الصحة تعلن إصدار البروتوكول

Management Protocol for

C VID-19 Patients

Ministry of Health and Population, Egypt Version 1.8 / July 2022

Version 1.8 / July 2022

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Table of contents Item

Page Number

Summary of Changes in the New Protocol.................................

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Patient diagnosis and severity assessment ...............................

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Patient management........................................................................

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Post- Acute COVID Syndrome......................................................

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Prevention and Control of Transmission of COVID-19...........

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Ministry of Health and Population Version 1.8 / July 2022

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Summary of Changes in the New Protocol

- Stopping the use of Ivermectin.

- Use of Favipiravir in mild cases only.

- Adding nirmatrelvir / ritonavir for use in mild & moderate cases.

- Stopping the use of colchicine & convalescent plasma.

- Modifying clinical risk factors.

- Use of anticoagulation only in hospitalized patients : prophylactic parenteral anticoagulants in moderate & critically ill patients while therapeutic anticoagulants in severe cases.

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Definition + severity assessment A close contact is defined as following: • face-to-face contact in any setting with a confirmed or probable case without using personal protective equipment (PPE), for greater than 15 minutes cumulative over the course of a week, in the period extending from 48 hours before onset of symptoms in the confirmed or probable case, or • sharing of a closed space with a confirmed or probable case for a prolonged period (e.g. more than 2 hours) in the period extending from 48 hours before onset of symptoms in the confirmed or probable case.

Suspected Case Definition OR

A) Clinical Criteria: Acute onset of fever and cough -Acute ≥ 3 of the following: fever, cough, general weakness/fatigue, headache, myalgia, sore throat, coryza, dyspnea, anorexia/ nausea/vomiting, diarrhea, altered mental status

B Patients with severe acute respiratory infections (SARI) defined as acute respiratory infection with symptoms within 10 days of presentation (cough, fever, and hospitalization).

Probable Case A patient who meets clinical criteria AND is a contact of a probable or confirmed case OR Suspect case with chest imaging showing findings suggestive of COVID-19 disease* OR Recent onset of loss of smell or taste in the absence of any other identified cause OR Unexplained death in an adult with respiratory distress who was a contact of a probable or confirmed case or epidemiologically linked to a cluster with at least 1 confirmed case *Hazy opacities with peripheral and lower lung distribution on chest radiography; multiple bilateral ground glass opacities with peripheral and lower lung distribution on chest CT; or thickened pleural lines, B lines, or consolidative patterns on lung ultrasound.

Confirmed Case A person with laboratory confirmation* of COVID-19 infection, irrespective of clinical signs and symptoms *Molecular testing (PCR) with deep nasal swab is the current test of choice for the diagnosis of acute COVID-19 infection.

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Method of testing • We recommend using a nucleic acid amplification test (NAAT) with a sample collected from the upper respiratory tract (i.e., nasopharyngeal, nasal mid-turbinate, anterior nasal, or oropharyngeal) to diagnose acute infection of SARS-CoV-2; if it is not practical to use a NAAT or if NAATs are not available, an antigen test may be used.

• For intubated and mechanically ventilated adults who are suspected to have COVID-19 but who do not have a confirmed diagnosis, we recommend obtaining lower respiratory tract samples to establish a diagnosis of COVID-19 if an initial upper respiratory tract sample is negative.

• SARS-CoV-2 reinfection has been reported in people after an initial diagnosis of the infection; therefore, clinicians should consider using a NAAT for those who have recovered from a previous infection and who present with symptoms that are compatible with SARS-CoV-2 infection if there is no alternative diagnosis.

SARS-CoV-2 Variants • Like other RNA viruses, SARS-CoV-2 is constantly evolving through random mutations. New mutations can potentially increase or decrease infectiousness and virulence. In addition, mutations can increase the virus’ ability to evade adaptive immune responses from past SARS-CoV-2 infection or vaccination.

• This viral evolution may increase the risk of reinfection or decrease the efficacy of vaccines.

• There is evidence that some SARS-CoV-2 variants have reduced susceptibility to plasma from people who were previously infected or immunized, as well as to certain monoclonal antibodies (mAbs) that are being considered for prevention and treatment • The Omicron (B.1.1.529) variant was designated a VOC in November 2021 and rapidly became the dominant variant across the globe. More recently, the Omicron subvariants BA.1, BA.1.1, and BA.2 have emerged. The Omicron VOC is more transmissible than other variants and is not susceptible to some of the anti-SARS-CoV-2 mAbs that have been developed for treatment and prevention.

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Clinical risk factors 1. Age ≥65 2. Persistent fever > 38 3. SaO ≤ 92% 4. Heart Rate ≥ 110 5. Respiratory Rate ≥ 25 /min.

6. Neutrophil / lymphocyte ratio on CBC ≥ 3.1 7. Uncontrolled Comorbidities 8. Immunosuppressive Drug 9. Pregnancy 10. Active Malignancy 11. On Chemotherapy 12. Obesity (BMI>40) 13. Unvaccinated or not fully vaccinated

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Severity assessment Suspected case Antigen or RT PCR to confirm the diagnosis* Assess disease severity *(clinical, lab, imaging)

Mild symptoms Normal imaging

Imaging: +ve SpO2 ≥ 92%

SpO2 < 92%, PaO2/FiO2 <300, respiratory rate > 30 breaths/min, or lung infiltrates > 50%

Respiratory failure, septic shock, and/or multiorgan dysfunction

Mild

Moderate

Severe

Critical illness

Risk Factor+ No

Home isolation & close follow up If possible

Yes

Hospitals admission COVID area

Admit to Intermediate Care

Admit to Intensive care

In severe and critically ill patients, if-ve 1st PCR, repeat within 48 hours, negative case is considered after 2 –ve consecutive RT-PCR results from respiratory samples tested at least 1 day apart.

NB: Unstable patient who don’t meet the suspected criteria should receive 1st aid therapy in nonCOVID area before referral to general hospital.

All persons with suspected, probable or confirmed COVID-19 should be immediately isolated to contain the virus transmission.

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Simplified Case Definition: 1.Mild: No pneumonia - No hypoxia.

2.Moderate: Pneumonia without hypoxia.

3.Severe: Pneumonia with hypoxia responding to oxygen therapy.

4.Critically-ill: Pneumonia with hypoxia not responding to oxygen therapy and/or organ dysfunction.

2 nd Step: Management -All patients with symptomatic COVID-19 and risk factors for Progression of disease should be closely monitored.

-In some patients, the clinical course may rapidly progress.

-Timing is an important issue in the management of COVID-19. Before day 12(stage of viral load), Antiviral drugs are essential. After day 12, the role of antiviral drugs declines with augmentation for the role of anti-in-flammatory, immune-modulators (stage of hyper-immune state).

-There are insufficient data to recommend either with or against any anti-viral drug or immune-based therapy in patients with COVID-19 who have mild illness.

-Potential antiviral drugs under evaluation for the treatment of COVID-19 include:

• Molnupiravir 200 mg cap – 800 mg (4 capsules) twice/day for 5 days, • Favipiravir 1600 twice daily in the first day then 600 mg twice daily, • Remdesivir 200 mg IV on day 1, followed by 100 mg IV daily for highrisk population for 5 to 10 days.

• Nirmatrelvir 300mg with ritonavir 100mg (Paxlovid) orally twice daily for 5 days (if available).

• Monoclonal antibodies: in mild & moderate cases with any risk factor of progression.

-Antibiotics are not recommended to prevent bacterial infection in mild or ordinary patients. Administer empiric antibiotics if bacterial pneumonia/ sepsis strongly suspected; re-evaluate daily.

-In non-hospitalized patients, do not initiate therapeutic anticoagulants or antiplatelet unless other indications exist.

- In Pregnancy : • Remdesivir has a compassionate use approval.

• Mononclonal antibodies could be used if there is any other risk factor.

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Mild Case No pneumonia - No hypoxia.

Check for

All No

Risk Factor

If Any

AND

Age < 65

• Strict Home Isolation (Symptomatic Treatment).

• Follow and use personal protective guide equipment.

• If any deterioration occurs, back to hospital.

NB: Paracetamol is the preferred antipyretic.

Treatment

Molnupiravir 200 mg cap – 800 mg (4 capsules) twice/day for 5 days (To be used within 7 days from the start of symptoms) OR Favipiravir 1600 TWICE daily in the first day then 600 mg twice daily for 4 days OR Nirmatrelvir 300 mg with ritonavir 100mg (Paxlovid) orally twice daily for 5 days (if available) 10

Monoclonal Antibodies Therapy ± Supportive measures

Used in mild cases with any risk factor of progression to severe disease

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Moderate Case Patients with pneumonia and without hypoxia.

Anti-virals

Anti-inflammatory

Molnupiravir 200 mg cap - 800 mg (4 capsules) twice/ day for 5 days (To be used within 7 days from the start of symptoms)

Steroids (If patient has se v ere dyspnea) RR>24 or CT scan showing rapid deterioration

Nirmatrelvir 300 mg with ritonavir 100 mg (Paxlovid) orally twice daily for 5 days (if available)

Immune-modulators Anti-coagulation

Monoclonal antibodies therapy: Used in moderate cases with any risk factor* of progression to severe disease

Dexamethasone 6 mg or its oral equivalent

Remdesivir: (is indicated if fail ure of oral treatment or no response) 200 mg in the 1 day Then 100 mg daily for 5 days

Only for hospitalized patients Parentral Proph y lactic Anti coagulation Heparin or Enoxaparin 0.5 mg/kg/day Adjust prophy lactic dose if body weight 70 kg Therapeutic Anti Coagula tion only if indicat ed for another reason

*Check risk factors.

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Severe cases If any of the following criteria is met 1.RR > 30 2.Sa02 < 92 at room air 3.PaO2/FiO2 ratio < 300 4.Chest radiology showing more than 50% lesion or progressive lesion within 24 to 48 hrs.

Admit to Intermediate Care Antiinflammatory

Anti-virals Remdesivir 200 mg in the 1st day then 100 mg daily for 5 to 10 days

Immunomodulators

Anti-coagulation

Steroids Methyl Prednisolone (1 mg / kg /day)

Parenteral therapeutic

Tocilizumab 4-8 mg/kg/day for 2 doses 12 to 24 hours apart

heparin

OR Sarilumab 400 mg Single dose

Anti coagulation

OR Enoxaparin 1 mg/kg/day

OR Baricitinib 4 mg (should be started with Remdisivir ) once daily for 14 days or hospital discharge, whichever comes first (should be stopped if Tocilizumab or Sarilumab will be used ), its dose should be adjusted in renal impairment.

Contraindication for using Anti - IL6: -Bacterial Infection -ANC < 500 cells/mm3

-Plat. < 50.000 cells/mm3 -ALT > 5XULN

Baricitinib should not be used concomitantly with Tocilizumab or Sarilumab Due to risk of immune suppression.

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Critically ill patients Critically ill if: SaO2 <92, OR RR>30, and PaO2/FiO2 ratio < 200 despite Oxygen Therapy and/or additional organ dysfunction

Admit to Intensive care Anti-virals

Anti-inflammatory

Anti-coagulation

Remdesivir

Steroids Methyl Prednisolone (1 mg / kg /day)

Parentral Prophylactic

200 mg in 1st day Then 100 mg daily for 5 to 10 days

Anti-coagulation Heparin or Enoxaparin

Tocilizumab 4-8 mg/kg/day for 2 doses 12 to 24 hours apart

Adjust prophylactic dose if

OR

body weight > 70 kg

Sarilumab 400 mg Single dose Baricitinib 4 mg once daily for 14 days or hospital discharge, whichever comes first (should be stopped if Tocilizumab or Sarilumab will be used ), its dose should be adjusted in renal impairment.

0.5 mg/kg/day

Therapeutic Anti-Coagulation only if indicated for another reason

Use of therapeutic parenteral anticoagulation in severe cases & prophylactic parenteral anticoagulation in critically ill patients due to increased risk of bleeding.

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Early block the storm if steroids failed

Tocilizumab 4-8 mg/kg/dose (2 doses)

OR

Sarilumab 400mg (single dose)

Antiviral Drugs As in Severe Cases

Steroids: MethylPrednisolone 1-2mg/kg/d

If needed Add Antibiotics

1 mg for nonventilated and 2mg for ventilated

OR

Prohphylactic Parentral Anticoagulation

Heparin or Enoxaparin

Baricitinib

Prone Awake or Ventilated

Improve V/Q Matching and survival

Avoid Hypoxia O2/NIV/ HFNC/IMV

Don’t wait too much for any type of support Keep Plateau <30 cm H2O

If the patient is maintaining a good oxygen saturation but with high respiratory rate on oxygen therapy, it is wise to shift to either HFN/NIV or CPAP to decrease mortality & if distressed, shift early to invasive mechanical ventilation.

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Infectious complications in patients with COVID-19 can be categorized as follows: • Although most individuals present with only SARS-CoV-2 infection, concomitant viral infections, including influenza and other respiratory viruses, have been reported.

• Community-acquired bacterial pneumonia has also been reported, but it is uncommon, with a prevalence that ranges from 0% to 6% of people with SARS-CoV-2 infection. Antibacterial therapy is generally not recommended unless additional evidence for bacterial pneumonia is present (e.g., leukocytosis, the presence of a focal infiltrate on imaging).

• Reactivation of latent infections: There are case reports of underlying chronic hepatitis B virus and latent tuberculosis infections reactivating in patients with COVID-19 who receive immunomodulators.

• Nosocomial infections in patients with COVID-19: Hospitalized patients with COVID-19 may acquire common nosocomial infections, such as hospital-acquired pneumonia (including ventilator-associated pneumonia), line-related bacteremia or fungemia, catheter-associated urinary tract infection.

• Opportunistic fungal infections: Invasive fungal infections, including aspergillosis and mucormycosis, have been reported in hospitalized patients with COVID-19.

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Antibiotics in COVID-19 Indications: • Rapid development of consolidation pattern.

• Development of lobar consolidation.

• Leucocytosis with absolute neutrophilia.

• Reappearance of fever after afebrile days.

• Increased CRP with improved other markers as ferritin.

• Procalcitonin is highly specific.

Low-risk inpatients: • Combination therapy: β-lactam (e.g., ceftriaxone, or cefotaxime) plus either a macrolide (e.g., azithromycin or clarithromycin) or doxycycline.

• Monotherapy: Respiratory fluoroquinolone (e.g., levofloxacin or moxifloxacin)

High-risk inpatients: • β-lactam plus a macrolide or fluoroquinolone is recommended.

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Mucormycosis co-infection in COVID-19 patient

•Routes of infection include inhalation, ingestion and traumatic inoculation.

•Can not be transmitted from per-son to person, so there is no need for people to be isolated unless, they have another reason.

•Types of mucormycosis: Rhinoc-erebral, pulmonary, cutaneous, gastrointestinal, disseminated… etc.

Risk Factors: -Uncontrolled diabetes mellitus, -Neutropenic patients + cancer, -Receiving broad-spectrum a ntibiotics, or immunosuppressive agents (i.e. steroids).

Diagnosis: A high index of suspicion is very important - Suspected findings that need prompt immediate further testing include cranial nerve palsy, diplopia, sinus pain, periorbital swelling, orbital proptosis or ulcer-ation or blackish discoloration of the palatal mucosa.

Imaging: •Paranasal sinuses CT scan for any bony erosion.

•High-resolution chest CT (HRCT): Multiple (≥10) nodules, pleural effusion and the reverse halo sign (RHS).

•CT and MRI for orbit and brain with MRV Histopathology and cultures: For definite diagnosis.

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Management of Covid-19 patients with mucormycosis

1-Necessitating a multidisciplinary team.

2-Control diabetes, reduce steroid, and discontinue immunomodulating drugs.

3-Prompt antifungal drugs and surgical debridement: A- Liposomal amphotericin B is the drug of choice 5 to 10 mg/kg/day IV infusion for at least 4-6 weeks.

B- Conventional Amphotericin B (deoxy cholate) in the dose 1-1.5mg/kg may be used if liposomal form is not available (renal functions and serum electrolytes monitoring) 4-Step-down oral therapy: After parenteral amphotericin B, step-dawn oral therapy

by Posaconazole or isavuconazole: A- Posaconazole: the dose is 3 tablets (300 mg) twice daily on day 1 then 3 tablets ( 300 mg ) daily.

B- Isavuconazole: the dose is 2 capsules (200 mg ) three times/ day for two days then 2 capsules (200 mg) daily.

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Non Invasive Ventilation or High Flow Nasal Cannula (HFNC) •Conscious patients with minimal secretions.

•Hypoxia SpO2 < 90% on oxygen. Or PaCO2 >40 mmHg provided pH 7.3 and above.

•NIV trial shall be short with ABG 30 minutes apart.

•Any deterioration in blood gases from baseline or oxygen saturation or conscious-ness level shift to IMV. •CPAP gradually increased from 5-10 cmH2O. •Pressure support from 10-15 cm H2O. •HFNC can be alternative to NIV. •Consider ROX index for HFNC.

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Invasive Mechanical Ventilation •Use PPE including goggles during intubation and avoid bagging.

Indications: •Failed NIV or not available or not practical. (HACOR Score> 6 ) •PaO2 < 60 mmHg despite oxygen supplementation.

•Progressive Hypercapnia.

•Respiratory acidosis (PH < 7.30).

•Progressive or refractory septic shock.

•Disturbed consciousness level (GCS ≤ 8) or deterioration in consciousness level from baseline

Step 1:

Initiation of Invasive Mechanical Ventilation

VCV TV 8 ml/kg PEEP 5 cmH2O

Plateau Pressure

Less than 30 cmH2O Sat >93 Keep and Watch

Inspiratory Pause for 1 second

Less than 30 Sat<93 Increase PEEP to 10

IF PLATEAU ABOVE 30 cmH2O

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More than 30 ARDSnet protocol

Step 2:

Shift to ARDSNet protocol if needed

- ARDSNet protocol:

LOW TV 6-4 ml/kg

Incremental PEEP

Plateau P<30 cmH2O Driving P<15 cmH2O

Start with tidal volume of 6 ml/Kg to keep plateau pressure on volume controlled ventilation (VCV) below 30 cmH2O, decrease to 4 ml/kg if the plateau remain higher than 30 allow permissive hypercapnia so long the pH is above 7.3 compensate by increasing respiratory rate up to 30 breath/ minute. Consider heavy sedation and paralysis. If pressures are high or any evidence of barotrauma shift to pressure controlled ventilation and be cautious about low tidal volume alarms for fear of unnoticed endotracheal tube obstruction. Consider ECMO early if eligible. Increase PEEP gradually if the patient remains hypoxic according to FIO2 level to keep driving pressure < 15cmH2O. NEVER FORGET PRONE POSITION.

Step 3:

Assessment of respiratory support outcome Assess

ABGs, Clinical Radiological

Improved Weaning of respiratory support

Stationary Continue respiratory support as needed

Deteriorating Criteria for ECMO*

*Criteria for VV ECMO: Age below 49, mechanical ventilation duration less than 72 hours, no comorbidities, preserved conscious level, PaO2/FiO2 <100 despite prone RESPscore >0.

Expert opinion is needed and depends on availability.

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High Velocity Nasal Insufflation (Hi-VNI) • High-velocity nasal insufflation, a form of high-flow nasal cannula, focuses on optimum efficiency of the dead-space purge to augment ventilation (removal of carbon dioxide from the dead space between breaths), in addition to providing other effects of high-flow nasal cannula.

• Hi-VNI Technology has a simple nasal cannula that delivers warm, humidified gas, and doesn’t seal to the face. While being treated, patients can talk, eat, drink, and take medication. It is a front-line tool for respiratory distress—including hypoxemia, hypercapnia, and dyspnea.

• Mask-Free NIV™ for spontaneously breathing patients, and offers ventilatory support as an alternative to NiPPV for treating undifferentiated respiratory distress. The nasal cannula used with Hi-VNI Technology is comfortable for patients and reduces the risks and care complexities associated with mask therapies.

Hi-VNI is a first-line therapy for COVID-19 hypoxemic patients.

• Hi-VNI Technology and WOB reduction: The fact that smallbore cannulas reduce the time required to fully purge the upper airway dead space is significant because as the respiratory rate of a patient in respiratory distress increases, the time between breaths decreases. By quickly clearing the upper airway dead space of end-expiratory gas rich in CO2, Hi-VNI Technology helps patients breathe directly from a fresh gas reservoir and thereby reduces their WOB.

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Velocity (m.sec-1)

70 60 50 40 30 20 10 0

HVNI

HFNC

10

20

30

40

50

60

Volumetric Flow (L.min-1)

Monitoring of patients on HFNC: •ROX index: (SpO2 (%)/F102) Respiratory Rate Example: SpO2 = 98, FIO2 = 75 %, RR = 25 (ROX = (98/0.75))= 130.667 / 25 = 5.23 25 •To be done after 1, 2, 6, 12 hours from starting HFNC and then every 12 hours.

Score

Action

> 4.88

Little risk of intubation

3.85 – 4.87

Monitor due to increased risk of intubation

2.85 – 3.84

Close monitoring, high risk for intubation

< 2.85

Intubation

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Oxygen Therapy Target SpO2 is 92 – 96 % Start oxygen therapy once SpO2 < 92 % Once Oxygen is required, the patient is indicated for: •Awake proning •Remdesivir as an antiviral therapy •Steroids •Anticoagulation 1.Nasal cannula: 1 – 6 L/min Gives 0.24 – 0.4 FIO2 2.Face mask: 5 – 10 L/min Gives 0.35 – 0.6 FIO2 3.Nonrebreather mask: 10 – 15 L/min Gives up to 0.9 FIO2 4.Venturi mask: 4 – 15 L/min Gives 0.24 – 0.6 FIO2 5.High flow nasal oxygen therapy : •HFNC •Hi-VNI

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6. CPAP / BiPAP Monitoring of patients on CPAP •HACOR score: ( > 6 High Probability of Failure)

Parameter

Value

Score

Heart

HR

≤ 120

0

Acidosis

PH

7.30 – 7.34

2

< 7.25

4

15 13 – 14 11 – 12 ≤ 10

0 10

> 201 176 – 200 151 – 175 126 – 150 101 – 125 ≤ 100

0 2 3 4 5 6

31 – 35

1

Consciousness

Glasgow coma scale

Oxygenation

PaO2 / FiO2

Respiration

RR

41 – 45

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Post- acute COVID syndrome (long COVID) Definition: Post-acute COVID-19 is a multifactorial syndrome of unknown pathophysiology characterized by the persistence of clinical symptoms beyond four weeks from the onset of acute symptoms , commonly affects the respiratory, cardiovascular, and hematopoietic systems. In addition, neuropsychiatric, renal, and endocrine systems are also involved to a lesser extent. Patients range from ages 18 and older, but the average age group is between 20 to 50 years old. It’s typically reported as a lower percentage of children that end up with long-haul symptoms, but there are some children that experience long COVID.

Clinical manifestations: The typical clinical symptoms in “long covid” “are: • Dyspnea is the predominant pulmonary symptom (40% to 50% prevalence at 100 days) • Tiredness.

• Symptoms that get worse after physical or mental effort (also known as “post-exertional malaise”).

• Fatigue.

• brain fogginess • autonomic dysfunction. (postural orthostatic tachycardia syndrome.)

• Headache.

• persistent loss of smell or taste.

• Cough.

• oxygen dependence .

• depression.

• low-grade fevers.

• palpitations • myocarditis • Dizziness.

• muscle pain.

• joint pains.

• decreased diffusion capacity • Decreased average 6-minute walking distance.

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Classifications : Based on the chronicity of symptoms post COVID-19 infection was classified post-acute COVID-19 as follows• Subacute or persistent symptomatic COVID-19 symptoms (up to 12 weeks from the initial acute episode).

• Chronic or post-Covid syndrome, symptoms present beyond 12 weeks.

However, it should not be attributable to an alternative diagnosis.

Risk factors • Prolonged duration of ICU stay, prolonged intubation • pre-existing pulmonary conditions • older age • obesity • People who did not get a COVID-19 vaccine • Female patients • Black race

Radiological assessment: • a high-resolution CT scan : Three main categories of post-COVID-19 sequelae can be distinguished: - irreversible lesions (The early pulmonary FIBROTIC phenotype): reticulation, irregular pleural interfaces, traction bronchiectases or honeycomb lesions.

Responsive to antifibrotic treatment.

- reversible lesions (The early AUTO-INFLAMMATORY phenotype) : groundglass opacity (GGO)-type anomalies Responsive to corticosteroid treatment.

-lesions of undetermined evolution (residual condensations and ventilatory disorders such as curvilinear opacity.)

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Management: It’s a multi-disciplinary management.

• Specialist referral may be indicated based on clinical finding, for example: - Respiratory: if suspected pulmonary embolism, severe pneumonia - Cardiology: if suspected myocardial infarction, pericarditis, myocarditis or new heart failure - Neurology: if suspected neurovascular or acute neurological event • Pulmonary rehabilitation may be indicated if patient has persistent breathlessness.

Medical management: •Symptomatic: treating fever by paracetamol & NSAIDs •Management of co-morbidities including diabetes, hypertension, kidney diseases & ischemic heart diseases •Consider antibiotics for secondary infection •Treat specific complication as indicated •Psychological support.

Self-management: •Daily pulse oximetry.

•Attention to general health like: -Good diet -Good sleep hygiene -Quitting smoking -Limiting alcohol -limiting caffeine •Rest and relaxation.

•Self-pacing and gradual increase exercise.

•Set achievable targets.

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Prevention and Control of Transmission of COVID-19 inside Health Care Facilities

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General Recommendations for Prevention and Control of Transmission of COVID-19 inside Health Care Facilities 1-Daily screening of health care workers and patients before entering the health care facility (HCF) based on clinical signs (fever, respiratory symptoms…….).

2- Any health care worker appears/reports to be diseased should be segregated until proper examination/management.

3- All health care workers are required to wear surgical masks during work hours (during existence in HCFs).

4- Minimal number of health care workers should be present at the same time in patient’s units to keep social distancing 5- Restrict unneeded movements between departments.

6- Suspected or confirmed cases should take a separate route from other patients beginning from the facility entrance (Triage area), and all facility sections should follow the same separation.

7- Suspected or confirmed cases should be isolated in a well- ventilated isolation room.

8- Standard precaution should be applied : • Hand hygiene • Cough etiquette.

• Personal protective equipment.

• Clean and disinfected environmental surfaces.

• Sterile instrument and devices • Sharp safety.

• Isolation transmitted precaution.

• Safe injection practices.

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Recommendations According To The Type Of Procedure 1) Non Aerosol Generating Procedures (AGPs) • Standard precautions.

• Isolation precautions taken to prevent the spread of infection by spray and contact.

• The need to adhere to washing hands before donning personal protective equipment and immediately upon doffing.

• The necessity to adhere to donning personal protective equipment as follows: 1- Surgical mask.

2- Protect your eyes by wearing goggles or face shield.

3- Long-sleeve medical gowns (gown) clean, non-sterile or sterile, according to type of technique.

4- Clean or sterile gloves depending on type of technique.

5- Health care worker are not required to wear protective boots and protective suits during routine care of cases.

6- Extended use of surgical masks, gowns, eye protectors, and face shields can be applied while caring for COVID-19 patients in the event of a shortage of personal 2 protective equipment for the length of the work shift (preferably not more than six hours).

7- Always remember not to touch the eyes, mouth or nose with contaminated hands or used gloves (wash your hands or rub using alcohol when touch any environmental surface).

8- Always clean and disinfect surfaces .

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2) Procedures that include (AGPs): • Tracheal intubation .

• Non-invasive ventilation e.g. BiPAP, CPAP. • Tracheotomy.

• Cardiopulmonary resuscitation.

• Manual ventilation before intubation or bronchoscopy.

• Sputum induction by using nebulizer hypertonic saline.

The health care workers must adhere to the following: • Standard precautions.

• Perform procedures inside a well-ventilated room.

• Follow the isolation precautions taken to prevent the spread of infection through air and contact.

• The need to adhere to washing hands before donning personal protective equipment and immediately upon doffing them.

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Donning personal protective equipment as follows: - A high-performance respiratory masks such as N95 or FFP2 or equivalent, with the need to conduct a tightness test to ensure that there is no leakage.

- Protect your eyes by wearing goggles or face shield.

- Long-sleeve medical gowns (gown) clean, non-sterile or sterile according to the procedure.

- Clean or sterile gloves depending on type of technique.

- The extended use of a mask, medical gown, eye goggles, or face shield (Extended use) can be applied while caring for patients with COVID-19 in the event of a lack of personal protective equipment and for the length of the work shift (preferably no more than six hours).

- Care must be taken not to touch the eyes, mouth or nose with contaminated bare hands or using gloves (wash your hands or rub using alcohol when touch any environmental surface).

- Always clean and disinfect surfaces regularly.

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Treatment Protocol Revised By:

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NAME

AFFILIATION

Prof. Hossam Hosny Masoud

Professor of Chest Diseases. Head of Pulmonary Hypertension Unit, Faculty of Medicine, Cairo University

Prof. Gehan Elassal

Professor of Chest Diseases, faculty of Medicine , Ain Shams University

Prof. Mohamed Abdel Hakim

Professor of Chest Diseases, faculty of Medicine , Cairo University

Prof. Ahmed Shawky

Professor of Chest Diseases, faculty of Medicine , Tanta University

Prof. Samy Zaky

Professor of Hepatogastroentrology and Infectious Diseases, faculty of Medicine , Al Azhar University

Prof. Amin Abdel Baki

Consultant and Head of Hepatology , Gastroentrology and Infectious Diseases Department. National Hepatology and Tropical Medicine Research Institute

Prof. Akram Abdelbary

Professor of Critical care Medicine , Cairo University Chairman elect of ELSO SWAAC chapter

Dr. Mohamed Hassany

Associate Professor of Infectious Diseases and Endemic Hepatogastroentrology , National Hepatology and Tropical Medicine Research Institute

Prof. Khaled Taema

Assistant Professor of Critical care Medicine , faculty of Medicine, Cairo University

Dr. Ehab Kamal

Minister assistant for continuous medical education ,MoHP Associate Professor of Tropical Medicine , National Research Center

Dr. Hamdy Ibrahim

Infectious Diseases Consultant , National Hepatology and Tropical Medicine Research Institute

Version 1.8 / July 2022

NAME

AFFILIATION

Dr. Wagdy Amin

Director General , Chest Disease Directorate , Consultant of Chest Diseases , MoHP

Dr. Ehab Attia

Consultant of infection control , MoHP

Version 1.8 / July 2022

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Ministry of Health and Population Egypt / July 2022 Version 1.8 / July 2022