TREATMENT PROTOCOL

FOR COVID-19 INFECTED

PATIENTS

RAJENDRA INSTITUTE OF MEDICAL SCIENCES,

RANCHI-834009

GOVERNMENT OF JHARKHAND

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 Convener: Dr. Prabhat Kumar, Associate Professor, Dept of dermatology, RIMS, Ranchi.

1. Dr. Mohd Saif Khan, Associate Professor, Dept of critical care medicine, RIMS, Ranchi.
2. Dr. Nishit M Paul Ekka, Assistant Professor, Dept of Surgery, RIMS, Ranchi.
3. Dr. Rishi TuhinGuria, Associate Professor, Dept of Medicine, RIMS, Ranchi.
4. Dr. Ajit Dungdung, Associate Professor, Dept of Medicine, RIMS, Ranchi.
5. Dr. Ashok Kumar Sharma, Associate Professor, Dept of Microbiology, RIMS, Ranchi.
6. Dr. Praveen Tiwari, Associate Professor, Dept of Anesthesiology, RIMS, Ranchi.
7. Dr. Shio Priye, Professor and Incharge, Dept of Superspecialty Anesthesia, RIMS, Ranchi.
8. Dr. Sunil Mahto, Associate Professor, Dept of Pathology, RIMS, Ranchi.
9. Dr. Mithelesh Kumar, Associate Professor, PSM Department, RIMS Ranchi

 Dr. Naveen Kumar, Assistant Professor, Dept. of Radiodiagnosis, RIMS, Ranchi.

 Dr. Kumari Seema, Assistant Professor, Dept of Microbiology, RIMS, Ranchi.

 Date of writing protocol: 28/3/2020

 Date of review: 30/3/2020
 Reviewed by:
Dr. (Professor) J K Mitra
Dr. (Professor) Pradip Bhattacharya,
Dr. Brajesh Mishra
 Date of correction: 31/3/2020
 Date of approval: 01/04/2020

Approved by: Dr. Vivek Kashyap, Medical Superintendent, RIMS, Ranchi

Date of release: 1/4/2020

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This document is drafted by clinicians of different specialties of
RIMS, Ranchi, Jharkhand state, India. The references are sought
from latest guidelines from world health organization (WHO),
Centre for disease control (CDC), Ministry of Health and Family
Welfare (MOHFW), Society of critical care medicine (SCCM),
European Society of Intensive Care Medicine(ESICM) and various
latest research articles. This protocol will guide clinicians
(especially resident physicians)involved in care of hospitalized
adult patients of COVID – 19. However, this protocol also
respects clinical judgment of physician involved in such kind of
patients. This protocol should be updated as new evidence is
available. Every effort and care has been exercised to provide
accurate information but despite this, few errors are bound to
happen and hence comments are always welcome to improve
protocol.

--RIMS COVID-19 Protocol Committee

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S. No. Title Page No.
1. Definitions 5
2. Symptomatology and disease course and grading of 6
severity
3. Ensuring safety of healthcare worker: appropriate IPC 8
measures
4. Laboratory investigations 10
5. Imaging strategy of COVID-19 patients 12
6. Treatment of symptomatic COVID-19 patients 14
7. Intubation and mechanical ventilation 18
8. Prevention of complications 22
9. Discharge policy of COVID-19 patients 24
10. Disposal of dead body of COVID-19 25
11. Bio-Medical Waste Management For COVID-19 27
12. References 29

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COVID-19 SUSPECT CASE: any of following should be suspected to have COVID-19 virus:

 All hospitalized patients with severe acute respiratory illness ( SARI) (fever AND cough
and/or shortness of breath)
 Asymptomatic direct and high risk contacts of a confirmed case (should be tested once
between day 5 and day 14 after contact)
 All symptomatic individuals who have undertaken international travel in the last 14
days
 All symptomatic contacts of laboratory confirmed cases
 All symptomatic healthcare personnel (HCP)

SEVERE ACUTE RESPIRATORY INFECTION(SARI): An ARI (acute respiratory

infection) with history of fever or measured temperature ≥38 C° and cough; onset
within the last ~10 days; and requiring hospitalization.

CLOSE CONTACT: this is defined as following criteria:

 Health care associated exposure, including providing direct care for COVID – 19
patients,
 Working with health care workers infected with COVID – 19,
 Visiting patients or staying in the same close environment of a COVID - 19
patients.
 Working together in close proximity or sharing the same classroom environment
with a COVID - 19 patient
 Travelling together with COVID - 19 patients in any kind of conveyance.
 Living in the same household as a COVID - 19 patients

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COVID–19 may present with mild, moderate, or severe illness; the latter includes severe
pneumonia, ARDS (acute respiratory distress syndrome, sepsis and septic shock. Early
recognition of suspected patients allows for timely initiation of treatment. Early
identification of those with severe manifestations allows for immediate optimized
supportive care treatments and safe, rapid admission (or referral) to intensive care unit
according to national protocols. For those with mild illness, hospitalization may not be
required unless there is concern for rapid deterioration. All patients discharged for
home should be instructed to return to hospital if they develop any worsening of
illness.

Grading of severity

Uncomplicated illness: Patients with uncomplicated upper respiratory tract viral

infection, may have non-specific symptoms such as fever, cough, sore throat, nasal
congestion, malaise, headache. The elderly and immunocompromised patients may
present with atypical symptoms (hypothermia, drowsiness, disorientation). These
patients do not have any signs of dehydration, sepsis or shortness of breath.

Mild pneumonia: Patient with pneumonia and no signs of severe pneumonia.

Moderate to severe pneumonia: Fever or suspected respiratory infection, plus one of

the following; respiratory rate >30 breaths/min, severe respiratory distress, SpO2 <90%
on room air, bilateral opacities on Chest radiograph.

Acute Respiratory Distress Syndrome (ARDS): Berlin’s definition (2012) criteria are as
follows-

 Onset: Within 1 week of a known clinical insult or new or worsening respiratory

symptoms

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  Oxygenation: Mild: PaO2 /FiO2 >200 mmHg but ≤300 mmHg
Moderate: PaO2 /FiO2 >100 mmHg but ≤200 mmHg
Severe: PaO2 /FiO2 ≤100 mmHg
 Imaging (opacity):Bilateral opacities not fully explained by effusions, lobar/lung
collapse or nodules by chest radiograph or CT.
 Origin of edema: Respiratory failure not fully explained by cardiac failure or
fluid overload (need objective assessment, such as echocardiography, to exclude
hydrostatic oedema if no risk factor present)

SEPSIS: According to sepsis-3 definition, sepsis is defined as life-threatening organ

dysfunction caused by a dysregulated host response to suspected or proven infection,
with organ dysfunction. Signs of organ dysfunction include: altered mental status,
difficult or fast breathing, low oxygen saturation, reduced urine output, fast heart rate,
weak pulse, cold extremities or low blood pressure, skin mottling, or laboratory
evidence of coagulopathy, thrombocytopenia, acidosis, high lactate or
hyperbilirubinemia.

SEPTIC SHOCK: Persisting hypotension despite volume resuscitation, requiring

vasopressors to maintain MAP ≥65 mmHg and serum lactate level < 2 mmol/L.

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IPC stands for infection prevention and control measure, which is important for both
patient and healthcare worker. COVID-19 viral illness is highly transmissible through
direct contact, fomite or droplet routes. IPC is a critical and integral part of clinical
management of patients and should be initiated at the point of entry of the patient to
COVID 19 facility. Standard precautions should always be routinely applied in all areas
of health care facilities. Standard precautions include hand hygiene; use of PPE to avoid
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.

At first medical contact (screening room/help desk at COVID-19 facility): Give

suspect patient a triple layer surgical mask and direct patient to separate waiting area or
isolation room. Instruct all patients to cover nose and mouth during coughing or
sneezing with tissue or flexed elbow for others. Perform hand hygiene after contact
with respiratory secretions.

Apply contact precautions: Droplet and contact precautions prevent direct or indirect
transmission from contact with contaminated surfaces or equipment (i.e. contact with
contaminated oxygen tubing/interfaces). Use PPE (triple layer surgical mask, eye
protection, gloves and gown) when entering room and remove PPE when leaving. If
possible, use either disposable or dedicated equipment (e.g. stethoscopes, blood
pressure cuffs and thermometers). Incase dedicated equipment is in shortage; it should
be cleaned and disinfected between each patient use. All healthcare workers (HCW)
must refrain from touching their eyes, nose, and mouth with potentially contaminated
gloved or ungloved hands, therefore it is advisable that a head cover and goggle (eye-

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protection) must be worn all time during stay inside COVID-19 facility. Avoid
contaminating environmental surfaces that are not directly related to patient care (e.g.
door handles and light switches). Ensure adequate room ventilation (using exhaust
fans). Avoid movement of patients or transport.

Apply airborne precautions while performing an aerosol generating procedure:

Ensure that HCW performing aerosol-generating procedures (i.e. intubation,
bronchoscopy, cardiopulmonary resuscitation) use PPE, including gloves, long-sleeved
gowns, eye protection, and fit-tested particulate respirators (N95 Masks). Whenever
possible, use adequately ventilated rooms. Avoid the presence of unnecessary
individuals in the room during procedure. Avoid bag and mask ventilation as it
generates aerosol in high amount. After intubation directly connect the ET tube to
ventilator circuit. Minimize disconnection of ventilator tubing. Use HME filters at two
places i.e.; patient end and expiratory port of ventilator. Always use closed suction
catheter for suctioning of ET tube during mechanical ventilation of critically ill.

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There are few routine baseline investigations which should be sent in all COVID-19
patients. Specific investigations are required to detect complications and monitor
therapeutic response.

Complete blood count (CBC): This investigation will be valuable to detect presence of
infections or inflammation (high total leucocyte count). Underlying anemia may be
present in malnourished patients. Thrombocytopenia is due to presence of sepsis or
marker of disease severity.

Biochemistry panel: In case of pneumonic sepsis, it is intuitive to know the status of

organ functions hence, renal function tests (Urea, creatinine), Liver function tests
(Bilirubin, SGOT, SGPT, Albumin) should be ordered. Serum electrolytes (sodium and
potassium) are done to ascertain hyponatremia and hypokalemia and should be
accordingly corrected. Trop T and D-dimer can laso be sent which are suggestive of
myocarditis in COVID-19.

Microbiological culture: in asymptomatic or mild pneumonia cases, throat and nasal

swab is collected in viral transport media (VTM) and transported on ice. In moderate to
severe cases, other specimens such as BAL (broncho-alveolar lavage) fluid or
endotracheal aspirate should be collected in all ventilated patients, which has to be
mixed with the viral transport medium and transported on ice to microbiology lab for
gram staining and cultures. In patients with febrile spikes and signs of sepsis, blood,
pleural fluid and urine are also sent for culture before starting empirical antibiotics.
Culture reports help to stream line antibiotic therapy and also to de-escalate antibiotics
early.

Respiratory specimen collection methods: Clinicians may collect BAL or tracheal

aspirate samples when these are readily available (for example, in mechanically
ventilated patients). In hospitalized patients with confirmed COVID - 19 infection,

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repeat upper respiratory tract samples should be collected to demonstrate viral
clearance.

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A. Bronchoalveolar lavage, tracheal aspirate, sputum: Collect 2-3 mL into a sterile,
leak-proof, screw-cap sputum collection cup or sterile dry container.

B. Oropharyngeal swab (e.g. throat swab): Tilt patient’s head back 70 degrees. Rub
swab over both tonsillar pillars and posterior oropharynx and avoid touching the
tongue, teeth, and gums. Use only synthetic fiberswabs with plastic shafts. Do not use
calcium alginate swabs or swabs with wooden shafts. Place swabs immediately into
sterile tubes containing 2-3 ml of viral transport media.

Combined nasal & throat swab: Tilt patient’s head back 70 degrees. While gently
rotating the swab, insert swab less than one inch into nostril (until resistance is met at
turbinates). Rotate the swab several times against nasal wall and repeat in other nostril
using the same swab. Place tip of the swab into sterile viral transport media tube and
cut off the applicator stick. For throat swab, take a second dry polyester swab, insert
into mouth, and swab the posterior pharynx and tonsillar areas (avoid the tongue).
Place tip of swab into the same tube and cut off the applicator tip.

Nasopharyngeal swab: Tilt patient’s head back 70 degrees. Insert flexible swab through
the nares parallel to the palate (not upwards) until resistance is encountered or the
distance is equivalent to that from the ear to the nostril of the patient. Gently, rub and
roll the swab. Leave the swab in place for several seconds to absorb secretions before
removing.

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

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Handling of equipment and contact precautions for radiographer:

 Avoid unnecessary patient transport to the department.

 Equipment should be placed in isolation wards / ICUs only.

 Appropriate infection control procedures should be followed before scanning

any patient.

 A specific time period is allotted for CXR for all the patients in a day, so that PPE
could be used judiciously.

 Equipments should be disinfected after every single usage as recommended .

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

Supplemental oxygen therapy is indicated for the COVID-19 patients with SARI and
respiratory distress, hypoxaemia, or shock. Initiate oxygen therapy at 5 L/min and
titrate flow rates to reach target SpO2 ≥90% in non-pregnant adults and SpO2 ≥92-95 %
in pregnant patients. COVID-19 wards/HDU and ICUs should be equipped with
adequate number of pulse oximeters, functioning oxygen delivery systems and
disposable, single-use, oxygen-delivering interfaces (nasal cannula, simple face mask,
and mask with reservoir bag).

A patient who is in respiratory distress, shock or altered mentation, should be cared in

high dependency unit (HDU) or intensive care unit (ICU). Such patients should be
monitored for following parameters; SpO2, HR, ECG, blood pressure and temperature.
Hemodynamic monitoring is indicated in patients with signs of shock (altered
mentation, cold peripheries and oligoanuria). Dynamic parameters (stroke volume
change with passive leg raising, stroke volume variation, pulse pressure variation and
inferior vena caval diameter change with respiration, distensibility or collapsibility
index using echocardiography) are recommended to guide fluid therapy. All COVID 19
critically ill patients should also be monitored for hourly intake and urine output.
Random blood glucose of capillary or venous blood should be performed every 2-4
hourly in critically ill and every 8 hourly in non-critically ill COVID-19 patients.

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Use conservative fluid management in patients with SARI when there is no evidence of
shock. Patients with SARI should be treated cautiously with intravenous fluids,
because aggressive fluid resuscitation may worsen oxygenation, especially in the
settings where there is limited availability of mechanical ventilation. In adults and
children with ARDS & sepsis, a conservative or deresuscitative fluid strategy results in
an increased number of ventilator-free days and a decreased length of ICU stay
compared with a liberal strategy or standard care. Regarding choice of fluid,
crystalloids are preferred over colloid as many colloids are harmful and all are costlier
than crystalloids. Among crystalloids, Ringer lactate is preferred over normal saline if
available as it is associated with lesser degree of acute kidney injury, less normal anion
gap metabolic acidosis (hyperchloremic acidosis).

In case of hemodynamic shock and signs of poor peripheral perfusion (altered

mentation, cold extremities, poor capillary refill or lactate level>4 mmoL/L), start
vasopressor infusion early.

Noradrenaline is first line vasopressor of choice, which should be commenced early in

patients with hemodynamic shock while being fluid resuscitated. The dose of
noradrenaline is 0.01 microgram/kg/min to 2 microgram/kg/min. The dilutions are as
follows; 4 ampoules of Noradrenaline are mixed in 50 mL normal saline or 5% dextrose
solution and start at 10 mL/hr. Titrate the dose of vasopressor (infusion rate) to mean
arterial pressure (MAP) between 60-65 mmHg. If patient is hypertensive then higher
MAP (75-80 mmHg) may be targeted. If Noradrenaline is not available, Adrenaline or
Vasopressin infusion may be used as second line vasopressor. If patient is not
responding to high dose Noradrenaline then add vasopressin infusion and start
parenteral steroid therapy. Dopamine and any other vasopressor is not suggested to be
used. If patient continues to have signs of poor peripheral perfusion (delayed capillary

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refill time, cold peripheral extremities or high lactate), Dobutamine infusion may be
commenced. Role of thiamine and vitamin C is controversial in septic shock, hence, is
not suggested.

Administer empiric antimicrobials (Pipracillin-Tazobactam, Azithromycin,

Moxifloxacin and or Doxycycline) to treat all likely pathogens causing SARI. Antibiotics
must be administered within one hour of initial patient assessment for patients with
sepsis. Empirical antibiotic treatment should be based on the clinical diagnosis
(community-acquired pneumonia, health care-associated pneumonia [if infection was
acquired in healthcare setting], or sepsis), local epidemiology and susceptibility data,
and treatment guidelines. Empirical therapy should be de-escalated on the basis of
microbiology results and clinical judgment.

At present, there is no consensus and strong evidence to use antiviral agent and other
therapeutic agents for COVID-19 except some role of Hydroxychloroquine has been
established. In a small preliminary clinical trial, Hydroxychloroquine treatment is
significantly associated with viral load reduction or disappearance in COVID-19 patients and
its effect is reinforced by azithromycin.

According to latest surviving sepsis guidelines for COVID 19 patients (published in

2020), low dose corticosteroid is suggested for ARDS patients and also in patients with
hemodynamic shock. Low dose corticosteroid therapy reverses shock early and is
associated with shorter length of stay in ICU as well as in hospital compared to no
corticosteroid therapy.

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Parenteral hydrocortisone (100 mg loading dose followed by 50 mg QID or 200
mg/day infusion) or parenteral methylprednisolone (2mg/kg/day for 3 days) followed
by oral prednisolone for 7 days then taper over a week. If there is no clinical response is
noted for 3 days of steroid therapy, it better to taper and stop to avoid complications of
its use.

Patients who are non-critically ill hemodynamically stable patients in ward should be
fed orally. Oral feed should consist of balanced diet rich in al l nutrients and vitamins
and dieticians should be advised to plan whole day menu. In critically ill patients,
enteral feeding should be commenced via ryles tube if oral intake is poor. In
mechanically ventilated patients enteral feeding should be started within 24-48 hours of
intubation.

According to past medical history, continue all drugs for control of hypertension,
diabetes mellitus, asthma, COPD, chronic renal disease, rheumatoid arthritis etc.
During intensive care management of SARI, determine which chronic therapies should
be continued and which therapies should be stopped temporarily. There is also need for
adjusting doses of medications and changing the route of administration.

Communicate pro-actively with patients and families and provide support and
prognostic information. Understand the patient’s values and preferences regarding life -
sustaining interventions.

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The indications of intubation for COVID-19 infected patients are as follows: patients
who are severely hypoxemic despite high flow oxygen therapy, or patients developing
hemodynamic shock, poor mentation (Glasgow coma scale<7), cardiac arrest patients.
The intubation of trachea should be performed by most experienced healthcare worker
in single attempt. Prexygenation with 100% oxygen for five minutes may be performed
before intubation, however, bag and mask ventilation should be avoided during apnea
after relaxant has been administered as it is associated with aerosol generation. Proper
PPE should be applied including head cover and eye protection by HCW.
Videolaryngoscopy should be preferred over conventional laryngoscopy as
Videolaryngoscopy minimized proximity between the operator and the patient.
However, if videolaryngoscope or an operator skilled in this technique is not available,
conventional direct laryngoscope may be used.

Following intubation, endotracheal tube cuff should be inflated with 5-6 mL air and
tube should be connected to ventilator circuit through a HME filter. Bilateral air entry
must be confirmed with chest auscultation.

Drugs for intubation

During preoxygenation for five minutes with 100% O2, Inj Midazolam 5mg IV with
opioid (Inj Fentanyl 100 micrograms IV or Inj Morphine 7.5 mg IV) should be
administered slowly to induce the state of anesthesia. Following this immediately,
muscle relaxant (Inj Succinylcholine 100 mg IV or Inj Vecuronium 6-8 mg IV) is
administered.

Ventilator Setting
Initial setting of ventilator should be as follows: tidal volume 4-8 mL/kg predicted body
weight, FiO2 100%, PEEP 5 cmH2O, RR 16-20/min and I:E ratio 1:2. Setting may be
changed after arterial blood gas (ABG) evaluation. Most of the patients of COVID 19

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develop ARDS therefore, it is imperative to monitor plateu pressure (Pplat) and tidal
volume should be adjusted to keep Pplat<30 cmH2O. FiO2 and PEEP is adjusted to
maintain SpO2 88 to 92% (PaO2, 55 to 80 mmHg). The use of lung recruitment
maneuvers (intended to open otherwise closed lung segments, such as 40 cm H2O
inspiratory hold for 40 seconds) is suggested, over not using recruitment maneuvers.

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In critically ill patients, it is imperative to prevent complications related to critical
illness, invasive devices, positioning and side effects of therapeutics. Following
interventions should be employed as bundles approach to prevent complications.

 Stress ulcers are common in patients on mechanical ventilation (>48 hours

duration) or/and in those who are coagulopathy. Stress ulcers can be prevented
using proton pump inhibitors or histamine-2 receptor blockers.
 Stress induce hyperglycemia is very common in medical ICU patients and is
associated with negative outcomes. Hyperglycemia is corrected using human
insulin infusion titrated to glucose levels (140-180 mg/dL). Sugar monitoring
should be performed every 2-4 hourly in all ICU patients..
 Spontaneous awakening trials (SAT) and Spontaneous breathing trials (SBT) are
done to wean early of ventilator. Minimize continuous or intermittent sedation,
targeting specific endpoints (light sedation unless contraindicated) or with daily
interruption of continuous sedative infusions
 In order to prevent VAP (ventilator associated pneumonia): Oral intubation is
preferable to nasal intubation in adolescents and adults. Keeping head end
elevated to 30-45º and using closed suction catheters help prevent VAP too.
 Use a new ventilator circuit for each patient; once patient is ventilated, change
circuit if it is soiled or damaged but not routinely. Change HME (heat moisture
exchanger) filter every 2nd day and closed suction catheters every 7 th day are
parts of good ventilator practice to prevent VAP.
 Thromboprophylaxis should be provided in the form of intermittent pneumatic
compression device or heparinization (using low molecular weight heparin of
unfractionated heparin). Central line bundle (during insertion and maintenance)
help prevent CRBSI (catheter related blood stream infections). Remove central
line if not indicated.

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 Timely de-escalation of antibiotics may prevent development antibiotic toxicities,
reduce cost and improve outcome.
 Changing position of patient every two hours can prevent development of
pressure ulcers.
 Mobilization therapy to chair/in-bed sitting position help to wean off ventilator
early and also prevent ICU acquired weakness,

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Clinical samples of COVID-19 suspect or recovered patient will be sent to microbiology
laboratory for testing of 2019-ncoV, till then patient will be kept in isolation. If patient
becomes 2019-ncoV negative, the discharge will be done by treating physicianafter
confirmed report by laboratory as guided by patient’s clinical condition. The case shall
still be monitored for 14 days after their last contact with a confirmed 2019-nCoV case.
In case the laboratory results are positive for nCOV, the case shall be managed as per
the confirmed case management protocol. The case shall be discharged only after
evidence of chest radiographic clearance and viral clearance in respiratory samples after
two specimens test negative for nCOV within a period of 24 hours.

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The health worker attending to the dead body should perform hand hygiene, ensure
proper use of PPE (water resistant apron, goggles, N95 mask, gloves). After death of
COVID-19 positive patient, the dead body will be cleared off all invasive devices (tubes,
catheters and drains whatsoever) and puncture hole should be disinfected with 1%
sodium hypochlorite solution and plugged or sealed with micropore/dynaplast to
prevent leakage of infectious tissue fluid. All sharps should be disposed into a sharps
container. Oral, nasal orifices of the dead body should be plugged using dry cotton
gauze to prevent leakage of body fluids. The dead body should be placed in leak -proof
plastic body bag. The exterior of the body bag can be decontaminated with 1%
hypochlorite. The body bag can be wrapped with a mortuary sheet or sheet provided by
the family members. The body will be transported from hospital facility to
crematorium/burial ground through designated “Shav Vahan” (body carrier vehicle)
by designated staff (trolley-man). Inside vehicle, one relative will be allowed
throughout journey. The trolley-man and relative should also wear surgical mask and
hand-glove for their safety.

The vehicle, after the transfer of the body to cremation/ burial site, will be
decontaminated with 1% Sodium Hypochlorite.

The Crematorium/ burial Ground staff should be sensitized that COVID 19 does not
pose additional risk. The staff will practice standard precautions of hand hygiene, use of
masks and gloves. Viewing of the dead body by unzipping the face end of the body bag
(by the staff using standard precautions) may be allowed, for the relatives to see the
body for one last time. Religious rituals such as reading from religious scripts,
sprinkling holy water and any other last rites that does not require touching of the body
can be allowed. Bathing, kissing, hugging, etc. of the dead body should not be allowed.
The funeral/ burial staff and family members should perform hand hygiene after
cremation/ burial. The ash does not pose any risk and can be collected to perform the

25
last rites. Large gathering at the crematorium/ burial ground should be avoided as a
social distancing measure as it is possible that close family contacts may be
symptomatic and/ or shedding the virus.

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COVID-19 Corona isolation wards need to follow these steps to ensure safe handling
and disposal of biomedical waste generated during patient care.Follow the same
principle segregation of waste as per Bio-medical Waste Management,
(Amendment) Rules, 2018.

Table.1. Segregation of biomedical waste and disposal

Color coded bag/box Broadly include Items Disposal method

Yellow Infectious non-plastic, non- Incineration
sharp
Red Infectious plastic, non- Autoclave or microwave
sharp (recycle)
White Sharp box Sharp (metal ) Sharp pit
Blue Box Glass , metal implants Autoclave (recycle)

However, the following additional steps need to be kept in mind.

 Keep separate dedicated color coded bins/bags/containers in corona isolation

wards
 Use double layered bags (using 2 bags) should be used for collection of waste
from COVID-19isolation wards so as to ensure adequate strength and no-leaks
but depends on availability
 Use dedicated trolley and collection bins and Disinfect them with 1% sodium
hypochlorite
 Transport to Incineration - Waste collected from isolation ward and screening
area to be carried by dedicated personnel for incineration of wastes generated at
the respective areas.

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 Disinfection: The inner and outer surface of bags/containers/ collection bins/
trolleys should be
 disinfected with 5 % sodium hypochlorite also screening area and isolation
wards to be disinfected by hypochlorite mopping
 General waste not having contamination should be disposed as solid waste
(black bag) like papers etc
 Maintain separate record of waste generated from COVID-19 isolation wards
 PPEs: For Housekeeping personnels - 2 layered Gloves , N95 Masks and PPE to
be used and changed accordingly
 PPE disposal: All to be disposed in Yellow bag.

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10. American College of Radiology. ACR recommendations for the use of chest
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