch with all the team members. Education and awareness
are important especially for lower‑level healthcare workers, Conflicts of interest
who need to be trained to prevent the spread of infection. It There are no conflicts of interest.
is also equally important that they are made aware of the fact
that if proper precautions are followed, the risk of a healthcare References
worker getting infected is very low. Social media should also be
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Supplementary File 1: Clinical Management of Severe Acute Respiratory Infection (SARI) when COVID-19
Disease is Suspected, Interim Guidance, 13th March 2020, WHO
Clinical management of severe acute respiratory infection

(SARI) when COVID-19 disease is suspected
Interim guidance
13 March 2020
This is the second edition (version 1.2) of this document, which was originally adapted from Clinical management of severe
acute respiratory infection when MERS‑CoV infection is suspected (WHO, 2019).
It is intended for clinicians involved in the care of adult, pregnant, and paediatric patients with or at risk for severe acute
respiratory infection (SARI) when infection with the COVID‑19 virus is suspected. Considerations for paediatric patients and
pregnant women are highlighted throughout the text. It is not meant to replace clinical judgment or specialist consultation but
rather to strengthen clinical management of these patients and to provide up‑to‑date guidance. Best practices for infection
prevention and control (IPC), triage and optimized supportive care are included.
This document is organized into the following sections:
1. Background
2. Screening and triage: early recognition of patients with SARI associated with COVID‑19
3. Immediate implementation of appropriate IPC measures
4. Collection of specimens for laboratory diagnosis
5. Management of mild COVID‑19: symptomatic treatment and monitoring
6. Management of severe COVID‑19: oxygen therapy and monitoring
7. Management of severe COVID‑19: treatment of co‑infections
8. Management of critical COVID‑19: acute respiratory distress syndrome (ARDS)
9. Management of critical illness and COVID‑19: prevention of complications
10. Management of critical illness and COVID‑19: septic shock
11. Adjunctive therapies for COVID‑19: corticosteroids
12. Caring for pregnant women with COVID‑19
13. Caring for infants and mothers with COVID‑19: IPC and breastfeeding
14. Care for older persons with COVID‑19
15. Clinical research and specific anti‑COVID‑19 treatments
Appendix: resources for supporting management of SARI in children
These symbols are used to flag interventions:

Do: the intervention is beneficial (strong recommendation) OR the intervention is a best practice statement.
Don’t: the intervention is known to be harmful.
Consider: the intervention may be beneficial in selected patients (conditional recommendation) OR be careful when
considering this intervention.
This document provides clinicians with updated interim guidance on timely, effective, and safe supportive management of
patients with suspected and confirmed COVID‑19. The definitions of mild and severe illness are in Table 2. Those with critical
illness are defined as patients with acute respiratory distress syndrome (ARDS) or sepsis with acute organ dysfunction.
The recommendations in this document are derived from WHO publications. Where WHO guidance is not available, we refer
to evidence‑based guidelines. Members of a WHO global network of clinicians and clinicians who have treated patients with
SARS, MERS, or severe influenza have reviewed the recommendations (see Acknowledgements). For queries, please email:
outbreak@who.int with “COVID‑19 clinical question” in the subject line.
Background
Coronavirus disease 2019 (COVID‑19) is a respiratory tract infection caused by a newly emergent coronavirus , that was first
recognized in Wuhan, China, in December 2019. Genetic sequencing of the virus suggests that it is a betacoronavirus closely
linked to the SARS virus (1).
While most people with COVID‑19 develop only mild or uncomplicated illness, approximately 14% develop severe disease that
requires hospitalization and oxygen support, and 5% require admission to an intensive care unit (1). In severe cases, COVID‑19
can be complicated by the acute respiratory distress syndrome (ARDS), sepsis and septic shock, multiorgan failure, including
acute kidney injury and cardiac injury (2). Older age and co‑morbid disease have been reported as risk factors for death, and
Clinical management of severe acute respiratory infection (SARI) when COVID-19 disease is suspected: Interim guidance
recent multivariable analysis confirmed older age, higher Sequential Organ Failure Assessment (SOFA) score and d‑dimer > 1
µg/L on admission were associated with higher mortality. This study also observed a median duration of viral RNA detection of
20.0 days (IQR 17.0–24.0) in survivors, but COVID‑19 virus was detectable until death in non‑survivors. The longest observed
duration of viral shedding in survivors was 37 days (3, 4).
Building on evidence‑informed guidelines developed by a multidisciplinary panel of health care providers with experience in the
clinical management of patients with COVID‑19 and other viral infections, including SARS and MERS, as well as sepsis and
ARDS, this guidance should serve as a foundation for optimized supportive care to ensure the best possible chance for survival
and to allow for reliable comparison of investigational therapeutic interventions as part of randomized controlled trials (5, 6).
There are few data on the clinical presentation of COVID‑19 in specific populations, such as children and pregnant women. In
children with COVID‑19 the symptoms are usually less severe than adults and present mainly with cough and fever, and co‑
infection has been observed (7, 8). Relatively few cases have been reported of infants confirmed with COVID‑19; those
experienced mild illness (9). There is currently no known difference between the clinical manifestations of COVID‑19 pregnant
and non‑pregnant women or adults of reproductive age. Pregnant and recently pregnant women with suspected or confirmed
COVID‑19 should be treated with supportive and management therapies, as described below, taking into account the
immunologic and physiologic adaptations during and after pregnancy.
1. Screening and triage: early recognition of patients with SARI associated with COVID-19
Screening and triage: Screen and isolate all patients with suspected COVID-19 at the first point of contact with the
health care system (such as the emergency department or outpatient department/clinic). Consider COVID-19 as a
possible etiology of patients with acute respiratory illness under certain conditions (see Table 1). Triage patients using
standardized triage tools and start first-line treatments.
Remark 1: Although the majority of people with COVID‑19 have uncomplicated or mild illness (81%), some will develop
severe illness requiring oxygen therapy (14%) and approximately 5% will require intensive care unit treatment. Of those
critically ill, most will require mechanical ventilation (2, 10). The most common diagnosis in severe COVID‑19 patients is
severe pneumonia.
Remark 2: Early recognition of suspected patients allows for timely initiation of appropriate IPC measures (see Table 3). Early
identification of those with severe illness, such as severe pneumonia (see Table 2), allows for optimized supportive care
treatments and safe, rapid referral and admission to a designated hospital ward or intensive care unit according to institutional or
national protocols.
Remark 3: Older patients and those with comorbidities, such as cardiovascular disease and diabetes mellitus, have increased risk
of severe disease and mortality. They may present with mild symptoms but have high risk of deterioration and should be
admitted to a designated unit for close monitoring.
Remark 4: For those with mild illness, hospitalization may not be required unless there is concern about rapid deterioration or an
inability to promptly return to hospital, but isolation to contain/mitigate virus transmission should be prioritized. All patients
cared for outside hospital (i.e. at home or non‑traditional settings) should be instructed to manage themselves appropriately
according to local/regional public health protocols for home isolation and return to a designated COVID‑19 hospital if they get
worse (https://www.who.int/publications‑detail/home‑care‑for‑patients‑with‑suspected‑novel‑coronavirus‑(ncov)‑infection‑
presenting‑with‑mild‑symptoms‑and‑management‑of‑contacts).
Table 1. Definitions of SARI and surveillance case definitions for COVID-19*

Suspect case
Surveillance
case See latest WHO case definitions for suspect case of COVID-19*
definitions
for COVID-
19*
Confirmed case
A person with laboratory confirmation of COVID-19 infection, irrespective of clinical signs and symptoms.
* See Global Surveillance for human infection with coronavirus disease (COVID-19) for latest case definitions.
2
Table 2. Clinical syndromes associated with COVID-19

Patients uncomplicated upper respiratory tract viral infection may have non-specific symptoms such as fever,
Mild illness fatigue, cough (with or without sputum production), anorexia, malaise, muscle pain, sore throat, dyspnea,
nasal congestion, or headache. Rarely, patients may also present with diarrhoea, nausea, and vomiting
(3, 11-13).
The elderly and immunosuppressed may present with atypical symptoms. Symptoms due to physiologic adaptations of
pregnancy or adverse pregnancy events, such as dyspnea, fever, GI-symptoms or fatigue, may overlap with COVID-
19 symptoms.
Adult with pneumonia but no signs of severe pneumonia and no need for supplemental oxygen.
Pneumonia
Child with non-severe pneumonia who has cough or difficulty breathing + fast breathing: fast breathing (in
breaths/min):
< 2 months: ≥ 60; 2–11 months: ≥ 50; 1–5 years: ≥ 40, and no signs of severe pneumonia.
Adolescent or adult: fever or suspected respiratory infection, plus one of the following: respiratory rate > 30
Severe
breaths/min; severe respiratory distress; or SpO2 ≤ 93% on room air (adapted from 14).
pneumonia
Child with cough or difficulty in breathing, plus at least one of the following: central cyanosis or SpO2 < 90%; severe
respiratory distress (e.g. grunting, very severe chest indrawing); signs of pneumonia with a general danger sign:
inability to breastfeed or drink, lethargy or unconsciousness, or convulsions (15). Other signs of pneumonia may be
present: chest indrawing, fast breathing (in breaths/min): < 2 months: ≥ 60; 2–11 months: ≥ 50; 1–5 years: ≥ 40 (16).
While the diagnosis is made on clinical grounds; chest imaging may identify or exclude some pulmonary
complications.
Acute Onset: within 1 week of a known clinical insult or new or worsening respiratory symptoms.
respiratory Chest imaging (radiograph, CT scan, or lung ultrasound): bilateral opacities, not fully explained by volume
distress overload, lobar or lung collapse, or nodules.
syndrome Origin of pulmonary infiltrates: respiratory failure not fully explained by cardiac failure or fluid overload. Need
(ARDS) (17- objective assessment (e.g. echocardiography) to exclude hydrostatic cause of infiltrates/oedema if no risk
19) factor present.
Oxygenation impairment in adults (17, 19):
• Mild ARDS: 200 mmHg < PaO2/FiO2a ≤ 300 mmHg (with PEEP or CPAP ≥ 5 cmH2O, or non-ventilated)
• Moderate ARDS: 100 mmHg < PaO2/FiO2 ≤ 200 mmHg (with PEEP ≥ 5 cmH2O, or non-ventilated)
• Severe ARDS: PaO2/FiO2 ≤ 100 mmHg (with PEEP ≥ 5 cmH2O, or non-ventilated)
• When PaO2 is not available, SpO2/FiO2 ≤ 315 suggests ARDS (including in non-ventilated patients).
Oxygenation impairment in children: note OI = Oxygenation Index and OSI = Oxygenation Index using SpO2.
Use PaO2-based metric when available. If PaO2 not available, wean FiO2 to maintain SpO2 ≤ 97% to
calculate OSI or SpO2/FiO2 ratio:
• Bilevel (NIV or CPAP) ≥ 5 cmH2O via full face mask: PaO2/FiO2 ≤ 300 mmHg or SpO2/FiO2 ≤ 264
• Mild ARDS (invasively ventilated): 4 ≤ OI < 8 or 5 ≤ OSI < 7.5
• Moderate ARDS (invasively ventilated): 8 ≤ OI < 16 or 7.5 ≤ OSI < 12.3
Severe ARDS (invasively ventilated): OI ≥ 16 or OSI ≥ 12.3.
Sepsis (5, 6) Adults: life-threatening organ dysfunction caused by a dysregulated host response to suspected or proven infection.b
Signs of organ dysfunction include: altered mental status, difficult or fast breathing, low oxygen saturation,
reduced urine output (5, 20), fast heart rate, weak pulse, cold extremities or low blood pressure, skin
mottling, or laboratory evidence of coagulopathy, thrombocytopenia, acidosis, high lactate, or
hyperbilirubinemia.
Children: suspected or proven infection and ≥ 2 age- based systemic inflammatory response syndrome criteria, of
which one must be abnormal temperature or white blood cell count.
Septic shock Adults: persisting hypotension despite volume resuscitation, requiring vasopressors to maintain MAP MAP ≥ 65
(5, 6) mmHg and serum lactate level > 2 mmol/L.
Children: any hypotension (SBP < 5th centile or > 2 SD below normal for age) or two or three of the following: altered
mental state; tachycardia or bradycardia (HR < 90 bpm or > 160 bpm in infants and HR < 70 bpm or > 150 bpm in
children); prolonged capillary refill (> 2 sec) or feeble pulse; tachypnoea; mottled or cool skin or petechial or purpuric
rash; increased lactate; oliguria; hyperthermia or hypothermia (21).
a Ifaltitude is higher than 1000 m, then correction factor should be calculated as follows: PaO2/FiO2 x barometric pressure/760.
b The SOFA score ranges from 0 to 24 and includes points related to six organ systems: respiratory (hypoxemia defined by low PaO2/FiO2); coagulation (low platelets); liver (high
bilirubin); cardiovascular (hypotension); central nervous system (low level of consciousness defined by Glasgow Coma Scale); and renal (low urine output or high creatinine).
Sepsis is defined by an increase in the sepsis-related SOFA score of ≥ 2 points. Assume the baseline score is 0 if data are not available (22).
Abbreviations: ARI acute respiratory infection; BP blood pressure; bpm beats/minute; CPAP continuous positive airway pressure; FiO2 fraction of inspired oxygen; MAP mean
arterial pressure; NIV non-invasive ventilation; OI Oxygenation Index; OSI Oxygenation Index using SpO2; PaO2 partial pressure of oxygen; PEEP positive end-expiratory
pressure; SBP systolic blood pressure; SD standard deviation; SIRS systemic inflammatory response syndrome; SOFA sequential organ failure assessment; SpO2 oxygen
saturation.
3
2. Immediate implementation of appropriate IPC measures

IPC is a critical and integral part of clinical management of patients and WHO guidance is available
(https://www.who.int/emergencies/diseases/novel‑coronavirus‑2019/technical‑guidance/infection‑prevention‑and‑control).
Initiate IPC at the point of entry of the patient to hospital. Screening should be done at first point of contact at the
emergency department or outpatient department/clinics. Suspected COVID-19 patients should be given a mask and
directed to separate area. Keep at least 1 m distance between suspected patients.
Standard precautions should always be applied in all areas of health care facilities. Standard precautions include
hand hygiene and the use of personal protective equipment (PPE) when in indirect and direct contact with patients’
blood, body fluids, secretions (including respiratory secretions) and non-intact skin. Standard precautions also include
prevention of needle-stick or sharps injury; safe waste management; cleaning and disinfection of equipment; and
cleaning of the environment.
In addition to standard precautions, health care workers should do a point-of-care risk assessment at every patient
contact to determine whether additional precautions (e.g. droplet, contact, or airborne) are required.
Table 3. How to implement IPC measures for patients with suspected or confirmed COVID-19
Instructions for patients
Give suspect patient a medical mask and direct patient to separate area; --aan isolation room if available. Keep at least 1 m distance between suspected
patients and other patients. Instruct all patients to cover nose and mouth during coughing or sneezing with tissue or flexed elbow and perform hand
hygiene after contact with respiratory secretions.
Apply droplet precautions
Droplet precautions prevent large droplet transmission of respiratory viruses. Use a medical mask if working within 1 m of the patient. Place patients in
single rooms, or group together those with the same etiological diagnosis. If an etiological diagnosis is not possible, group patients with similar clinical
diagnosis and based on epidemiological risk factors, with a spatial separation. When providing care in close contact with a patient with respiratory
symptoms (e.g. coughing or sneezing), use eye protection (face mask or goggles), because sprays of secretions may occur. Limit patient movement within
the institution and ensure that patients wear medical masks when outside their rooms.
Apply contact precautions Contact precautions prevent direct or indirect transmission from contact with contaminated surfaces or equipment (i.e.
contact with contaminated oxygen tubing/interfaces). Use PPE (medical mask, eye protection, gloves and gown) when entering room and remove PPE
when leaving and practise hand hygiene after PPE removal. If possible, use either disposable or dedicated equipment (e.g. stethoscopes, blood pressure
cuffs, pulse oximeters, and thermometers). If equipment needs to be shared among patients, clean and disinfect between each patient use. Ensure that
health care workers refrain from touching their eyes, nose, and mouth with potentially contaminated gloved or ungloved hands. Avoid contaminating
environmental surfaces that are not directly related to patient care (e.g. door handles and light switches). Avoid medically unnecessary movement of
patients or transport. Perform hand hygiene.
Apply airborne precautions when performing an aerosol-generating procedure
Ensure that health care workers performing aerosol-generating procedures (e.g. open suctioning of respiratory tract, intubation, bronchoscopy,
cardiopulmonary resuscitation) use the appropriate PPE, including gloves, long-sleeved gowns, eye protection, and fit-tested particulate respirators (N95 or
equivalent, or higher level of protection). A scheduled fit test should not be confused with a user’s’ seal check before each use. Whenever possible, use
adequately ventilated single rooms when performing aerosol-generating procedures, meaning negative pressure rooms with a minimum of 12 air changes
per hour or at least 160 L/second/patient in facilities with natural ventilation. Avoid the presence of unnecessary persons individuals in the room. Care for
the patient in the same type of room after mechanical ventilation begins. commences.
Abbreviations: ARI acute respiratory infection; PPE personal protective equipment.
3. Collection of specimens for laboratory diagnosis

WHO guidance on specimen collection, processing and laboratory testing is available (https://www.who.int/publications‑
detail/laboratory‑testing‑for‑2019‑novel‑coronavirus‑in‑suspected‑human‑cases‑20200117). Additionally, guidance on related
biosafety procedures is available (https://apps.who.int/iris/bitstream/handle/10665/331138/WHO‑WPE‑GIH‑2020.1‑eng.pdf).
Collect blood cultures for bacteria that cause pneumonia and sepsis, ideally before antimicrobial therapy. DO NOT
delay antimicrobial therapy to collect blood cultures.
Collect specimens from the upper respiratory tract (URT; nasopharyngeal and oropharyngeal) AND, where clinical
suspicion remains and URT specimens are negative, collect specimens from the lower respiratory tract when readily
available (LRT; expectorated sputum, endotracheal aspirate, or bronchoalveolar lavage in ventilated patient) for COVID-
19 virus testing by RT-PCR and bacterial stains/cultures.
In hospitalized patients with confirmed COVID-19, repeated URT and LRT samples can be collected to demonstrate
viral clearance. The frequency of specimen collection will depend on local epidemic characteristics and resources. For
hospital discharge, in a clinically recovered patient, two negative tests, at least 24 hours apart, is recommended.
Remark 1: Use appropriate PPE for specimen collection (droplet and contact precautions for URT specimens; airborne
precautions for LRT specimens). When collecting URT samples, use viral swabs (sterile Dacron or rayon, not cotton) and viral
4
transport media. Do not sample the nostrils or tonsils. In a patient with suspected COVID‑19, especially with pneumonia or
severe illness, a single URT sample does not exclude the diagnosis, and additional URT and LRT samples are recommended.
LRT (vs URT) samples are more likely to be positive and for a longer period (23). Clinicians may elect to collect only LRT
samples when these are readily available (for example, in mechanically ventilated patients). Sputum induction should be avoided
owing to increased risk of aerosol transmission.
Remark 2 for pregnant patients: COVID‑19 testing of symptomatic pregnant women may need to be prioritized to enable
access to specialized care.
Remark 3: Dual infections with other respiratory viral and bacterial infections have been found in SARS, MERS and COVID‑19
patients (8). As a result, a positive test for a non‑COVID‑19 pathogen does not rule out COVID‑19. At this stage, detailed
microbiologic studies are needed in all suspected cases. Both URT and LRT specimens can be tested for other respiratory
viruses, such as influenza A and B (including zoonotic influenza A), respiratory syncytial virus, parainfluenza viruses,
rhinoviruses, adenoviruses, enteroviruses (e.g. EVD68), human metapneumovirus and endemic human coronaviruses (i.e.
HKU1, OC43, NL63, and 229E). LRT specimens can also be tested for bacterial pathogens, including Legionella pneumophila.
In malaria‑endemic areas, patients with fever should be tested for the presence of malaria or other co‑infections with validated
rapid diagnostic tests (RDTs) or thick and thin blood films and treated as appropriate. In endemic settings arbovirus infection
(dengue/chikungunya) should also be considered in the differential diagnosis of undifferentiated febrile illness, particularly when
thrombocytopenia is present. Co‑infection with COVID‑19 virus may also occur and a positive diagnostic test for dengue (e.g.
dengue RDTs) does not exclude the testing for COVID‑19 (24).
4. Management of mild COVID-19: symptomatic treatment and monitoring

Patients with mild disease do not require hospital interventions, but isolation is necessary to contain virus
transmission and will depend on national strategy and resources.
Remark: Although most patients with mild disease may not have indications for hospitalization, it is necessary to implement
appropriate IPC to contain and mitigate transmission. This can be done either in hospital, if there are only sporadic cases or small
clusters, or in repurposed, non‑traditional settings; or at home.
Provide patients with mild COVID-19 with symptomatic treatment such as antipyretics for fever.
Counsel patients with mild COVID-19 about signs and symptoms of complicated disease. If they develop any of these
symptoms, they should seek urgent care through national referral systems.
5. Management of severe COVID-19: oxygen therapy and monitoring

Give supplemental oxygen therapy immediately to patients with SARI and respiratory distress, hypoxaemia or shock
and target SpO2 > 94%.
Remarks for adults: Adults with emergency signs (obstructed or absent breathing, severe respiratory distress, central cyanosis,
shock, coma, or convulsions) should receive airway management and oxygen therapy during resuscitation to target SpO 2 ≥ 94%.
Initiate oxygen therapy at 5 L/min and titrate flow rates to reach target SpO2 ≥ 93% during resuscitation; or use face mask with
reservoir bag (at 10–15 L/min) if patient in critical condition. Once patient is stable, the target is > 90% SpO2 in non‑pregnant
adults and ≥ 92–95% in pregnant patients (16, 25).
Remarks for children: Children with emergency signs (obstructed or absent breathing, severe respiratory distress, central
cyanosis, shock, coma or convulsions) should receive airway management and oxygen therapy during resuscitation to target
SpO2 ≥ 94%; otherwise, the target SpO2 is ≥ 90% (25). Use of nasal prongs or nasal cannula is preferred in young children, as
they may be better tolerated.
Remark 3: All areas where patients with SARI are cared for should be equipped with pulse oximeters, functioning oxygen
systems and disposable, single‑use, oxygen‑delivering interfaces (nasal cannula, nasal prongs, simple face mask, and mask with
reservoir bag). See Appendix for details of resources.
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.
Remark 1: Patients hospitalized with COVID‑19 require regular monitoring of vital signs and, where possible, utilization of
medical early warning scores (e.g. NEWS2) that facilitate early recognition and escalation of treatment of the deteriorating
patient (26).
Remark 2: Haematology and biochemistry laboratory testing and ECG should be performed at admission and as clinically
indicated to monitor for complications, such as acute liver injury, acute kidney injury, acute cardiac injury, or shock. Application
5
of timely, effective, and safe supportive therapies is the cornerstone of therapy for patients who develop severe manifestations of
COVID‑19.
Remarks 3: After resuscitation and stabilization of the pregnant patient, then fetal well‑being should be monitored.
Understand the patient’s co-morbid condition(s) to tailor the management of critical illness.
Remark 1: Determine which chronic therapies should be continued and which therapies should be stopped temporarily. Monitor
for drug‑drug interactions.
Use conservative fluid management in patients with SARI when there is no evidence of shock.
Remarks: Patients with SARI should be treated cautiously with intravenous fluids, because aggressive fluid resuscitation may
worsen oxygenation, especially in settings where there is limited availability of mechanical ventilation (27). This applies for care
of children and adults.
6. Management of severe COVID-19: treatment of co-infections

Give empiric antimicrobials to treat all likely pathogens causing SARI and sepsis as soon as possible, within 1 hour
of initial assessment for patients with sepsis.
Remark 1: Although the patient may be suspected to have COVID‑19, administer appropriate empiric antimicrobials within 1
hour of identification of sepsis (5). Empiric antibiotic treatment should be based on the clinical diagnosis (community‑acquired
pneumonia, health care‑associated pneumonia [if infection was acquired in health care setting] or sepsis), local epidemiology and
susceptibility data, and national treatment guidelines.
Remark 2: When there is ongoing local circulation of seasonal influenza, empiric therapy with a neuraminidase inhibitor should
be considered for the treatment for patients with influenza or at risk for severe disease (5).
Empiric therapy should be de-escalated on the basis of microbiology results and clinical judgment.
7. Management of critical COVID-19: acute respiratory distress syndrome (ARDS)

Recognize severe hypoxemic respiratory failure when a patient with respiratory distress is failing to respond to
standard oxygen therapy and prepare to provide advanced oxygen/ventilatory support.
Remarks: Patients may continue to have increased work of breathing or hypoxemia even when oxygen is delivered via a face
mask with reservoir bag (flow rates of 10–15 L/min, which is typically the minimum flow required to maintain bag inflation;
FiO2 0.60–0.95). Hypoxemic respiratory failure in ARDS commonly results from intrapulmonary ventilation‑perfusion mismatch
or shunt and usually requires mechanical ventilation (5).
Endotracheal intubation should be performed by a trained and experienced provider using airborne precautions.
Remarks: Patients with ARDS, especially young children or those who are obese or pregnant, may desaturate quickly during
intubation. Pre‑oxygenate with 100% FiO2 for 5 minutes, via a face mask with reservoir bag, bag‑valve mask, HFNO or NIV.
Rapid‑sequence intubation is appropriate after an airway assessment that identifies no signs of difficult intubation (28, 29,.30).
The following recommendations pertain to mechanically ventilated adults and paediatric patients with ARDS (5, 31).
Implement mechanical ventilation using lower tidal volumes (4–8 mL/kg predicted body weight, PBW) and lower
inspiratory pressures (plateau pressure < 30 cmH2O).
Remarks for adults: This is a strong recommendation from a clinical guideline for patients with ARDS (5), and is suggested for
patients with sepsis‑induced respiratory failure who do not meet ARDS criteria (5). The initial tidal volume is 6 mL/kg PBW;
tidal volume up to 8 mL/kg PBW is allowed if undesirable side effects occur (e.g. dyssynchrony, pH < 7.15). Permissive
hypercapnia is permitted. Ventilator protocols are available (32). The use of deep sedation may be required to control respiratory
drive and achieve tidal volume targets.
Remarks for children: In children, a lower level of plateau pressure (< 28 cmH2O) is targeted, and lower target of pH is
permitted (7.15–7.30). Tidal volumes should be adapted to disease severity: 3–6 mL/kg PBW in the case of poor respiratory
system compliance, and 5–8 mL/kg PBW with better preserved compliance (31).
In adult patients with severe ARDS, prone ventilation for 12–16 hours per day is recommended.
Remarks for adults and children: Application of prone ventilation is strongly recommended for adult patients, and may be
6
considered for paediatric patients with severe ARDS but requires sufficient human resources and expertise to be performed
safely; protocols (including videos) are available (33, 34) (https://www.nejm.org/doi/full/10.1056/NEJMoa1214103).
Remark for pregnant women: There is little evidence on prone positioning in pregnant women. Pregnant women may benefit
from being placed in the lateral decubitus position.
Use a conservative fluid management strategy for ARDS patients without tissue hypoperfusion.
Remarks for adults and children: This is a strong guideline recommendation (5); the main effect is to shorten the duration of
ventilation. See reference (35) for details of a sample protocol.
In patients with moderate or severe ARDS, higher PEEP instead of lower PEEP is suggested.
Remark 1: PEEP titration requires consideration of benefits (reducing atelectrauma and improving alveolar recruitment) vs risks
(end‑inspiratory overdistension leading to lung injury and higher pulmonary vascular resistance). Tables are available to guide
PEEP titration based on the FiO2 required to maintain SpO2 (32). In younger children, maximal PEEP rates are 15 cmH 2O.
Although high driving pressure (plateau pressure − PEEP) may more accurately predict increased mortality in ARDS compared
with high tidal volume or plateau pressure (36), data from RCTs of ventilation strategies that target driving pressure are not
currently available.
Remark 2: A related intervention of recruitment manoeuvres (RMs) is delivered as episodic periods of high continuous positive
airway pressure (CPAP) (30–40 cmH2O), progressive incremental increases in PEEP with constant driving pressure, or high
driving pressure; considerations of benefits vs risks are similar. Higher PEEP and RMs were both conditionally recommended in
a clinical practice guideline. For PEEP, the guideline considered an individual patient data meta‑analysis (37) of three RCTs.
However, a subsequent RCT of high PEEP and prolonged high‑pressure RMs showed harm, suggesting that the protocol in this
RCT should be avoided (38). Monitoring of patients to identify those who respond to the initial application of higher PEEP or a
different RM protocol and stopping these interventions in non‑responders are suggested (39).
In patients with moderate-severe ARDS (PaO2/FiO2 < 150), neuromuscular blockade by continuous infusion should
not be routinely used.
Remark: A trial found that this strategy improved survival in adult patients with severe ARDS (PaO2/FiO2 < 150) without
causing significant weakness (40), but results of a recent larger trial found that use of neuromuscular blockade with high PEEP
strategy was not associated with a survival benefit when compared with a light sedation strategy without neuromuscular blockade
(41). Continuous neuromuscular blockade may still be considered in patients with ARDS, both adults and children, in certain
situations: ventilator dyssnchrony despite sedation, such that tidal volume limitation cannot be reliably achieved; or refractory
hypoxemia or hypercapnia.
Avoid disconnecting the patient from the ventilator, which results in loss of PEEP and atelectasis.
Use in-line catheters for airway suctioning and clamp endotracheal tube when disconnection is required (for
example, transfer to a transport ventilator).
The following recommendations pertain to adult and paediatric patients with ARDS who are treated with non-invasive or
high-flow oxygen systems.
High-flow nasal oxygen (HFNO) should be used only in selected patients with hypoxemic respiratory failure.
Non-invasive ventilation (NIV) should be used only in selected patients with hypoxemic respiratory failure.
Patients treated with either HFNO or NIV should be closely monitored for clinical deterioration.
Remark 1: Adult HFNO systems can deliver 60 L/min of gas flow and FiO2 up to 1.0. Paediatric circuits generally only handle
up to 25 L/min, and many children will require an adult circuit to deliver adequate flow.
Remark 2: Because of uncertainty around the potential for aerosolization, HFO, NIV, including bubble CPAP, should be used
with airborne precautions until further evaluation of safety can be completed.
Remark 3: Compared with standard oxygen therapy, HFNO reduces the need for intubation (42). Patients with hypercapnia
(exacerbation of obstructive lung disease, cardiogenic pulmonary oedema), hemodynamic instability, multiorgan failure, or
abnormal mental status should generally not receive HFNO, although emerging data suggest that HFNO may be safe in patients
with mild‑moderate and non‑worsening hypercapnia (42, 43, 44). Patients receiving HFNO should be in a monitored setting and
cared for by experienced personnel capable of performing endotracheal intubation in case the patient acutely deteriorates or does
not improve after a short trial (about 1 hour). Evidence‑based guidelines on HFNO do not exist, and reports on HFNO in patients
infected with other coronaviruses are limited (44).
7
Remark 4: NIV guidelines make no recommendation on use in hypoxemic respiratory failure (apart from cardiogenic
pulmonary oedema and postoperative respiratory failure) or pandemic viral illness (referring to studies of SARS and pandemic
influenza) (5). Risks include delayed intubation, large tidal volumes, and injurious transpulmonary pressures. Limited data
suggest a high failure rate in patients with other viral infections such as MERS‑CoV who receive NIV (45).
Remark 5: Patients receiving a trial of NIV should be in a monitored setting and cared for by experienced personnel capable of
performing endotracheal intubation in case the patient acutely deteriorates or does not improve after a short trial (about 1 hour).
Patients with haemodynamic instability, multiorgan failure, or abnormal mental status should likely not receive NIV in place of
other options such as invasive ventilation.
Remark 6: In situations where mechanical ventilation might not be available, bubble nasal CPAP may be used for newborns and
children with severe hypoxemia, and may be a more readily available alternative in resource‑limited settings (46).
The following recommendations pertain to adult and paediatric patients with ARDS in whom lung protective ventilation
strategy fails.
In settings with access to expertise in extracorporeal membrane oxygenation (ECMO), consider referral of patients who have
refractory hypoxemia despite lung protective ventilation.
Remarks for adult and children: An RCT of ECMO for adult patients with ARDS was stopped early and found no statistically
significant difference in the primary outcome of 60‑day mortality between ECMO and standard medical management (including
prone positioning and neuromuscular blockade) (47). However, ECMO was associated with a reduced risk of the composite
outcome of mortality and crossover to ECMO (47), and a post hoc Bayesian analysis of this RCT showed that ECMO is very
likely to reduce mortality across a range of prior assumptions (48). In patients with MERS, ECMO vs conventional treatment was
associated with reduced mortality in a cohort study (49). ECMO should be offered only in expert centres with a sufficient case
volume to maintain expertise and that can apply the IPC measures required for adult and paediatric COVID‑19 patients (50, 51).
8. Management of critical illness and COVID-19: prevention of complications

Implement the following interventions (Table 4) to prevent complications associated with critical illness. These interventions are
based on Surviving Sepsis (5) or other guidelines (52-55), and are generally limited to feasible recommendations based on high‑
quality evidence.
Table 4. Prevention of complications
Anticipated Interventions
outcome
Reduce days of • Use weaning protocols that include daily assessment for readiness to breathe spontaneously
invasive
• Minimize continuous or intermittent sedation, targeting specific titration endpoints (light sedation unless
mechanical contraindicated) or with daily interruption of continuous sedative infusions
ventilation
Reduce incidence • Oral intubation is preferable to nasal intubation in adolescents and adults
of ventilator- • Keep patient in semi-recumbent position (head of bed elevation 30–45º)
associated
• Use a closed suctioning system; periodically drain and discard condensate in tubing
pneumonia
• Use a new ventilator circuit for each patient; once patient is ventilated, change circuit if it is soiled or
damaged, but not routinely
• Change heat moisture exchanger when it malfunctions, when soiled, or every 5–7 days
Reduce incidence • Use pharmacological prophylaxis (low molecular-weight heparin [preferred if available] or heparin 5000
of venous units subcutaneously twice daily) in adolescents and adults without contraindications. For those with
thromboembolism contraindications, use mechanical prophylaxis (intermittent pneumatic compression devices)
Reduce incidence • Use a checklist with completion verified by a real-time observer as reminder of each step needed for
of catheter-related sterile insertion and as a daily reminder to remove catheter if no longer needed
bloodstream
infection
Reduce incidence • Turn patient every 2 hours
of pressure ulcers
Reduce incidence • Give early enteral nutrition (within 24–48 hours of admission)
of stress ulcers • Administer histamine-2 receptor blockers or proton-pump inhibitors in patients with risk factors for GI
and bleeding. Risk factors for GI bleeding include mechanical ventilation for ≥ 48 hours, coagulopathy, renal
gastrointestinal replacement therapy, liver disease, multiple comorbidities, and higher organ failure score
(GI) bleeding
Reduce incidence • Actively mobilize the patient early in the course of illness when safe to do so
of ICU-related
weakness
8
9. Management of critical illness and COVID-19: 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: altered mental state; bradycardia or tachycardia (HR < 90 bpm or >
160 bpm in infants and HR < 70 bpm or > 150 bpm in children); prolonged capillary refill (> 2 sec) or feeble pulses;
tachypnea; mottled or cold skin or petechial or purpuric rash; increased lactate; oliguria; hyperthermia or hypothermia.
Remark 1: In the absence of a lactate measurement, use blood pressure (i.e. MAP) and clinical signs of perfusion to define
shock.
Remark 2: Standard care includes early recognition and the following treatments within 1 hour of recognition: antimicrobial
therapy, and initiation of fluid bolus and vasopressors for hypotension (5). The use of central venous and arterial catheters should
be based on resource availability and individual patient needs. Detailed guidelines from the Surviving Sepsis Campaign and
WHO are available for the management of septic shock in adults (5) and children (6, 16). Alternate fluid regimens are suggested
when caring for adults and children in resource‑limited settings (56, 57).
The following recommendations pertain to resuscitation strategies for adult and paediatric patients with septic shock.
In resuscitation for septic shock in adults, give 250–500 mL crystalloid fluid as rapid bolus in first 15–30 minutes
and reassess for signs of fluid overload after each bolus.
In resuscitation from septic shock in children, give 10–20 mL/kg crystalloid fluid as a bolus in the first 30–60
minutes and reassess for signs of fluid after each bolus.
Fluid resuscitation may lead to volume overload, including respiratory failure, particularly with ARDS. If there is no
response to fluid loading or signs of volume overload appear (e.g. jugular venous distension, crackles on lung
auscultation, pulmonary oedema on imaging, or hepatomegaly in children), then reduce or discontinue fluid
administration. This step is particularly important in patients with hypoxemic respiratory failure.
Remark 1: Crystalloids include normal saline and Ringer’s lactate.
Remark 2: Determine need for additional fluid boluses (250–500 mL in adults or 10–20 mL/kg in children) based on clinical
response and improvement of perfusion targets. Perfusion targets include MAP (> 65 mmHg or age‑appropriate targets in
children), urine output (> 0.5 mL/kg/hr in adults, 1 mL/kg/hr in children), and improvement of skin mottling and extremity
perfusion, capillary refill, heart rate, level of consciousness, and lactate.
Remark 3: Consider dynamic indices of volume responsiveness to guide volume administration beyond initial resuscitation
based on local resources and experience (5). These indices include passive leg raises, fluid challenges with serial stroke volume
measurements, or variations in systolic pressure, pulse pressure, inferior vena cava size, or stroke volume in response to changes
in intrathoracic pressure during mechanical ventilation.
Remark 4: In pregnant women, compression of the inferior vena cava can cause a decrease in venous return and cardiac preload
and may result in hypotension. For this reason, pregnant women with sepsis and or septic shock may need to be placed in the
lateral decubitus position to off‑load the inferior vena cava (58).
Remark 5: Clinical trials conducted in resource‑limited studies comparing aggressive versus conservative fluid regimens
suggest higher mortality in patients treated with aggressive fluid regimens (56, 57).
Do not use hypotonic crystalloids, starches, or gelatins for resuscitation.
Remark 1: Starches are associated with an increased risk of death and acute kidney injury compared with crystalloids. The
effects of gelatins are less clear, but they are more expensive than crystalloids (5, 59). Hypotonic (vs isotonic) solutions are less
effective at increasing intravascular volume. Surviving Sepsis also suggests albumin for resuscitation when patients require
substantial amounts of crystalloids, but this conditional recommendation is based on low‑quality evidence (5).
In adults, administer vasopressors when shock persists during or after fluid resuscitation. The initial blood
pressure target is MAP ≥ 65 mmHg in adults and improvement of markers of perfusion.
In children administer vasopressors if:

1. Signs of shock such as altered mental state; bradycardia or tachycardia (HR < 90 bpm or > 160 bpm in infants and
H R < 70 bpm or > 150 bpm in children); prolonged capillary refill (> 2 seconds) or feeble pulses; tachypnea; mottled
or cool skin or petechial or purpuric rash; increased lactate; oliguria persists after two repeat boluses; or
2. age-appropriate blood pressure targets are not achieved; or
3. signs of fluid overload are apparent (6).
9
If central venous catheters are not available, vasopressors can be given through a peripheral IV, but use a large vein
and closely monitor for signs of extravasation and local tissue necrosis. If extravasation occurs, stop infusion.
Vasopressors can also be administered through intraosseous needles.
If signs of poor perfusion and cardiac dysfunction persist despite achieving MAP target with fluids and vasopressors,
consider an inotrope such as dobutamine.
Remark 1: Vasopressors (i.e. norepinephrine, epinephrine, vasopressin, and dopamine) are most safely given through a central
venous catheter at a strictly controlled rate, but it is also possible to safely administer them via peripheral vein (60) and
intraosseous needle. Monitor blood pressure frequently and titrate the vasopressor to the minimum dose necessary to maintain
perfusion and prevent side effects. A recent study suggests that in adults 65 years or older a MAP 60–65 mmHg target is
equivalent to ≥ 65 mmHg (61).
Remark 2: Norepinephrine is considered first‑line treatment in adult patients; epinephrine or vasopressin can be added to
achieve the MAP target. Because of the risk of tachyarrhythmia, reserve dopamine for selected patients with low risk of
tachyarrhythmia or those with bradycardia.
Remark 3: In children, epinephrine is considered first‑line treatment, while norepinephrine can be added if shock persists
despite optimal dose of epinephrine.
Remark 4: No RCTs have compared dobutamine with placebo for clinical outcomes.
Remark 5: See section 11 on adjunctive therapies for remarks on corticosteroids and sepsis.
10. Adjunctive therapies for COVID-19: corticosteroids

Do not routinely give systemic corticosteroids for treatment of viral pneumonia outside clinical trials.
Remark 1: A systematic review of observational studies of corticosteroids administered to patients with SARS reported no
survival benefit and possible harms (avascular necrosis, psychosis, diabetes, and delayed viral clearance) (62). A systematic
review of observational studies in influenza found a higher risk of mortality and secondary infections with corticosteroids; the
evidence was judged as very low to low quality owing to confounding by indication (63). A subsequent study that addressed this
limitation by adjusting for time‑varying confounders found no effect on mortality (64). Finally, a recent study of patients
receiving corticosteroids for MERS used a similar statistical approach and found no effect of corticosteroids on mortality but
delayed LRT clearance of MERS‑CoV (65). Given the lack of effectiveness and possible harm, routine corticosteroids should be
avoided unless they are indicated for another reason. Other reasons may include exacerbation of asthma or COPD, septic shock,
and risk/benefit analysis needs to be conducted for individual patients.
Remark 2: A recent guideline issued by an international panel and based on the findings of two recent large RCTs makes a
conditional recommendation for corticosteroids for all patients with sepsis (including septic shock) (66). Surviving Sepsis
guidelines, written before these RCTs were reported, recommend corticosteroids only for patients in whom adequate fluids and
vasopressor therapy do not restore hemodynamic stability (5). Clinicians considering corticosteroids for a patient with COVID‑
19 and sepsis must balance the potential small reduction in mortality with the potential downside of prolonged shedding of
coronavirus in the respiratory tract, as has been observed in patients with MERS (65). If corticosteroids are prescribed, monitor
and treat hyperglycaemia, hypernatraemia, and hypokalaemia. Monitor for recurrence of inflammation and signs of adrenal
insufficiency after stopping corticosteroids, which may have to be tapered. Because of the risk of strongyloides stercoralis
hyper‑infection with steroid therapy, diagnosis or empiric treatment should be considered in endemic areas if steroids are used
(67).
Remark 2 for pregnant women: WHO recommends antenatal corticosteroid therapy for women at risk of preterm birth from 24
to 34 weeks of gestation when there is no clinical evidence of maternal infection, and adequate childbirth and newborn care is
available. However, in cases where the woman presents with mild COVID‑19, the clinical benefits of aantenatal corticosteroid
might outweigh the risks of potential harm to the mother. In this situation, the balance of benefits and harms for the woman and
the preterm newborn should be discussed with the woman to ensure an informed decision, as this assessment may vary
depending on the woman’s clinical condition, her wishes and that of her family, and available health care resources
(https://www.who.int/reproductivehealth/publications/maternal_perinatal_health/preterm‑birth‑highlights/en/).
Remark 3: WHO has prioritized the evaluation of corticosteroids in clinical trials to assess safety and efficacy
(https://www.who.int/blueprint/priority‑diseases/key‑
action/Global_Research_Forum_FINAL_VERSION_for_web_14_feb_2020.pdf?ua=1).
11. Caring for pregnant women with COVID-19
10
To date, there are limited data on clinical presentation and perinatal outcomes after COVID‑19 during pregnancy or the
puerperium. There is no evidence that pregnant women present with different signs or symptoms or are at higher risk of severe
illness. So far, there is no evidence on mother‑to‑child transmission when infection manifests in the third trimester, based on
negative samples from amniotic fluid, cord blood, vaginal discharge, neonatal throat swabs or breastmilk. Similarly, evidence of
increased severe maternal or neonatal outcomes is uncertain, and limited to infection in the third trimester, with some cases of
premature rupture of membranes, fetal distress, and preterm birth reported (68, 69).
This section builds on existing recommendations from WHO on pregnancy and infectious diseases and provides
additional remarks for the management of pregnant and recently pregnant women.
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 suspected, probable, or confirmed COVID-19, including women who may need to spend time
in isolation, should have access to woman-centred, respectful skilled care, including obstetric, fetal medicine and neonatal
care, as well as mental health and psychosocial support, with readiness to care for maternal and neonatal complications.
Remark 1: Appropriate IPC measures and prevention of complications as described above also apply to pregnant and recently
pregnant women, including those with miscarriage, late pregnancy fetal loss, and postpartum/postabortion women. These IPC
precautions should be applied for all interactions between an infected caregiver and a child.
Remark 2: Mode of birth should be individualized based on obstetric indications and the woman’s preferences. WHO
recommends that caesarean section should ideally be undertaken only when medically justified
(https://apps.who.int/iris/bitstream/handle/10665/161442/WHO_RHR_15.02_eng.pdf?sequence=1).
Emergency delivery and pregnancy termination decisions are challenging and based on many factors such as gestational age,
severity of maternal condition, and fetal viability and well‑being.
Remark 3: Multidisciplinary consultations from obstetric, perinatal, neonatal and intensive care specialists are essential.
All recently pregnant women with COVID-19 or who have recovered from COVID-19 should be provided with
information and counselling on safe infant feeding and appropriate IPC measures to prevent COVID-19 virus
transmission.
At this point, there is 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, postpartum, or postabortion care as appropriate. Additional care should be
provided if there are any complications.
Remark 1: All pregnant women with or recovering from COVID‑19 should be provided with counselling and information
related to the potential risk of adverse pregnancy outcomes.
Remark 2: Women’s choices and rights to sexual and reproductive health care should be respected regardless of COVID‑19
status, including access to contraception and safe abortion to the full extent of the law.
12. Caring for infants and mothers with COVID-19: IPC and breastfeeding
Relatively few cases have been reported of infants confirmed with COVID‑19; those that have been reported experienced mild
illness. No vertical transmission has been documented. Amniotic fluid from six mothers positive for COVID‑19 and cord blood
and throat swabs from their neonates who were delivered by caesarean section all tested negative for the COVID‑19 virus by
RT‑PCR. Breastmilk samples from the mothers after the first lactation were also all negative for the COVID‑19 virus (68, 69).
Breastfeeding protects against morbidity and death in the post‑neonatal period and throughout infancy and childhood. The
protective effect is particularly strong against infectious diseases that are prevented through both direct transfer of antibodies and
other anti‑infective factors and long‑lasting transfer of immunological competence and memory. See WHO Essential newborn
care and breastfeeding (https://apps.who.int/iris/bitstream/handle/10665/107481/e79227.pdf). Therefore, standard infant feeding
guidelines should be followed with appropriate precautions for IPC.
Infants born to mothers with suspected, probable, or confirmed COVID-19 should be fed according to standard
infant feeding guidelines, while applying necessary precautions for IPC.
Remarks: Breastfeeding should be initiated within 1 hour of birth. Exclusive breastfeeding should continue for 6 months with
timely introduction of adequate, safe and properly fed complementary foods at age 6 months, while continuing breastfeeding up
to 2
11
years of age or beyond. Because there is a dose‑response effect, in that earlier initiation of breastfeeding results in greater benefits,
mothers who are not able to initiate breastfeeding during the first hour after delivery should still be supported to breastfeed as soon
as they are able. This may be relevant to mothers who deliver by caesarean section, after an anaesthetic, or those who have medical
instability that precludes initiation of breastfeeding within the first hour after birth. This recommendation is consistent with the
Global strategy for infant and young child feeding (https://apps.who.int/iris/bitstream/handle/10665/42590/9241562218.pdf),
as endorsed by the Fifty‑fifth World Health Assembly, in resolution WHA54.2 in 2002, to promote optimal feeding for all infants
and young children.
As with all confirmed or suspected COVID-19 cases, symptomatic mothers who are breastfeeding or practising
skin-to-skin contact or kangaroo mother care should practise respiratory hygiene, including during feeding (for example,
use of a medical mask when near a child if the mother has respiratory symptoms), perform hand hygiene before and after
contact with the child, and routinely clean and disinfect surfaces with which the symptomatic mother has been in contact.
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.
Remark 1: All mothers should receive practical support to enable them to initiate and establish breastfeeding and manage
common breastfeeding difficulties, including IPC measures. This support should be provided by appropriately trained health care
professionals and community‑based lay and peer breastfeeding counsellors. See Guideline: counselling of women to improve
breastfeeding practices (https://apps.who.int/iris/bitstream/handle/10665/280133/9789241550468‑eng.pdf) and the WHO
Guideline: protection, promoting and supporting breastfeeding in facilities providing maternity and newborn services
(https://apps.who.int/iris/bitstream/handle/10665/259386/9789241550086‑eng.pdf).
In situations when severe illness in a mother with COVID-19 or other complications prevents her from caring for
her infant or prevents 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.
Remarks: In the event that the mother is too unwell to breastfeed or express breastmilk, explore the viability of relactation, wet
nursing, donor human milk, or appropriate breastmilk substitutes, informed by cultural context, acceptability to the mother, and
service availability. There should be no promotion of breastmilk substitutes, feeding bottles and teats, pacifiers or dummies in
any part of facilities providing maternity and newborn services, or by any of the staff. Health facilities and their staff should not
give feeding bottles and teats or other products within the scope of the International Code of Marketing of Breast-milk
Substitutes and its subsequent related WHA resolutions, to breastfeeding infants. This recommendation is consistent with the
WHO guidance Acceptable medical reasons for use of breast-milk substitutes
(https://apps.who.int/iris/bitstream/handle/10665/69938/WHO_FCH_CAH_09.01_eng.pdf;jsessionid=709AE28402D49263C8D
F6D50048A0E58?sequence=1).
Mothers and infants should be enabled to remain together and practise skin-to-skin contact, kangaroo mother
care and to remain together and to practise rooming-in throughout the day and night, especially immediately after birth
during establishment of breastfeeding, whether they or their infants have suspected, probable, or confirmed COVID-19.
Remarks: Minimizing disruption to breastfeeding during the stay in the facilities providing maternity and newborn services will
require health care practices that enable a mother to breastfeed for as much, as frequently, and as long as she wishes. See WHO
Guideline: protection, promoting and supporting breastfeeding in facilities providing maternity and newborn services
(https://apps.who.int/iris/bitstream/handle/10665/259386/9789241550086‑eng.pdf).
Parents and caregivers who may need to be separated from their children, and children who may need to be
separated from their primary caregivers, should have access to appropriately trained health or non-health workers for
mental health and psychosocial support.
Remarks: Given the high prevalence of common mental disorders among women in the antenatal and postpartum period, and
the acceptability of programmes aimed at them, interventions targeted to these women need to be more widely implemented.
Prevention services should be available in addition to services that treat mental health difficulties. This recommendation is
consistent with the IASC Reference group for Mental Health and Psychosocial Support in Emergency Setting 2020 Briefing note
on addressing mental health and psychosocial aspects of COVID-19 outbreak – version 1.1
(https://interagencystandingcommittee.org/system/files/2020‑
03/MHPSS%20COVID19%20Briefing%20Note%202%20March%202020‑English.pdf) and the Improving early childhood
development: WHO guideline (https://www.who.int/publications‑detail/improving‑early‑childhood‑development‑who‑guideline).
13. Caring for older persons with COVID-19
12
Older age and comorbid diseases such as diabetes and hypertension have been reported as a risk factor for death with people with
COVID‑19 (4). Therefore, older people are at highest risk for fatality and are one of the most vulnerable populations. It is
important to recognize that older people have the same rights as others to receive high‑quality health care, including intensive
care. Refer to the guidance Integrated care for older people (ICOPE) (https://www.who.int/ageing/publications/icope‑
handbook/en/).
For older people with probable or suspected COVID‑19, provide person‑centred assessment, including not only
conventional history taking, but a thorough understanding of the person’s life, values, priorities, and preferences for health
management.
Ensure multidisciplinary collaboration among physicians, nurses, pharmacists, and other health care professionals in the
decision‑making process to address multimorbidity and functional decline.
Remark 1: Physiological changes with age lead to declines in intrinsic capacity, manifested as malnutrition, cognitive decline,
and depressive symptoms; those conditions should be managed comprehensively.
Early detection of inappropriate medication prescriptions is recommended to prevent adverse drug events and drug
interactions for those being treated for COVID‑19.
Remark 2: Older people are at greater risk of polypharmacy, as a result of newly prescribed medications, inadequate medication
reconciliation, and a lack of coordination of care, all of which increases the risk of negative health consequences.
Involve caregivers and family members in decision‑making and goal‑setting throughout the management of older COVID‑
19 patients.
14. Clinical research and specific anti-COVID-19 treatments

There is no current evidence to recommend any specific anti‑COVID‑19 treatment for patients with confirmed COVID‑19. There
are many ongoing clinical trials testing various potential antivirals; these are registered on https://clinicaltrials.gov/ or on the
Chinese Clinical Trial Registry (http://www.chictr.org.cn/abouten.aspx).
Collect standardized clinical data on all hospitalized patients to improve our understanding of the natural history
of disease.
Remark 1: Contribute anonymized data to the WHO Global COVID‑19 Clinical Data Platform; contact EDCARN@who.int to get
log‑in credentials. Disaggregated data for children and pregnant women are needed.
Remark 2: There is an urgent need to collect standardized data for the clinical characterization of COVID‑19 to better understand
the natural history of disease with serial biological sampling. Clinical characterization research protocols are available
(https://isaric.tghn.org/protocols/severe‑acute‑respiratory‑infection‑data‑tools/).
Investigational anti-COVID-19 therapeutics should be used only in approved, randomized, controlled trials.
Remark 1: Refer to the WHO R&D Blueprint website for the most up‑to‑date prioritization of therapeutics
(https://www.who.int/blueprint/priority‑diseases/key‑action/novel‑coronavirus/en/).
Remark 2: Refer to the WHO Core Clinical Randomized Controlled Trial protocol for use in evaluating the efficacy and safety of
investigational therapeutic agents in combination with standard of care for the treatment of hospitalized patients with novel
coronavirus disease (COVID‑19) (https://www.who.int/blueprint/priority‑diseases/key‑action/multicenter‑adaptive‑RCT‑of‑
investigational‑therapeutics‑for‑COVID‑19.pdf?ua=1).
Remark 3: If conducting an RCT is not possible, then investigational therapeutics should be used under Monitored Emergency
Use of Unregistered Interventions Framework (MEURI), until an RCT can be initiated
(https://www.who.int/ethics/publications/infectious‑disease‑outbreaks/en/)
13
Acknowledgements
The original version of this document was developed in consultation with International Forum for Acute Care Trialists (InFACT),
ISARIC and Surviving Sepsis Campaign. The following individuals contributed to or reviewed the current version. Confidentiality
and declarations of interest were collected and reviewed. The methodology was reviewed with a representative of the WHO
Guideline Review Committee.
WHO: Janet V Diaz (Lead), April Baller, William Fischer (consultant), Tom Fletcher (consultant), Mercedes Bonet Semenas,
Anshu Banerjee, Jane Cunningham, Meg Doherty, Paul Nathan Ford, Laurence Grummer‑Strawn, Olufemi Oladapo, Lisa Rogers,
Nigel Rollins, Maria Pura Solon, Marco Vitoria, Prinzo Weise, Wilson Were, Caron Kim, Anna Thorson, Maurice Bucagu,
Anayda Portela, Yuka Sumi, Howard Sobel, Maria Van Kerkhove.
UNICEF: Maya Arii, Joseph Senesie, Diane Holland.
Non-WHO experts: Neill Adhikari, Sunnybrook Health Sciences Centre and University of Toronto; Yaseen Arabi, King Saud Bin
Abdulaziz University for Health Sciences, Saudi Arabia; Bin Cao, China‑Japan Friendship Hospital, Capital Medical University,
Beijing, China; Jake Dunning, Public Health England, UK; Rob Fowler, University of Toronto, Canada; Charles David Gomersall,
The Chinese University of Hong Kong, Hong Kong SAR, China; David Hui, Chinese University of Hong Kong, Hong Kong SAR,
China; Yae‑Jean Kim, Sungkyunkwan University, Samsung Medical Center, Republic of Korea; Norio Ohmagari, WHO
Collaborating Centre for Prevention, Preparedness and Response to Emerging Infectious Diseases, National Center for Global
Health and Medicine Hospital Toyama, Tokyo, Japan; Yinzhong Shen, Shanghai Public Health Clinical Center, Fudan University,
Shanghai, China; Tim Uyeki, Centers for Disease Control and Prevention, USA; Vu Quoc Dat, Hanoi Medical University, Viet
Nam; Niranjan Kissoon, UBC & BC Children’s Hospital Professor in Critical Care, Vancouver Canada; Joāo Paulo Souza,
Professor Titular de Saúde Pública, Universidade de São Paulo, Brazil; Pisake Lumbiganon, Director WHO Collaborating Centre
for Research Synthesis in Reproductive Health Faculty of Medicine Khon Kaen University Khon Kaen, Thailand; Lucille
Blumberg, National Institute for Communicable Diseases (NICD), South Africa; Arthur Kwizera, Department of Anaesthesia and
Critical Care, Makerere University Kampala, Uganda.
Special thanks to the team that contributed to the writing of this document: Caroline Quach‑Thanh, University of Montréal,
Canada; Patrice Savard, l’Université de Montréal, Canada; Jesse Papenburg, McGill University, Canada; Guillaume Poliquin,
Public Health Agency of Canada, Canada; Samira Mubareka, Sunnybrook Hospital, Canada; Srinivas Murthy, University of
British Columbia, Canada; Marianna Offner, Public Health Agency of Canada, Canada; Tracie Jones, Vancouver, British
Columbia, Canada; Sarah Forgie, Stollery Children’s Hospital, Canada; Susy Hota, University of Toronto, Canada; Gerald Evans,
Queens University, Canada; Guillaume Emeriaud, CHU Sainte‑Justine l’Université de Montréal, Canada; Perry Gray, University
of Manitoba, Canada; Todd Hatchette, Dalhousie University, Canada; Jim Strong, Public Health Agency of Canada, Canada; Titus
Yeung, Vancouver General Hospital, Canada.
Special thanks also go to the WHO COVID‑19 IPC Global Expert Panel for their input.
© World Health Organization 2020. All rights reserved.
This document may not be reviewed, abstracted, quoted, reproduced, transmitted, distributed, translated or adapted, in part or in whole, in any
form or by any means without the permission of the World Health Organization.
Appendix: resources for supporting management of severe acute respiratory infections in children
Pocket book of hospital care for children: guidelines for the management of common
childhood illnesses (second edition) (2013).
For use by doctors, nurses, and other health workers caring for children at first-level referral
hospitals with basic laboratory facilities and essential medicines. These guidelines focus on
the management of the major causes of childhood mortality in most developing countries,
including pneumonia, and also cover common procedures, patient monitoring, and
supportive care on the wards.
https://www.who.int/maternal_child_adolescent/documents/child_hospital_care/en/.
Oxygen therapy for children (2016).

A bedside manual for health workers to guide the provision of oxygen therapy for children.
The manual focuses on the availability and clinical use of oxygen therapy in children in
health facilities to guide health workers, biomedical engineer,s and administrators. It
addresses detection of hypoxaemia, use of pulse oximetry, clinical use of oxygen, delivery
systems, and monitoring of patients on oxygen therapy. The manual also addresses the
practical use of pulse oximetry, and oxygen concentrators and cylinders.
http://www.who.int/maternal_child_adolescent/documents/child-oxygen-therapy/en/.
Technical specifications for oxygen concentrators (2015).

Provides an overview of oxygen concentrators and technical specifications to aid in
selection, procurement, and quality assurance. It highlights the minimum performance
requirements and technical characteristics for oxygen concentrators and related equipment
that are suitable for the use in health facilities.
https://www.who.int/medical_devices/publications/tech_specs_oxygen-concentrators/en/.
WHO-UNICEF technical specifications and guidance for oxygen therapy devices

(2019)
The purpose of this document is to increase access to quality products to ensure the supply
of oxygen, especially in low- and middle-income countries and low-resource settings within
countries from all income groups. It aims to support ministries of health to ensure that
oxygen supply is available, as well as to raise awareness of the importance of appropriate
selection, procurement, maintenance, and use of medical devices, both capital equipment
and single-use devices.
https://www.who.int/medical_devices/publications/tech_specs_oxygen_therapy_devices/en/
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accessed 4 March).
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PMID: 32154135; PMCID: PMC7036645.
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© World Health Organization 2020. Some rights reserved. This work is available under the CC BY‑NC‑SA 3.0 IGO licence.
WHO reference number: WHO/2019‑nCoV/clinical/2020.4

Supplementary File 2: Recommendation for Empiric Use of Hydroxychloroquine for Prophylaxis of

SARS-CoV-2 Infection. (Adapted from ICMR)
Recommendation for empiric use of hydroxy-chloroquine for prophylaxis of SARS-CoV-2

infection
Background:
Hydroxy-chloroquine is found to be effective against coronavirus in laboratory studies and in-vivo
studies. Its use in prophylaxis is derived from available evidence of benefit as treatment and supported
by pre-clinical data. The following recommendation for the use of hydroxy-chloroquine as a prophylactic
agent against SARS-CoV-2 infection is based on these considerations, as well as risk-benefit
consideration, under exceptional circumstances that call for the protection of high-risk individuals.
The National Taskforce for COVID-19 recommends the use of hydroxy-chloroquine for
prophylaxis of SARS-CoV-2 infection for selected individuals as follows:
Eligible individuals:
 Asymptomatic healthcare workers involved in the care of suspected or confirmed cases of
COVID-19
 Asymptomatic household contacts of laboratory confirmed cases
Dose:
 Asymptomatic healthcare workers involved in the care of suspected or confirmed cases of
COVID-19: 400 mg twice a day on Day 1, followed by 400 mg once weekly for next 7 weeks; to be
taken with meals
 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
Exclusion/contraindications:
 The drug is not recommended for prophylaxis in children under 15 years of age.
 The drug is contraindicated in persons with known case of retinopathy, known hypersensitivity to
hydroxychloroquine, 4-aminoquinoline compounds
Key considerations:
 The drug has to be given only on the prescription of a registered medical practitioner.
 Advised to consult with a physician for any adverse event or potential drug interaction before
initiation of medication
 The prophylactic use of hydroxychloroquine to be coupled with the pharmacovigilance for
adverse drug reactions through self-reporting using the Pharmacovigilance Program of India
(PvPI) helpline/app.
 If anyone becomes symptomatic while on prophylaxis he/she should immediately contact the
health facility, get tested as per national guidelines and follow the standard treatment protocol.
 All asymptomatic contacts of laboratory confirmed cases should remain in home quarantine as
per the national guidelines, even if they are on prophylactic therapy.
 Simultaneously, proof of concept and pharmacokinetics studies be taken up expeditiously.
Findings from these studies and other new evidence will guide any change in the
recommendation.
Note - It is reiterated that the intake of above medicine should not in still sense of false
secuirity. The hydroxy-chloroquine may not be replaced by any other compound.
Supplementary File 3: Infection Prevention and Control Guidelines for 2019-nCoV (COVID-19)
Hospital Infection Control Committee

AIIMS, New Delhi
Infection Prevention &Control Guidelines for

2019-nCoV (COVID-19)
HICC, AIIMS, New Delhi Version 1.2 26 March 2020

Index
Sl. Chapter Page No.
No.
1 Introduction 3
2 Advice on the usage of PPE in the context of COVID-19 4

 General Advice
 Community setting
 Health Care Facilities
 Masks Management
3 Rational Use Of Personal Protective Equipment 6
 Guidance for use of PPE in different settings
 Donning and Doffing of PPE
4 Practices for Environmental Cleaning in Healthcare Facilities 14
 Cleaning agents and disinfectants
 Personal Protective Equipment (PPE) to wear while
carrying out cleaning and disinfection works
 Cleaning Guidelines For Clinical Area
 Cleaning Guidelines For Non‑Clinical Areas
 Cleaning Of Toilets
 Frequency of cleaning of surfaces
5 Specific instructions on prevention of CORONA VIRUS 21
(COVID 19) transmission at Centre for Dental Education and
Research, AIIMS
6 Guidelines for handling Biomedical Waste generated in 22
Hospitals during diagnostics and treatment of COVID-19
suspected / confirmed patients
7 Precautions for Handling and disposal of Dead Bodies 23
 General Recommendations
 Recommendations For Health Care Worker
 Environmental Control
 Autopsy
 Precautions Specific For Dead Bodies Of Covid‑19

1. Introduction
Coronaviruses (CoV) belong to a family of viruses that cause illness ranging from the common
cold to more severe diseases. A novel coronavirus (2019‑nCoV) is a new strain that has not been
previously identified in humans. The infection is spread through respiratory route i.e. respiratory
droplets and direct human contact. Healthcare personnel (HCP) are at risk of infection through
respiratory routes and direct contact with infectious patients.
In view the current situation regarding COVID ‑19 disease in India, we need to be prepared for
the handling of suspect and confirmed cases, who might present to the AIIMS hospital.
These guidelines are supplementary to the existing Hospital Infection control Manual of AIIMS.
The guidelines have been adapted from the existing WHO & CDC recommendations.
Standard recommendations to prevent infection spread include standard precautions,

contact precautions and respiratory precautions.
Patients suspected of having 2019‑nCoV infection should be shifted to the isolation facility from
the triage area as soon as possible. The HCP should do this after donning appropriate PPE. The
patient should wear mask/respirator.
Standard precautions
Health‑care workers caring for PUI (Patient under investigation) patients should implement
standard infection control precautions. These include basic hand hygiene, use of personal
protective equipment, respiratory etiquettes, and environmental disinfection.
Patient placement
The PUI has to be admitted in an isolation room with negative pressure and at least 6 air
changes per hour.
 Only essential personnel should enter the room. Implement staffing policies to minimize
the number of HCP who enter the room.
 Facilities should keep a log of all persons who care for or enter the rooms or care area of
these patients.
 Use dedicated or disposable noncritical patient‑care equipment (e.g., blood pressure
cuffs). If equipment will be used for more than one patient, clean and disinfect such
equipment before use on another patient according to manufacturer’s instructions.
 HCP entering the room soon after a patient vacates the room should use respiratory
protection.

2. Advice on the usage of PPE in the context of COVID-19

The following are recommendations for the rational use of personal protective equipment (PPE)
at health care facilities. PPE includes gloves, medical masks, goggles or a face shield, and
gowns, as well as for specific procedures, respirators (i.e., N95) and aprons. It is intended for
HCPs, infection prevention and control (IPC) professionals and health care managers.
General Advice
Hand hygiene remains one of the most important measures for all persons for the prevention
and control of majority of the respiratory viral infections ‑, including 2019‑nCoV infections or
COVID‑19. This can be performed with soap and water or alcohol‑based hand rubs. Wearing a
medical mask is one of the prevention measures to limit spread of certain respiratory diseases,
including 2019‑nCoV, is useful when worn by the persons suffering from the disease or contacts
of the patients. These measures must be combined with other IPC measures to prevent the
human‑to‑human transmission of COVID‑19, depending on the specific situation.
Community setting (Applicable to all staff)
Individuals without respiratory symptoms should:

i. avoid agglomerations and frequency of closed crowded spaces;
ii. maintain distance of at least 1 meter from any individual with 2019‑nCoV respiratory
symptoms (e.g., coughing, sneezing);
iii. perform hand hygiene frequently, using alcohol‑based hand rub if hands are not visibly
soiled or soap and water when hands are visibly soiled;
iv. if coughing or sneezing, cover nose and mouth with flexed elbow or paper tissue,
dispose‑off tissue immediately after use and perform hand hygiene;
v. refrain from touching mouth and nose;
vi. a medical mask is not required, as no evidence is available on its usefulness to protect
non‑sick persons. However, masks might be worn according to local cultural habits. If
masks are used, best practices should be followed on how to wear, remove, and dispose
of them and on hand hygiene action after removal (see below advice regarding
appropriate mask management).
Individuals with respiratory symptoms should:

i. wear a medical mask and seek medical care if experiencing fever, cough and difficulty
breathing, as soon as possible or in accordance with to local protocols;
ii. follow the below advice regarding appropriate mask management.

Health Care Facilities
Individuals with respiratory symptoms should:

i. wear a medical mask while waiting in triage or waiting areas or during transportation
within the facility;
ii. wear a medical mask when staying in cohorting areas dedicated to suspected or
confirmed cases;
iii. do not wear a medical mask when isolated in single rooms but cover mouth and nose
when coughing or sneezing with disposable paper tissues. Dispose them appropriately
and perform hand hygiene immediately afterwards.
Health care workers should:

a. wear a medical mask when entering a room where patients suspected or confirmed of
being infected with 2019‑nCoV are admitted and in any situation of care provided to a
suspected or confirmed case;
b. use a particulate respirator at least as protective as a US National Institute for

Occupational Safety and Health (NIOSH)‑certified N95, European Union (EU) standard
FFP2, or equivalent, when performing aerosol‑generating procedures such as:
 tracheal intubation
 non‑invasive ventilation
 tracheotomy
 cardiopulmonary resuscitation
 manual ventilation before intubation and
 bronchoscopy
Masks management
If medical masks are worn, appropriate use and disposal is essential to ensure they are effective
and to avoid any increase in risk of transmission associated with the incorrect use and disposal of
masks.
The following information on correct use of medical masks derives from the practices in health‑
care settings:
a. place mask carefully to cover mouth and nose and tie securely to minimise any gaps
between the face and the mask;
b. while in use, avoid touching the mask;
c. remove the mask by using appropriate technique (i.e. do not touch the front but remove
the lace from behind);
d. after removal or whenever you inadvertently touch a used mask, clean hands by using an
alcohol‑based hand rub or soap and water if visibly soiled
e. replace masks with a new clean, dry mask as soon as they become damp/humid;
f. do not re‑use single‑use masks;
g. discard single‑use masks after each use and dispose‑off them immediately upon removal.

3. Rational use of personal protective equipment
PPE use is based on the risk of exposure (e.g., type of activity) and the transmission dynamics of
the pathogen (e.g., contact, droplet or aerosol). Observing the following recommendations will
ensure rational use of PPE.
1. The type of PPE used when caring for COVID‑19 patients will vary according to the
setting and type of personnel and activity (Below Table).
2. Healthcare workers involved in the direct care of patients should use the following PPE:
a. gowns,
b. gloves,
c. medical mask and
d. eye protection (goggles or face shield).
3. Specifically, for aerosol-generating procedures (e.g., tracheal intubation, non‑invasive
ventilation, tracheostomy, cardiopulmonary resuscitation, manual ventilation before
intubation, bronchoscopy) healthcare workers should use respirators (N95), eye
protection, gloves and gowns; aprons should also be used if gowns are not fluid resistant.
4. Respirators (e.g., N95, FFP2 or equivalent standard) have been used for an extended time
during previous public health emergencies involving acute respiratory illness when PPE
was in short supply. This refers to wearing the same respirator while caring for multiple
patients who have the same diagnosis without removing it, and evidence indicates that
respirators maintain their protection when used for extended periods. However, using one
respirator for longer than 4 hours can lead to discomfort and should be avoided.
5. Among the general public, persons with respiratory symptoms or those caring for
COVID‑19 patients at home should receive medical masks.
6. For asymptomatic individuals, wearing a mask of any type is not recommended.
7. Wearing medical masks when they are not indicated may cause unnecessary cost
and a procurement burden and create a false sense of security that can lead to the
neglect of other essential preventive measures.
Table 1: Guidance for use of PPE in different settings4
Setting Target personel/patients Activity PPE

DESIGNATED COVID AREAS
ICU Healthcare workers Aerosol Generating N95
(Doctor/Nurses/Technician) procedures Goggles or Face
shield
Gown (Water
resistant)
Gloves (Double)
Apron (optional)
Shoe cover
Hood
Cleaner/Sweeper/HA Disinfection N95
Goggles
Gown(Water

resistant)
Heavy Duty Gloves
Boots
Hood
Ward Healthcare workers Non‑Aerosol N95
(Doctor/Nurses/Technician) Generating Goggles
Procedure Gown(Water
resistant)
Gloves (Double)
Shoe cover
Hood
Cleaner/Sweeper/HA Disinfection/Patient N95
Shifting Heavy Duty
Gloves/
Gloves (Patient
shifting)
Goggles
Gown(Water
resistant)
Boots
Hood
Screening (Burns Healthcare workers Screening N95
and plastic (Doctor/Nurses) Goggles
surgery) Gown(Water
resistant)
Gloves (Double)
Healthcare workers Sampling N95
(Doctor/Nurses) Goggles
Gown(Water
resistant)
Gloves (Double)
Shoe cover
Hood
Cleaner/Sweeper/HA Disinfection/Patient Triple layer mask
Shifting Gloves(Patient
shifting)
Heavy Duty Gloves
DESIGNATED SCREENING AREAS
Screening (New Healthcare workers Screening N95
RAK OPD) (Doctor/Nurses) Gloves (Single)
Cleaner/Sweeper/HA Disinfection Triple layer mask
Gloves(Patient
shifting)
Heavy Duty Gloves
Screening Healthcare workers Screening N95
(Emergency (Doctor/Nurses) Goggles

medicine; Gown(Surgical
pediatrics OPD) Linen
Gown)use with an
apron
Gloves (Double)
Heavy Duty Gloves
TRANSPORT of COVID SUSPECT / CONFIRMED CASE IN AMBULANCE
Ambulance (HCW Healthcare workers Attending patient N95
travelling in (Doctor/Nurses) (Direct contact >15 Goggles
patient min) Gown(Water
compartment) resistant)
Gloves (Double)
Heavy Duty Gloves
Driver No Direct contact Triple layer mask
Emergency Healthcare workers Non‑Aerosol Triple layer mask*
Medicine (New (Doctor/Nurses/Technician) generating procedure Gown (In Red area
Emergency; Non‑Aerosol only)
Pediatric generating Gloves (Double)
Emergency; *N95 [Red area
Surgical only]
Emergency Cleaner/Sweeper/HA Disinfection/Patient Triple layer mask
Shifting Gloves (Patient
Shifting)
Heavy Duty Gloves
General OPD/EHS Healthcare workers Non‑Aerosol Triple layer mask
OPD (Doctor/Nurses) generating procedure
Heavy Duty Gloves
General Healthcare workers Non‑Aerosol Triple layer mask
Ward/Private (Doctor/Nurses) generating procedure
Wards Cleaner/Sweeper/HA Disinfection/ Patient Triple layer mask
Shifting Gloves (Patient
Shifting)
Heavy Duty Gloves
ICUs Healthcare workers Aerosol Generating Triple layer mask
(Doctor/Nurses/Technician) procedures in Non‑ Cap
COVID Area Gown(Water
resistant)
Gloves
Shoe cover
Cleaner/Sweeper/HA Disinfection/Patient Triple layer mask
Shifting Cap
Gown(Water
resistant)

Gloves (Patient
Shifting)
Heavy Duty Gloves
Boots
EHS Dispensary Pharmacist Drug Dispensing Triple layer mask
Laboratory Doctor/Technician Dealing with Triple layer mask
personnel Respiratory samples Gown(Water
resistant)
Gloves
Goggles
Radiodiagnosis Doctor/Technician Non‑aerosol Triple layer mask
generating
procedures
Administrative All staff No direct/indirect No PPE
offices patient contact
COVID Patient For Droplet Triple layer mask
Confirmed prevention
case/Suspect
Check list for PPE Donning and Doffing
1. Name of staff : __________________________________

2. Name of observer :__________________________________
3. Date : __________________________________
Note:
1. Get into scrubs or comfortable clothes, remove jewellery, ensure you had water and food
and visited washrooms etc. as the residents and nurses are expected to stay inside for at
least 6 hrs.
2. The observer needs to be in PPE when observing doffing.
3. Two chairs should be placed in doffing area labeled DIRTY & CLEAN
4. Check all PPE before starting donning.
Table 2: Check list for Donning
S.No. Procedure YES/NO

1. Wash hands with soap and water
2. Wear shoe cover
3. Wear 1st pair of gloves
4. Wear gown
5. Wear the mask/respirator (check for any leaks)
6. Wear goggles/face shield
7. Wear hood
8. Wear 2nd pair of gloves
9. Gown fitness check (ask buddy to help)

10
Table 3: Check list for Doffing
S.No. Procedure YES/NO

1. Check for any leak or soiling in PPE before doffing, (disinfect site if
contaminated)
2. Disinfect the hands while wearing gloves (similar to hand hygiene

procedure).
3. Remove shoe covers only by touching the outer surface (by sitting on
DIRTY chair)
4. Perform hand hygiene

5. Remove outer gloves
7. Remove hood
9. Remove gown
11. Remove goggles/face shield
12. Perform hand hygiene.
13. Remove second pair of gloves
15. Wear new pair for gloves
16. Remove mask (don’t touch the front of mask, handle with slings/bands)
18. Clean shoes with alcohol swabs (by sitting on CLEAN chair)
19. Remove last pair of gloves and perform hand hygiene
Note: All PPE to be discarded in RED bag. This red bag to be placed inside another red bag and
sent for treatment (“double bagging”).

11
Donning (putting on) PPE

These requirements apply to all staff entering the room of a corona virus infected patient. The
following PPE is required to be donned prior to entry into the patient room. Donning in the
following order is recommended.
1. Gown
A clean, sterile, disposable gown must be worn. Ensure that gown is tied in back and provides
full coverage.
2. N-95 respirator
a. All staff must wear approved respiratory protection (N‑95 respirator).
b. Before using an N‑95 respirator, staff must be medically cleared and trained in how to
wear/use each device.
c. For N‑95 respirators, staff must have been fit‑tested within the past year to ensure proper
size and fit.
d. A “fit‑check” (also known as a “seal check”) should be performed before each N‑95
respirator use.
e. The N‑95 respirator must be discarded after each use.
3. Goggles/Face shield
All staff must wear goggles or face shield to protect mucous membranes from exposure due to
splash or potential for hand contamination of eyes, nose or mouth.
4. Gloves
The 1st pair of gloves must be clean may not be sterile. The 2nd pair of gloves must be pulled
over the sleeves/cuffs of gown.
Removal
Remove all PPE in anteroom. Remove all the PPE (gloves, gown, face shield or goggles, N‑95)
in the dirty area as per the checklist. After finishing the doffing process completely the person
has to leave the doffing area and directly go to the designated shower area. There the person can
remove all the scrubs and take shower with soap and water.

12
Figure 1: Sequence for Putting on PPE

13
Figure 2: Example for Removal of PPE

14
Decontamination and Waste Management

 In addition to using the appropriate PPE, frequent hand hygiene and respiratory hygiene
should always be performed. PPE should be discarded in an appropriate waste container
after use, and hand hygiene should be performed before putting on and after taking off
PPE.
 Any surface or material known to be, or potentially be, contaminated by biological agents
during laboratory operations must be correctly disinfected to control infectious risks.
 Proper processes for the identification and segregation of contaminated materials must be
adopted before decontamination and/or disposal.
 Where decontamination cannot be performed in the laboratory area or onsite, the
contaminated waste must be packaged in an approved (that is, leakproof) manner, for
transfer to another facility with decontamination capacity.
4. Practices for Environmental Cleaning in Healthcare Facilities

Environmental cleaning is part of Standard Precautions, which should be applied to all patients
in all healthcare facilities
Ensure that cleaning and disinfection procedures are followed consistently and correctly.
Cleaning environmental surfaces with water and detergent and applying commonly used hospital
disinfectants (such as sodium hypochlorite) is an effective and sufficient procedure. 6
Cleaning agents and disinfectants
1. 1% Sodium Hypochlorite can be used as a disinfectant for cleaning and disinfection

2. The solution should be prepared fresh.
3. Leaving the solution for a contact time of at least 10 minutes is recommended.
4. Alcohol (e.g. isopropyl 70% or ethyl alcohol 70%) can be used to wipe down surfaces
where the use of bleach is not suitable, e.g. metals.
Personal Protective Equipment (PPE) to wear while carrying out cleaning and disinfection
works
1. Wear heavy duty/disposable gloves, disposable long‑sleeved gowns, eye goggles or a

face shield, and a medical mask (please see the PPE document for details)
2. Avoid touching the nose and mouth (goggles may help as they will prevent hands from
touching eyes)
3. Disposable gloves should be removed and discarded if they become soiled or damaged,
and a new pair worn
4. All other disposable PPE should be removed and discarded after cleaning activities are
completed. Eye goggles, if used, should be disinfected after each use, according to the
manufacturer’s instructions.

15
5. Hands should be washed with soap and water/alcohol‑based hand rub immediately after
each piece of PPE is removed, following completion of cleaning.
Cleaning guidelines
1. Where possible, seal off areas where the confirmed case has visited, before carrying out
cleaning and disinfection of the contaminated environmental surfaces. This is to prevent
unsuspecting persons from being exposed to those surfaces
2. When cleaning areas where a confirmed case has been, cleaning staff should be attired in
suitable PPE. Disposable gloves should be removed and discarded if they become soiled
or damaged, and a new pair worn. All other disposable PPE should be removed and
discarded, after cleaning activities are completed. Goggles, if used, should be disinfected
after each use, according to manufacturer’s instructions. Hands should be washed with
soap and water immediately after the PPE is removed.
3. Mop floor with routinely available disinfectant.
4. Wipe down all accessible surfaces of walls as well as blinds with disinfectant or bleach
solution.
5. Remove curtains/ fabrics/ quilts for washing, preferably using the hot water cycle. For
hot‑water laundry cycles, wash with detergent or disinfectant in water at 70ºC for at least
25 minutes.
6. Discard cleaning items made of cloth and absorbent materials, e.g. mop head and wiping
cloths, into biohazard bags after cleaning and disinfecting each area. Wear a new pair of
gloves and fasten the double‑bagged biohazard bag with a cable tie.
7. Disinfect buckets by soaking in disinfectant or bleach solution, or rinse in hot water
before filling.
8. Disinfectant or 1% sodium hypochlorite solution should be applied to surfaces using a
damp cloth. They should not be applied to surfaces using a spray pack, as coverage is
uncertain and spraying may promote the production of aerosols. The creation of
aerosols caused by splashing liquid during cleaning should be avoided. A steady
sweeping motion should be used when cleaning either floors or horizontal surfaces, to
prevent the creation of aerosols or splashing. Cleaning methods that might aerosolize
infectious material, such as the use of compressed air, must not be used.
9. Biohazard bags should be properly disposed‑off, upon completion of the disinfection
work.

16
Table 4: CLEANING GUIDELINES FOR CLINICAL AREA

Area/Item Process for Disinfection Method
Floors Detergent(DETREGENT (Three buckets, one with plain water and one with
TO BE USED AS PER detergent solution; one bucket for 1% sodium
AIIMS PROTOCOL)and hypochlorite
1% Sodium Hypochlorite  First mop the area with the warm water and detergent
solution
 After mopping clean the mop in plain water and
squeeze it
 Mop area again using sodium hypochlorite 1% after
drying the area
Mop the floor starting at the far corner of the room and
work towards the door.
Ceiling & Walls Detergent/ 1% Sodium Damp dusting
Hypochlorite
Damp dusting should be done in straight lines that
overlap one another
Doors & Door Detergent/ 1% Sodium The doors are to be washed with a brush
Knobs Hypochlorite
Isolation room Detergent and 1% Sodium Terminal cleaning:
Hypochlorite  Three buckets (As mentioned above)
All Clinical 1% Sodium Hypochlorite As per spill management protocol.

Areas/
At the end, Wash mop with detergent and
Laboratories/
hot water and allow it to dry.
where spill care
is required
Stethoscope Alcohol based rub/ Spirit Should be wiped with alcohol
Swab based rub/spirit swab before each
patient contact
BP Cuffs & Alcohol based disinfectant
Covers
Thermometer Wipe with alcohol rub in‑ Preferably one thermometer for
between each patient use each patient
Injection & Detergent & 70% Alcohol  Clean Daily with detergent & water
Dressing Trolley  After each use, should be disinfected with 70%
alcohol based reagent

17
Refrigerators Detergent & Water  Empty the fridge and store things appropriately
 Defrost, decontaminate and clean with detergent
Inside Cleaning: Weekly
 Dry it properly and replace the things
Surface Cleaning
Schedule: As mentioned
for High Touch Surfaces
Equipment  All Areas & Surfaces Whenever possible, portable radiographic equipment
of Equipment: 1% should be used to limit transportation of patients
(Equipment
Sodium Hypochlorite
need to be
 Sensitive Probes of
disinfected after
Equipment: 70%
every contact
Alcohol
with suspected
patient)  CT/MR like machines
etc, (As per
manufacturer’s
Instructions)
Table 5: CLEANING GUIDELINES FOR NON-CLINICAL AREAS

Area/Item Process for Method
Disinfection
General cleaning Detergent and Water  Scrub floors with hot water and detergent
 Clean with plain water
(1% Sodium
Hypochlorite can be  Allow to dry
done)  Hypochlorite 1% mopping canbedone.
Lockers/ Detergent & Water Damp dusting

Tables/Cupboards/
Wardrobes/
Benches/ Shelves
Railings Detergent & 1% Damp dust with warm water and detergent followed by
Sodium Hypochlorite disinfection with hypochlorite
Three small buckets
 One with plain

18
water
 One with detergent
solution
 One for sodium
hypochlorite 1%
Mirrors & Glass Detergent & Water  Using warm water and a small quantity of detergent
and a damp cloth
 wipe over the mirror and surroundings
Stainless steel/ Detergent & Water
Any other sink
Furniture Detergent & Water  Damp dust with detergent
Telephone Detergent & Water  Damp dust with detergent
Chairs Detergent & Water  Damp dust with detergent
Light Switches Detergent & Water  Damp cloth (never wet) with detergent
Curtains Detergent & Water  Clean with water and detergent for curtains
Table 6: CLEANING OF TOILETS

Area/Item Process for Disinfection Method
 Toilet Pot & Floor  1% Sodium Hypochlorite Scrub with the recommended agents
andthe long handle angular brush.
 Rest all areas of Toilets  Detergent & Water Scrub

like
o Taps & Fittings
o Outside Sink
o Soap Dispensers
etc.

19
Frequency of cleaning of surfaces

High touch surfaces: Disinfection of high touch surfaces like (doorknobs, telephone, call bells,
bedrails, stair rails, light switches, wall areas around the toilet) should be done:
CLINICAL AREAS NON-CLINICAL
AREAS
Where Suspected or Other areas, where no Suspected or
Confirmed COVID‑19 Case Confirmed COVID‑19 Case is kept
is kept
1‑2 Hourly 2‑3 Hourly 3‑4 Hourly
Low-touch surfaces: For Low‑touch surfaces (walls, mirrors, etc.) mopping should be done:
CLINICAL AREAS NON-CLINICAL
AREAS
Where Suspected or Other areas, where no Suspected or
Confirmed COVID‑19 Case Confirmed COVID‑19 Case is kept
is kept
2‑3 Hourly 3‑4 Hourly Once Per Shift
(Reference: Best Practices for Environmental Cleaning in Healthcare Facilities in
Resource‑Limited Settings. CDC. November, 2019)
Precautions to take after completing the clean-up and disinfection
1. Staff should wash their hands with soap and water immediately after removing the PPE,
and when cleaning and disinfection work is completed.
2. Discard all used PPE in a double‑bagged biohazard bag, which should then be securely
sealed and labeled.
3. The staff should be aware of the symptoms, and should report to their occupational health
service if they develop symptoms.

20
Figure 3: Disinfection Checklist for Operation Theatre
Figure 4: Disinfection Checklist for Non Critical areas(Wards)

21
Figure 5: Disinfection Checklist for Critical Areas (ICU, Cath Lab)
5.Specific instructions on prevention of CORONA VIRUS (COVID 19)

transmission at Centre for Dental Education and Research, AIIMS
General Instructions for dental operatory
1. All surfaces on the dental chairs and attachments, instrument tray should also be cleaned
with appropriate disinfectant (70% Alcohol, 0.5% Hydrogen peroxide, 0.1 % Sodium
Hypochlorite for 1 min) after every patient. 1‑3
2. The exposed tubings of the chair, instrument arm, light arm, adjoining equipments like
external scalers, light cure units base, working slabs should be disinfected after every
patient. 1‑3
3. The X ray unit handle, tube and casing should be disinfected after every patient. 1‑3
4. The dental X‑ray Units, CBCT Units and attached computers and monitors of the same
should be sanitized appropriately twice daily.
5. The patient registration and waiting areas should be specifically monitored for reducing
of crowding and safe distance.
Procedures in Dental Operatory – for all patients
 All the dental procedures which are associated with production of aerosols such as
ultrasonic scaling, use of airotor and micromotor should be used judiciously and if
possible restricted to only emergency or urgent conditions. 1
 The procedures not involving aerosols can be performed with lesser risk however they
must also be restricted as per the Institute’s policy.

22
The procedures involving impression making should be deferred and restricted to only
emergency patients.4
 Non‑invasive procedures required for patients already referred from other departments
for emergency care should be performed with extreme caution.
Procedures in Dental Operatory – for suspected or positive patients
 All the dental procedures should be deferred.
 If in case required as emergency and expected to produce aerosols such as ultrasonic
scaling, use of airotor and micromotor should be performed with high vacuum suction.
After completion of procedure, sterilization and disinfection of all surfaces, tubing etc in
critical and semi critical zones.1,3
 Procedures required as emergency and expected not to produce aerosols can be
performed with extreme caution.
 Preprocedural mouthrinse with 0.2 % povidone‑iodine is recommended to reduce the
viral load.5
 Extraoral radiographs i.e. Panaromic radiograph or CBCT instead of intraoral imaging
should be preferred to avoid gag reflex.
6.Guidelines for handling Biomedical Waste generated in

Hospitals during diagnostics and treatment of COVID-19
suspected / confirmed patients5
1. Keep separate color coded bins/bags/containers and maintain proper segregation of
waste as per existing rules.
2. As precaution double layered bags (using 2 bags) should be used for collection of waste
from COVID‑19 isolation wards so as to ensure adequate strength and prevent leakage.
3. Use a dedicated collection bin labelled as “COVID-19” to store COVID‑19 waste and
keep separately in temporary storage room prior to handing over to authorized staff.
4. Bags/containers used for collecting biomedical waste from COVID‑19 wards, should be
labelled as “COVID-19 Waste”. This marking would enable CBWTFs to identify the
waste easily for priority treatment and disposal immediately upon the receipt.
5. Maintain separate record of waste generated from COVID‑19 isolation wards/ICUs.
6. Use dedicated trolleys and collection bins in COVID ‑19 isolation wards/ICUs. A label
“COVID‑19 Waste” to be pasted on these items also.
7. The (inner and outer) surface of containers/bins/trolleys used for storage of COVID‑19
waste should be disinfected with 1% sodium hypochlorite solution.
8. General waste not having contamination should be disposed as solid waste as per SWM
Rules, 2016.

23
9. Depute dedicated sanitation workers separately for BMW and general solid waste so that
waste can be collected and transferred timely to temporary waste storage area.
10. Guidelines followed for isolation wards/ICUs, as mentioned above should be applied
suitably in case of Screening areas, Sample collection centres and Laboratories for
COVID‑19 suspected patients.
11. Sanitary Inspectors/Facility Managers Operator shall ensure regular sanitization of

workers involved in handling and collection of biomedical waste.
12. Workers involved in handling and collection of COVID‑19 biomedical waste shall be
provided with adequate PPEs including three layer masks, splash proof aprons/gowns,
nitrile gloves, gum boots and safety goggles.
13. Do not allow any worker showing symptoms of illness to work at the facility.
7.Precautions for Handling and disposal of Dead Bodies 8

General Recommendations
Vaccination
Hepatitis B vaccination is recommended for all personnel who are likely to come into contact
with dead bodies, such as health care worker, mortuary staff, funeral workers, and etc.
Personal hygienic measures and protective equipment
1. All staff should be trained in the prevention of infections. A high standard of personal
hygiene should be adopted.
2. When handling of dead bodies:
a. Avoid direct contact with blood or body fluids from the dead body.
b. Put on personal protective equipment (PPE) including : Gloves, water resistant
gown/ plastic apron over water repellent gown, and surgical mask. Use goggles
or face shield to protect eyes, if there may be splashes.
c. Make sure any wounds, cuts and abrasions, are covered with waterproof
bandages or dressings.
d. Do NOT smoke, drink or eat. Do NOT touch your eyes, mouth or nose.
e. Observe strict personal hygiene. Hand hygiene could be achieved by washing
hands with liquid soap and water or proper use of alcohol‑based hand rub.
f. Avoid sharps injury, both in the course of examination of dead body and
afterwards in dealing with waste disposal and decontamination.
3. Remove personal protective equipment after handling of the dead body. Then, wash
hands with liquid soap and water immediately

24
Accidental exposure to blood or body fluids
1. In case of per‑cutaneous injury or muco‑cutaneous exposure to blood or body fluids of

the dead body, the injured or exposed areas should be washed with
copious amount of water.
2.
All incidents of percutaneous or mucocutaneous exposure should be reported to the
supervisor. The injured person should immediately seek medical advice for proper wound
care and post‑exposure management
Recommendations for Health Care Worker
1. Staff should put on appropriate personal protective equipment before handling the dead
body. Gloves, water resistant gown/ plastic apron over water repellent gown, and surgical
mask. Use goggles or face shield to protect eyes, if there may be splashes.
2. All tubes, drains and catheters on the dead body should be removed.
3. Extreme caution should be exercised when removing intravenous catheters and other
sharp devices. They should be directly disposed into a sharps container.
4. Wound drainage and needle puncture holes should be disinfected and dressed with
impermeable material.
5. Secretions in oral and nasal orifices can be cleared by gentle suction if needed.
6. Oral, nasal and rectal orifices of the dead body have to be plugged to prevent leakage of
body fluids.
7. The body should be cleaned and dried.
8. The dead body should be first placed in a robust and leak‑proof zxztransparent plastic bag
of not less than 150 μm thick, which should be zippered closed. Pins are NOT to be used.
9. A second layer of cover is required. The bagged body should be either wrapped with a
mortuary sheet or placed in an opaque body bag.
10. The outside of the body bag should be wiped with 1 in 4 diluted household bleach
(mixing 1 part of 5.25% bleach with 4 parts of water) and allow to air dry.
11. Remove personal protective equipment after handling of the dead body. Then, perform
hand hygiene immediately.
Environmental control
1. Items classified as clinical waste must be handled and disposed of properly according
to the legal requirements.
2. All used linen should be handled with standard precautions. Used linen should be
handled as little as possible with minimum agitation to prevent possible
contamination of the person handling the linen and generation of potentially
contaminated lint aerosols in the areas. Laundry bag should be securely tied up. Staff
should follow their hospital guidelines on handling of soiled linen.
3. Used equipment should be autoclaved or decontaminated with disinfectant solutions
in accordance with established disinfectant policy.
4. All surfaces which may be contaminated should be wiped with “1 in 49 diluted
household bleach”* (mixing 1 part of 5.25% bleach with 49 parts of water), leave it
for 15‑30 minutes, and then rinse with water. Metal surfaces could be wiped with
70% alcohol.

25
5. Surfaces visibly contaminated with blood and body fluids should be wiped with “1 in
4 diluted household bleach”*(mixing 1 part of 5.25% bleach with 4 parts of water),
leave it for 10 minutes, and then rinse with water.
* Bleach solution should be freshly diluted.
AUTOPSY
Autopsies on dead bodies which have died with COVID‑19 expose staff to unwarranted risk and
should generally not be performed. However, if autopsy is to be carried out because of special
reasons, the following practices should be adopted:
a) It should be performed by a pathologist using recommended barrier techniques and

procedures to reduce the risk of infection.
b) The number of people allowed in the autopsy room should be limited to those directly
involved in the operation.
c) After completion of examination and local disinfection of skin with “1 in 49 diluted
household bleach” (mixing 1 part of 5.25% bleach with 49 parts of water), the dead body
should be placed in a robust and leak‑proof transparent bag of not less than 150 μm
thick. The bagged body should be placed in another opaque bag and zippered closed.
d) The outside of the dead body bags should be wiped with “1 in 4 diluted household
bleach”(mixing 1 part of 5.25% bleach with 4 parts of water) and allow to air dry.
e) The appropriate warning tag indicating Category 2 or Category 3 should be attached on
the outside of the body bag.
Precautions Specific for dead bodies of COVID-19
 Viewing in funeral parlour and hygienic preparation are allowed.

 Embalming is NOT allowed.
 Cremation is advisable.
References
1. https://www.cdc.gov/coronavirus/2019‑ncov/index.html
2. www.who.int›coronaviruse›20200126‑ncov‑ipc‑during‑health‑care
3. https://ncdc.gov.in/WriteReadData/l892s/89168637271584172711.pdf
4. Appropriate use of various types of Personal Protective Equipment ‑
https://www.aiims.edu/images/pdf/notice/PPE%20guideline%20chart%20final_1.pdf
5. Handling of Biomedical waste Central Pollution Control Board (CPCB)
https://www.india.gov.in/official‑website‑central‑pollution‑control‑board
6. Health Organization. (2019). Infection Prevention and Control during Health Care when
Novel Coronavirus (nCoV) Infection is Suspected. WHO/2019‑nCoV/IPC/v2020.1
7. AIIMS Information Booklet on COVID‑19
https://www.aiims.edu/images/pdf/notice/AIIMS%20COVID‑
19%20Information%20Booklet.pdf

26
8. Precautions for handling and disposal of Dead Bodies‑

https://www.chp.gov.hk/files/pdf/grp‑guideline‑hp‑ic‑
precautions_for_handling_and_disposal_of_dead_bodies_en.pdf

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Neurosurgery and Neurology Practices

Division of Innovation and

Gupta, et al.: Neurosurgery and neurology practices during COVID‑19 pandemic

2 Neurology India | Volume 68 | Issue 2 | March-April 2020

Gupta, et al.: Neurosurgery and neurology practices during COVID‑19 pandemic

Gupta, et al.: Neurosurgery and neurology practices during COVID‑19 pandemic

4 Neurology India | Volume 68 | Issue 2 | March-April 2020

Gupta, et al.: Donning and

Donning Sequence Doffing Sequence

Remove all personal items

Hand Wash Hood

Cap Cover all/ Gown

Shoe Cover Shoe Cover

Hand rub Hand rub (Gloved hand)

Inner glove Goggles

Cover all/ Gown Mask (Surgical or N95)

Mask (Surgical or N95)

Gupta, et al.: Neurosurgery and neurology practices during COVID‑19 pandemic

6 Neurology India | Volume 68 | Issue 2 | March-April 2020

Gupta, et al.: Neurosurgery and neurology practices during COVID‑19 pandemic

Figure 4: Suggested management paradigm for patients with COVID-19

Gupta, et al.: Neurosurgery and neurology practices during COVID‑19 pandemic

8 Neurology India | Volume 68 | Issue 2 | March-April 2020

Gupta, et al.: Neurosurgery and neurology practices during COVID‑19 pandemic

Neurology India | Volume 68 | Issue 2 | March-April 2020 9

Clinical management of severe acute respiratory infection

These symbols are used to flag interventions:

Table 1. Definitions of SARI and surveillance case definitions for COVID-19*

Table 2. Clinical syndromes associated with COVID-19

2. Immediate implementation of appropriate IPC measures

3. Collection of specimens for laboratory diagnosis

4. Management of mild COVID-19: symptomatic treatment and monitoring

5. Management of severe COVID-19: oxygen therapy and monitoring

6. Management of severe COVID-19: treatment of co-infections

7. Management of critical COVID-19: acute respiratory distress syndrome (ARDS)

8. Management of critical illness and COVID-19: prevention of complications

9. Management of critical illness and COVID-19: septic shock

Do not use hypotonic crystalloids, starches, or gelatins for resuscitation.

In children administer vasopressors if:

10. Adjunctive therapies for COVID-19: corticosteroids

11. Caring for pregnant women with COVID-19

13. Caring for older persons with COVID-19

14. Clinical research and specific anti-COVID-19 treatments

UNICEF: Maya Arii, Joseph Senesie, Diane Holland.

© World Health Organization 2020. All rights reserved.

Oxygen therapy for children (2016).

Technical specifications for oxygen concentrators (2015).

WHO-UNICEF technical specifications and guidance for oxygen therapy devices

doi: 10.1186/s13054‑016‑1230‑8. PubMed PMID: 27036638; PMCID: PMC4818504.

WHO reference number: WHO/2019‑nCoV/clinical/2020.4

Supplementary File 2: Recommendation for Empiric Use of Hydroxychloroquine for Prophylaxis of

Recommendation for empiric use of hydroxy-chloroquine for prophylaxis of SARS-CoV-2

Hospital Infection Control Committee

Infection Prevention &Control Guidelines for

HICC, AIIMS, New Delhi Version 1.2 26 March 2020

2 Advice on the usage of PPE in the context of COVID-19 4

HICC, AIIMS, New Delhi Version 1.2 26 March 2020

Standard recommendations to prevent infection spread include standard precautions,

HICC, AIIMS, New Delhi Version 1.2 26 March 2020

2. Advice on the usage of PPE in the context of COVID-19

Community setting (Applicable to all staff)

Individuals without respiratory symptoms should: