Preventing community transmission while awaiting COVID-19 test results

Given that India is nearing the community transmission phase of the COVID-19 pandemic, experts feel there is need for quarantine/isolation in the time lag between testing and receiving pathology results to prevent transmission from asymptomatic positive patients. Dr Meeta Ruparel, PhD Lean Six Sigma Operations and Healthcare Management, presents some solutions on which symptoms could assist in these decisions

COVID-19! A pandemic outbreak never seen before! Many of us may have read in science on pandemics, but like me, are witnessing this wide spread for the first time.

The first case of COVID-19 detected in India was on 30th January, 2020. According to the World Health Organization (WHO) situation report; “As on 31^st January, 2020, a total of 9,720 confirmed cases and 213 deaths were reported in China. The epicentre of the outbreak was initially in Wuhan City, Hubei province but it rapidly extended to all other provinces of China. Outside of China, 19 countries reported a total of 106 confirmed cases, most with travel history from China.”

As per expert guidelines, social distancing and lock down were found as the best solutions to flatten the pandemic curve by all affected countries’ authorities.

WHO’s India situation report nine stated: “909 Confirmed cases and 19 Deaths.” A lockdown was announced by the Prime Minister of India on 25^th March, 2020 to break the chain of the pandemic spread. As I write, COVID-19 cases continue to rise in the country. As per media reports, “According to the health ministry of India, there were 1,965 total confirmed cases as on 2^nd April, 2020. While 151 people have been cured, the virus has claimed 50 lives.” As per television media news on 5^th April, 2020: “the total COVID-19 cases detected were 3,074, there were 77 deaths and 58 were at high risk.” Further, WHO’s India situation report 10 stated, “3,577 confirmed cases and 83 deaths” and as per television media reports on 10^th April, 2020, “the total COVID-19 cases detected are 6,412, there have been 199 deaths and 504 have recovered.”

Our healthcare workers are dedicatedly working 24×7 ever since the outbreak; all are striving to save lives. There is fear and panic but there is a firm and determined confidence that exudes united power prepared to confront the pandemic, amongst all citizens; the voice is loud and clear, it says, “We stand together! We will survive and come out safe!”Although prepared to confront amidst apprehensions of risk to life, there are many challenges that are arising every day that has made healthcare professionals pool in all their knowledge and experiences, to understand the virus, analyse its spread, curb it and cure the infected population. The challenges at large can be broadly categorised as:

• Medical: No confirmed medicinal cure, no vaccine (research initiated), speedy medicine supply chain management (all at once at all places), etc.
• Technical: Tests take at least two days to give results (We have an innovative solution now that enables test results in 45 minutes, trials in process). Lack of test kits, shortage of ventilators, shortage of PPE, shortage of infectious /contagious cases-speciality hospitals and isolations wards.
• Public health management: Detect, trace, test and quarantine /isolate to prevent further transmissions and ways to flatten the curve and reduce mortalities.
• Economic slowdown and building frustrations: Lockdown has shut all industries, work from home is limited and constrained, academics are affected, daily wages workers have lost their daily earnings and means of livelihood, migrant workers are stranded and unable to reach their homes.
• Digressed attention to patients already in hospitals or undergoing some treatment, scarcity of healthcare workers, unavailability of specialised doctors, unable to travel to their care provider, all due to the lockdown.

While uplifting the economic slowdown and academic revivals would be a strategy after we are safe from this pandemic, frustrations have been addressed by regular motivational speeches by our country leaders, sensitisation of hand hygiene, social distancing, etc. is also enforced by regular media (TV and social media) interventions by leaders, TV and Bollywood actors;  small creative audio visuals of exercise and self-care during lockout at home and motivational activities by our leaders calling all citizens to stand united; the bravery and strength displayed in such unity does build motivations and the positivity goes a long way in the minds of the people at all levels.

Non-COVID-19 patients under treatment are encouraged to opt for telephonic consultations unless an emergency, so that more healthcare workers are focused on COVID-19 patients. The government has also announced insurance schemes for these frontline caregivers thereby giving them security in advent of getting infected whilst at work. The state government, NGOs and citizens, all are meticulously working to provide meals, masks, medicines and shelters to poor, daily wagers and migrant workers and some states government have announced monthly monetary support and other indirect support like free gas cylinder, for three months.

However, the hovering challenges of “detect, trace, test, quarantine / isolate and cure”and resource shortages are still a confusion, which is not to be blamed given the large population of India. Shortage of isolation units, test kits, PPE, ventilators and healthcare manpower, is a challenge faced globally by all countries affected with the outbreak. Our government has encouraged indigenous manufacturing and placed orders for new test kits, ventilators and PPE in large numbers, based on presumed estimation of likely requirements in the coming days. However, these new orders would be available in the market for use after few weeks /months. The new test kits after trials and approvals shall be available after three/ four weeks and the ventilators after two/three months.

Allow me to highlight the fact that medical experts state that a high risk patient dies within 48 hours if not provided ventilator support, a healthcare worker exposed to the virus is likely infected if not wearing appropriate PPE and most importantly; one infected is passing the virus to at least three people in contact, indicating a fast transmission.

So, according to the feedback from authorities in the present situation, we are not adequately equipped and till the newly-ordered equipment arrives, the healthcare workers will continue working with risks and frustration of being unable to save a possible fatality if a ventilator was unavailable and the inability of conducting more tests per day to detect and quarantine infected patients to avoid further transmission and flatten the curve as early as possible.

The question is, how can we address these shortages and scarcities in the current time, till the newly manufactured equipment arrives? Another candid question is, wouldn’t the pandemic curve flatten in next two/three months? Once the curve is flattened and if the pandemic spread is contained before the new ventilators arrive, probably these expensive new ventilators may remain idle and be a waste of investment unless utilised to fill the lack of adequate ventilators to its fullest capacity, in the country.

Moreover, as the pathology test currently takes two days and the flow of COVID-19 cases is continuous in this outbreak, resulting in crowding, long waiting and likely transmission at test centres, a system needs to be in place to mitigate these challenges.Today, I herein discuss some of the solutions that can assist in efficient mitigation response system addressing the issues and challenges faced due to the COVID-19 pandemic.

Below is a checklist of COVID-19 tests and symptoms to assist in quarantine/isolation decisions before COVID-19 pathology test results arrive:

• Recent international travel or in contact with someone who had a recent travel
• Cold
• Cough
• Sore throat
• Fever
• Breathing difficulty

Some international scientists have also shared their observations of few cases of headaches, few cases having experienced loss of sense of smell, etc. This, however, needs to be evaluated to be considered as a symptomatic parameter. Hence, not all countries include it in the symptoms checklist, except loss of sense of smell observed in National Health Services (NHS), UK’s symptom checklist.

Apart from these symptoms, let’s understand that COVID-19 infects the respiratory tract and lungs; the oxygen saturation level goes low and infection spreads in lungs, which is observed with inflammation in lungs. Hence, other two tests that could be conducted are:

• SpO2 level with pulse-oximeter that indicates the oxygen saturation level
• X-ray that shows infection spread in the lungs

Although, not all countries monitor SpO2 and chest X-ray, i.e. to my knowledge; Germany screens with X-rays and Italy measures SpO2 level as a symptomatic parameter. In an interview on television, a doctor from New York shared that they were monitoring SpO2 and X-rays, as it was observed that SpO2 levels changed drastically within three to four hours in acute cases. I believe both SpO2 monitoring and chest X-ray; as significantlyimportant indicating screening parameters that would be instrumental in detecting likely high-risk cases that may soon require ventilator support on an early stage basis wherever possible. As of April 10, 2020, current fatality due to COVID-19 in India is 199 and high risk is approximately 122, I therefore suggest including both these screening measures in the first symptomatic checklist to detect the onset of the lung inflammation at its initial stages and mitigate high-risk cases, ventilator shortages and intensive care isolation units requirements more efficiently and thereby enable  a proactive mode of approach to reduce mortalities due to COVID-19.

Challenges, addressing issues and solutions:

Ventilator shortage:

• In advent of absence of ventilator, “Ambu Bag” (manual resuscitator) can be used.
• If need be, the Ambu bag can be automated to pump in specified speed/frequency.
• There are critical care ambulance services in many metro cities, which are equipped with ventilators. Maybe some of them could be used as isolation units.
• Some doctors suggested exploring possibility of connecting two patients to one ventilator with a bivalve. However, this tends to be risky in likely transmissions through common airways and breach of social distancing protocols suggested minimum distance, hence, not recommended.

Lack of quarantine space and isolation units:

• Modular partitions covered with tent shades can be used to build quarantine rooms/isolation units in open space areas like parking lots, open grounds, stadiums, etc.
• These partitions are of porous in nature, since virus doesn’t stay on porous surface for more than few hours; it is suggested to use such partitions. In addition, these setups can be easily sanitised /fumigated.
• Since it is open area, the air cycle and environment would be as required (negative pressure), more sunlight, natural air and air cycle controlled with fans and exhausts; wherever required.
• The partitions so designed ensure social distancing within the detected/likely detections and isolated cases. Since the places identified are open areas, the residents around or (in case of hospital) hospital patients are safe and prevented from any likely infections.
• These types of modular structures in a controlled boundary with proper security would address security issues faced currently of patients quarantined that are found escaping, running away without a healthy status check approval.
• It has been observed by many doctors internationally and nationally that Vitamin D and Vitamin C are playing a crucial role in successfully treated cases by increasing the immunity levels.
• Keeping Tulsi (Holy Basil) plants in surrounding will also help in healing as Tulsi releases oxygen for 20 hours and ozone for four hours a day along with the formation of nascent oxygen which absorbs harmful gases like carbon dioxide, carbon monoxide and sulphur dioxide from the environment.
• High-risk isolation cases can be kept in critical care/ICU ambulances individually; to ensure focused intensive care with complete isolation.

Crowding, confusion and long waiting times:

Test centres are heavily burdened with rush of cases every minute/hour in situations of pandemics. A well-defined healthcare delivery system needs to be in place to reduce crowding, avoid confusions and reduce waiting times at such centres. A triage system could make the system more streamlined. The triage objectives should be as per COVID-19 test requirements:

(a) As soon as an individual enters/reports to the centre, data entry and registration process followed by identity proof, name, address, contact and other medical history details, along with first level of symptoms check, as described by the registrant (further referred as patient) should be noted.

(b) If recent international travel history/or in contact with a recent international traveller, send the patient to Section A and if no history of recent travel nor in contact with a recent traveller then send the patient to Section B. In this way, we can avoid likely transmission whilst waiting at the centres.

(c) Section 1 of triage: Clinical assessment of symptoms by doctor/healthcare staff

• Fever: Thermometer (temperature) reading documented
• Cold (running nose/sneezing /nose blocks, etc.), if observed documented
• Cough(dry/wet), if observed documented
• Sore throat, if observed documented
• Breathing difficulty, if observed documented
• SpO2 level: Pulse oximeter reading documented
• In case of abnormal SpO2 (less than 95) or difficulty in breathing, then X-ray is prescribed.

(d)          If x-ray issued patient sent to Section 2 of triage: waiting area for X-ray checks.

(e)          If SpO2 normal and no difficulty in breathing and no international travel history/not come in contact with any international traveller, but any one of the other symptom noted, patient is sent home for home quarantine followed with regular checks for seven days. If difficulty in breathing experienced and any other symptom from the check list observed in the seven-day check, patient is prescribed an X-ray; if any inflammation/infection spread observed, patient’s sample taken for COVID-19 pathology test and patient sent to quarantine area for further checks.

(f)           If no symptoms, but history of recent international travel or have come in contact with a traveller is in affirmative, then patient sent to quarantine area for seven days and patient’s sample taken for COVID-19 pathology test on first day and second pathology test report taken again on fifth day (because a likely COVID-19 case in window period) and then regularly checked for symptoms. If no symptoms after seven days and both pathology test reports are negative, patient sent to home quarantine followed with regular checks for 14 days.

(g)          If SpO2 normal and no difficulty in breathing, but any one of the other symptoms noted, along with recent international travel or have come in contact with a traveller is in affirmative, then patient sent to quarantine area for seven days. Patient’s sample taken for COVID-19 pathology test on first day and second pathology test report taken again on fifth day (because a likely COVID-19 case in window period) and then regularly checked for symptoms. If any one symptom after seven days, but both pathology test reports are negative, patient sent to home quarantine followed with regular checks for 14 days.

If any one of pathology test is positive, then patient sent to quarantine isolation area for 21 days followed with regular checks and sent to home quarantine for 14 days, only after pathology test shows negative and patient is cured/free from infection (checks include fever, SpO2 and X-ray, along with pathology test at regular intervals)

(h)          If SpO2 abnormal, but X-ray does not indicate any inflammation or infection spread in lungs, but any one of the other symptoms exist and there is history of recent international travel or have come in contact with a traveller is in affirmative, then patient sent to quarantine isolation area for seven days (because a likely COVID-19 case in window period) patient’s sample taken for COVID-19 pathology test on first day and second pathology test report taken again on fifth day. If both pathology tests are negative and X-ray is normal, then patient sent to home quarantine for 14 days followed with regular checks.

But if any one of pathology test is positive, then patient sent to quarantine isolation area for 21 days followed with regular checks and sent to home quarantine for 14 days, only after pathology test shows negative and patient is cured/free from infection (checks include fever, SpO2 and x-ray, along with pathology test at regular intervals)

(i)            If SpO2 abnormal, X-ray also indicates inflammation or infection spread in lungs and any one of the other symptoms exist and there is history of recent international travel or have come in contact with a traveller is in affirmative, then patient sent to high risk isolation area for three days (because a likely COVID-19 high risk case requiring ventilation) and patient’s sample taken for COVID-19 pathology test on first day and second pathology test report taken again on third day. If both pathology tests are negative, patient sent to a hospital ICU for further care.

But if any one of pathology test is positive, then patient sent to high risk isolation area and ICU zone if ventilation required. If no ventilator required, then patient is in high risk isolation area for seven days followed with regular checks in quarantine isolation area for next seven days, followed with quarantine area for next 14 days and sent to home quarantine for 14 days, only after pathology test shows negative and patient is cured/free from infection (checks include fever, SpO2 and X-ray, along with pathology test at regular intervals).

If patient is required to be ventilated, then patient is sent to the high-risk isolation intensive care area (like a stationed ICU ambulance in the premise) for three days or till patient requires to be on a ventilator for breathing assistance and further quarantine /isolation area depending on patient’s health condition, checks follow till the patient is cured and infection-free to be sent for home quarantine of 14 days followed with regular checks (checks include fever, SpO2 and X-ray, along with pathology test at regular intervals).

Lack of COVID-19 pathology test kits and facilities:

The triage system shall not only assist in organising a systematic quarantine infrastructure and care service that is confusion free, crowd free and efficient, but will also assist in estimating exact quarantine beds, isolation beds, high-risk isolation beds and ICU isolation beds, ventilators and other medicine supplies required for estimated time duration, which assists in proper bed and care management. This will also provide an insight to an approximate cumulative figure of COVID-19 tests to be conducted and when; in terms of priority. In situations of shortage of test kits and/or testing labs, prioritising is suggested on the basis of time factor, i.e. starting with high priority means the sample that is required to be tested immediately is sent first. Priority listing in terms of time is suggested as follows:

1. Patient’s samples of patient in high-risk isolation area/ICU isolation area (first day and second day samples)
2. Patient’s sample of patients in quarantine isolation area (first day samples)
3. Patient’s sample of patients in quarantine area (first day samples)
4. Patient’s sample of patients in quarantine isolation area (fifth day samples)
5. Patient’s sample of patients in quarantine area (fifth day samples)
6. Patient’s sample of patients in quarantine isolation area (seventh day samples)
7. Patient’s sample of patients in quarantine area (14th day samples)
8. Patient’s sample of patients in home quarantine area (first, fifth and 14th day samples)

Track record and traceability:

A cloud-based common web-based portal should be installed so every centre information (patient registered, count of quarantined, isolated, high risk, on ventilator and home quarantined) is daily updated by staff thus assisting in exacting estimates of pandemic spread, infection traceability, patient tracking, manpower requirements (number of doctors, nurses, paramedics, other healthcare workers, shifts, etc.) and resources like (material, equipment, space, food, PPE, linen and disposables, etc.) requirements and other resources-related demand-supply information.

This kind of updated information shall assist in mobilising resources appropriately to each centre; the supply chain being prioritised as per patient load, patient traffic, infection spread and time priorities for high risk cases.

Precautionary safety measures to be taken to prevent possible transmissions:

• Disinfect ambulances, quarantine beds /isolation beds/ICU beds and other medical and non-medical equipment after every patient use. Change gloves or disinfect with sanitising wipes, after every patient contact to avoid transmission through glove contamination, if any.
• Disinfect/fumigate quarantine area/isolation area/ICU area, its furniture, beds and equipment, after the place is vacated.
• Disinfect toilets and washroom areas of quarantine/isolation area/ICU area, at least twice a day and clean toilets and wash rooms after every patient use.
• Daily disinfect dirty linen/waste disposal and dirty utilities at the end of the day.
• Wash patient’s utensils separately or use disposables.
• Provide safe drinking water in a clean area.
• Provide good water supply for other cleansing purpose for each of the patients and healthcare workers in the area.
• Provide separate toilets/washroom area and changing area for healthcare workers and daily disinfect the areas, at the end of the day.
• Design beds in quarantine area/isolation area/ICU area and other waiting areas considering the safe social distance of three to four feet in between beds/chairs.
• Provide masks to all patients in quarantine /isolation/ICU/ waiting areas and give them guidelines to wash and reuse these masks, if reusable. Healthcare workers should also be provided with masks, gloves and other PPE and guidelines on safety protocols to follow in advent of inadequate PPE.
• Provide precautionary measures and disinfecting procedures guidelines to be followed by patients in home quarantine.
• Sensitise the patients and the population in general on importance of social distancing and ways to follow it in public areas and at home/work place.
• Sensitise the patients and the population in general on importance of wearing masks always when out in public area.
• Disinfect/fumigate school/colleges/parking lots/basements/stadiums/other public areas, if used, and also disinfect its furniture and other equipment, after the place is vacated and before it is opened for its intended public use.
• Disinfect/fumigate theatres, malls, clubs, trains, buses, planes, railway stations, bus depots, bus stands, airports and other public areas, and also disinfect its furniture and other equipment, before it is opened for its intended public use.
• Apart from fumigation, disinfection can be done with disinfectant sprays/wipes and can also be done with UV-C lights. There are special UV-C light sanitisers that sanitise mobile phones, laptops, medical equipment and other equipment, UV-C lights installed in a room sanitize the area when kept on for few minutes, for safety measures the light should be switched on in empty/unoccupied rooms/ areas.

No panic, no fear and a planned system shall ensure exacting estimates, meeting resources shortage challenges and addressing issues like crowding, waiting, confusion and any likely anxiety.