Guidelines for Management of Patients with Possible and Confirmed COVID-19

March 11, 2020

DOH DEPARTMENT MEMORANDUM NO. 2020-0108

 

I. BACKGROUND AND RATIONALE

After a cluster of pneumonia cases of unknown etiology was reported in Wuhan City, Hubei Province of China last December 31, 2019, Chinese health authorities preliminarily identified the cause of this vital pneumonia as a new or novel type of coronavirus (2019-nCOV).

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

In view of the continuation of the local case of COVID-19, the Department of Health (DOH), in collaboration with the Philippine Society for Microbiology and Infectious Disease (PISMID) hereby issues the following algorithms to guide frontline quarantine officers and healthcare providers in the identification and management of Patients Under Investigation (PUIs) and confirmed COVID-19 patients. These algorithms repeal all previous issuances on Decision Tool for COVID-19 infection.

II. IMPLEMENTING GUIDELINES

A. Algorithm for Triage of Travelers with Possible Coronavirus Disease-2019 (COVID-19) Infection in PORTS OF ENTRY

1. Defining Persons Under Investigation (PUIs) & Persons Under Monitoring

Annex A illustrates the algorithm for the triage of patients with possible COVID-19 infection in ports of entry (as of March 11, 2020).

2. Roles & Responsibilities

a. For PUIs identified at Ports of Entry, Bureau of Quarantine (BOQ) shall:

i. Isolate PUI

ii. Give face mask

iii. Collect and evaluate the BOQ Health Declaration Checklist (Annex B)

iv. Assess PUI For severity of symptoms, age, and co-morbidities:

1. For PUIs with mild symptoms, no co-morbidities and/or non-elderly, refer to item no. 2.

2. For PUIs with mild symptoms, elderly anchor with co-morbidities:

a. Collect swab (NPS/OPS)

b. Fill Case Investigation Form and submit this together with specimen to RITM

c. Transport PUI to Level 2/Level 3 hospital

v. Give DOH Coronavirus Disease 2019 (COVID-19) Emergency Operation Center (EOC) list of PUIs

b. For PUIs with mild symptoms, no co-morbidities and/or non-elderly and PUMs identified at Ports of Entry:

i. BOQ shall:

1. Collect and evaluate the signed BOQ Health Declaration Checklist (Annex B) at points of entry.

2. Fill Case Investigation Form and submit to Regional Epidemiologic Surveillance Unit for PUIs with mild symptoms, no co-morbidities and/or non-elderly.

3. Advise the person to go on home quarantine for 14 days (Annex C).

4. Provide the list of PUIs and PUMs to DILG, DOH COVID-19 Emergency Operation Center and concerned Center for Health Development by 6AM and 6PM of every day.

ii. Dept. of the Interior and Local Government shall:

1. Provide the list PUMs to the concerned DILG regional office which in turn will provide the segregated list to the city or municipal local chief executive.

iii. Center for Health Development shall:

1. Notify local Health Office (Provincial Health Office & City Health Office/Municipal Health Office) of the PUIs and PUMs profile, status and location of PUIs and PUMs

iv. Provincial Health Office & City Health Office/Municipal Health Office shall:

1. Provide a plan for self-monitoring instructions and notification if symptoms develop

2. Mobilize the local health workers and Barangay Health Emergency Response Teams to monitor on a daily basis the condition of the PUIs and PUMs respectively over the course of the home quarantine period

3. Mobilize Barangay Tanod and/or uniformed personnel as may be needed to enforce home quarantine

4. Issue certificate of completion of 14-day home quarantine (Annex D)

5. Report back to the Center for Health Development on the status of PUIs and PUMs

B. Algorithm for Triage of Patients with Possible Coronavirus Disease-2019 (COVID-19) Infection in HEALTHCARE FACILITIES

1. Defining Persons Under Investigation (PUIs) & Persons Under Monitoring

Annex E illustrates the algorithm for the triage of patients with possible COVID-19 infection in healthcare facilities (as of March 11, 2020).

2. Roles & Responsibilities of Health Care Providers

a. Hospitals shall download and completely fill Case Investigation Forms.

b. Hospitals shall keep one copy of the CIF, transmit one copy along with the specimen, and email the Research Institute for Tropical Medicine (RITM) or applicable subnational laboratory and the regional epidemiology surveillance unit simultaneously.

c. Hospitals shall ensure that all health practitioners follow DOH guidelines in clinical management.

C. Interim Guidelines on the Clinical Management of Coronavirus Disease 2019 (COVID-19)

1. Triage of Patients with Respiratory Symptoms

a. Patients with respiratory symptoms are encouraged to contact the DOH hotline for phone-based triaging.

b. Patients shall be referred to health center if symptoms are mild, and to a Level 2 or Level 3 hospital if severe.

2. Management of PUIs and Confirmed Cases of COVID-19

a. All health facilities shall ensure that PUIs are assessed, tested, managed, and referred accordingly:

i. If PUI has mild symptoms with no comorbids, and/or non-elderly, health facilities shall obtain specimens, advise them to be sent home for strict self-isolation and close monitoring by local health authorities for 14 days:

1. If symptoms persist or worsen, patient should be referred to the nearest Level 2 or Level 3 hospital

ii. If PUI has severe or critical symptoms, refer them to nearest Level 2 or Level 3 hospital for admission.

b. PUIs shall be tested using respiratory specimens for COVID-19 real-time PCR testing. Serological testing may be done in selected centers. If with limitations of testing kits, prioritize collection of specimens among high-risk patients:

i. All samples should be sent to RITM-accredited testing laboratories.

ii. All samples should be accompanied by completely filled Case Investigation Forms.

c. For mild PUIs who are elderly (60 years old and above) or with co-morbidities who require admission, admit to isolation rooms. Considering the nature of the pathogen, regular rooms may be converted to isolation rooms.

d. For severe or critical PUIs, admit to ICU with appropriate infection prevention and control protocols

e. All health care providers shall refer to clinical practice guidelines published by the Philippine Society for Microbiology and Infectious Diseases.

3. Recommendations for repeat testing for COVID-19

a. Repeat testing after an initial negative COVID-19 test.

Repeat testing for patients with an initial negative COVID-19 test result shall be performed ONLY if there is a high index for suspicion for COVID-19 infection despite an initial negative test result. Such conditions include, but are not limited, to the following:

1. Clinical deterioration in the presence of an established disease etiology and with adequate treatment. A single negative test result, particularly if this is from an upper respiratory tract specimen, does not exclude infection. Repeat sampling and testing, preferably of lower respiratory specimen, is strongly recommended in severe or progressive disease. Consider a possible co-infection with COVID-19.

2. Clinical specimen(s) initially sent was/were deemed to be unsatisfactory or insufficient (e.g., delay in transport and processing).

4. Criteria for discharge

a. Admitted PUIs with negative COVID-19 test can be discharged as clinically appropriate.

b. Criteria for discharge of patients with confirmed COVID-19:

1. Patients who have clinically recovered (with resolution of symptoms) may be discharged from the hospital and advised monitored self-isolation for 14 days.

2. Repeat testing after a positive COVID-19 test is not needed as a criteria for discharge.

3. The attending health care provider shall provide advise and refer to local health authority for monitored self-isolation.

4. Local health authority shall monitor discharged patient and ensure that repeat testing is carried out after 14 days.

(SGD.) FRANCISCO T. DUQUE III, MD, MScSecretary of Health

ANNEX A

Algorithm for Triage of Travellers with Possible Coronavirus Disease-2019 (COVID-19) Infection in Ports of Entry

 

ANNEX B

Health Declaration Checklist

ANNEX C

February 27, 2020

DEPARTMENT CIRCULARNo. 2020-0105

 

 

The Department of Health reiterates its directive to all Persons Under Monitoring (PUMs) for COVID-19 and their caretakers on the proper management response and home quarantine procedures. Identified PUMs shall be required to complete 14-day home quarantine. Respective local health officials shall issue the certificate of quarantine completion at the end of the prescribed period.

In the event that flu-like symptoms are experienced, passengers must contact the Department of Health or their preferred healthcare provider immediately. Previously published protocols remain in effect.

Dissemination of the information to all concerned is requested.

(SGD.) FRANCISCO T. DUQUE III, MD, MScSecretary of Health

February 17, 2020

DEPARTMENT MEMORANDUMNo. 2020-0090

 

 

I. BACKGROUND

After a cluster of pneumonia cases of unknown etiology was reported in Wuhan City, Hubei Province of China last December 31, 2019, Chinese health authorities preliminarily identified the cause of this viral pneumonia as a new or novel type of coronavirus.

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

The Department of Health (DOH) hereby issues interim guidelines on the management of persons under monitoring (PUMs) suspected with Coronavirus Disease 2019 (COVID-19) for home quarantine.

II. GENERAL GUIDELINES

A. Any person, regardless of nationality, race and age, who does not exhibit any sign nor symptom, has history of travel to other areas of China and/or history of exposure to a continued ease of COVID-19, within the past 14 days, shall be required to undergo monitored home quarantine.

B. Any person, regardless of nationality, race and age, who exhibits fever or any symptom of lower respiratory illness, and has a history of travel to other countries with a confirmed case of COVID-19 but without any history of exposure, shall be advised to undergo monitored home quarantine.

C. Those undergoing home quarantine shall be prohibited to leave their rooms/homes where they are quarantined until they have been certified by the local health official to have finished the 14-day requirement for quarantine procedures.

D. Initial coordination should be done with the Local Government Epidemiologic Surveillance Unit on the logistical, administrative and clinical parameters to be standardized in any attempt to refer a PUM for transfer or consultation.

III. IMPLEMENTING GUIDELINES

A. Room Isolation and Contacts of Persons Under Monitoring (PUM)

1. Place the PUM alone in a well-ventilated room, preferably with toilet and bathroom. If this is not possible, maintain a distance of at least 1 meter from the PUM (e.g., sleep in a separate bed).

2. Assign one person who is in good health as caretaker of the PUM.

3. Visitors, family members and even caregivers are not allowed in the PUM's room, if possible.

4. Confine activities of the PUM in his/her room only. If this is not possible, ensure that shared spaces (e.g., kitchen, bathroom) are well ventilated (e.g., keep windows open).

B. Use of Disposable Surgical Mask

1. The PUM should wear a surgical mask fitted tightly to the nose, mouth, and chin when in the same room with another household member or when talking to other people. The use of masks is not required for the person/s the PUM is/are interacting with.

2. If alone, the PUM is not required to wear a mask.

3. Masks should not be touched or handled during use. If the mask gets wet or dirty with secretions, it must be changed immediately and disposed properly.

4. Discard the used mask after a maximum use of 8 hours. Masks are not reusable and should not be washed. After removal of mask, wash hands using water and soap, or rub hands with 70% alcohol or any hand disinfectant.

C. Hand Hygiene Practice for ALL

1. All PUMs and household members should perform hand hygiene following contact with PUM or if in contact with their immediate environment.

2. Perform hand hygiene by washing hands with soap and water. If hands are not visibly soiled, 70% alcohol or any alcohol-based hand rub can be used.

3. When using soap and water, disposable paper towels to dry hands is desirable. If not available, use dedicated cloth towels and replace them when they become wet.

4. Hand hygiene should also be performed before and after preparing food, before eating, after using the toilet, and whenever hands look dirty.

5. Address safety concerns (e.g., accidental ingestion by children and fire hazards) on the use of alcohol-based hand rubs.

D. Respiratory Hygiene and Standard Precaution for ALL

1. Respiratory hygiene/cough etiquette should be practiced by all at all times. Respiratory hygiene refers to covering the mouth and nose during coughing or sneezing using surgical masks, tissues, flexed elbow, sleeves of clothes, or inside the neckline of shirts, followed by hand hygiene.

2. Avoid direct contact with body fluids, particularly oral or respiratory secretions, and feces. Use disposable gloves to provide oral or respiratory care and when handling feces, urine and waste. Wash hands before putting on and after removing gloves.

3. Avoid other types of possible exposure to PUM or contaminated items in their immediate environment (e.g., avoid sharing toothbrushes, cigarettes, towels, washcloths, bed linen).

E. Food Handling of PUM on Home Quarantine

1. The assigned caretaker of the PUM shall serve their plates/meal trays only up to the room door.

2. After eating, plates/meal trays should be picked up at the room door by the caretaker using disposable gloves to avoid contamination. Perform hand hygiene afterwards.

3. Eating utensils and dishes should be cleaned with soap or detergent and water after use and may be re-used instead of being discarded.

4. Do not share eating utensils, dishes, and drinks with PUM.

F. Disposal of Used Gloves, Tissues Papers, and Masks

1. Immediately discard materials used to cover the mouth or nose into the trash or clean reusable items appropriately after use (e.g., wash handkerchiefs using regular soap or detergent and water).

2. Gloves, tissues, masks and other waste generated by PUM should be placed in a container in PUM's room before disposal with other household waste.

G. Cleaning and Disinfection

1. PUMs are encouraged to clean and disinfect frequently touched surfaces such as bedside tables, doorknobs, bedframes, and other bedroom furniture daily with regular household disinfectant containing a diluted bleach solution (1-part bleach to 99 parts water).

2. Clean and disinfect bathroom and toilet at least once daily with regular household disinfectant containing diluted bleach solution (1-part bleach to 99-parts water).

3. Clean clothes, bedclothes, bath and hand towels, etc. of PUM using regular laundry soap and water or machine wash at 60-90 ºC with common household detergent, and sun-dry. Place used linen into a laundry bag. Do not shake soiled laundry. Additional measures may be needed to prevent unhygienic reuse of gloves, masks, avoid direct contact of the skin and clothes with the contaminated materials.

4. Use disposable gloves and protective clothing (e.g., plastic aprons) when cleaning or handling surfaces, clothing or linen soiled with body fluids. Perform hand hygiene before and after removing gloves.

H. Reporting

1. PUM who developed symptoms should be reported immediately to Regional Epidemiology and Surveillance Unit (RESU) or Local Surveillance Officer for transport to nearest health facility.

2. All household members of PUM should be advised to seek immediate medical care when signs and symptoms developed.

For strict compliance of all concerned.

(SGD.) FRANCISCO T. DUQUE III, MD, MScSecretary of Health

ANNEX D

Quarantine Clearance

ANNEX E

Algorithm for Triage of Patients with Possible Coronavirus Disease-2019 (COVID-19) Infection in Healthcare Facilities