Novel Coronavirus Preparedness and Response Plan- fbg-2
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Novel Coronavirus (COVID-19)
Preparedness and Response Plan
February 13th, 2020 Draft Version 3
Ministry of Health National Surveillance Unit
1
Table of Contents
Preface ......................................................................................................................................................... 5
International Health Regulations (IHR 2005) ..................................................................................... 6
Risk Communication and Community Engagement (RCCE) ........................................................ 8
Goals ......................................................................................................................................................... 8
Action steps .............................................................................................................................................. 8
Risk communication systems ............................................................................................................. 8
Internal and partner coordination ..................................................................................................... 8
Public communication ........................................................................................................................ 8
Community engagement ..................................................................................................................... 9
Addressing uncertainty and perceptions and managing misinformation ...................................... 9
Capacity building ................................................................................................................................. 9
Protocol on Management and Control ............................................................................................. 10
Port Surveillance ................................................................................................................................... 10
Surveillance Guidelines in Response to COVID-19 ........................................................................... 11
Targeted audiences ............................................................................................................................... 11
Overall objective .................................................................................................................................... 11
Specific objectives ................................................................................................................................. 11
Case Definition ....................................................................................................................................... 11
Type of Cases Definition ....................................................................................................................... 12
Confirmed case .................................................................................................................................. 12
Probable case ..................................................................................................................................... 12
Suspected cases ................................................................................................................................. 12
Functions of the Rapid Response Team Members.......................................................................... 13
Infection Disease Clinician ............................................................................................................... 13
Surveillance Nurse ............................................................................................................................ 13
Infection Control Officer ................................................................................................................... 13
Management of Cases ............................................................................................................................. 13
Management of Suspect Cases .............................................................................................................. 13
Management of Contacts of Suspect Cases .......................................................................................... 13
Management of Probable Cases in conjunction with the Infectious Disease Unit ........................... 14
Sampling and Testing ............................................................................................................................. 14
Contact tracing ......................................................................................................................................... 14
2
Recommended safety precautions for contact tracing teams ............................................................ 16
Contact tracing – non health sector partners ...................................................................................... 16
Contact tracing health care workers .................................................................................................... 17
Management of Contacts of Suspected and Probable Cases .............................................................. 17
Care for Patients with Probable COVID-19: Health Care Setting Infection Control Measures . 17
Laboratory Safety Guidelines for Handling Suspected Samples .................................................... 19
Decontamination ................................................................................................................................... 19
Waste Disposal ...................................................................................................................................... 20
Plan for Public and Private Primary Care Clinics ............................................................................. 20
Plan for Tertiary Hospitals (Emergency Department and Urgent Care): ......................................... 20
Plan for designated remote field hospital ........................................................................................... 21
Management of Suspected Cases in Quarantine ................................................................................. 21
Isolation (patient placement) ............................................................................................................. 21
Anterooms and putting on and removing PPE .................................................................................... 21
Notices about infection risks ................................................................................................................ 22
Entry records ......................................................................................................................................... 22
Staff considerations ............................................................................................................................... 22
Visitors ................................................................................................................................................... 22
Personal Protective Equipment (PPE) ................................................................................................. 22
Hand hygiene ......................................................................................................................................... 23
Aerosol generating procedures ............................................................................................................ 23
Equipment .............................................................................................................................................. 24
Environmental decontamination ......................................................................................................... 24
Linen ....................................................................................................................................................... 24
Waste ...................................................................................................................................................... 24
Specimens .............................................................................................................................................. 25
Addendum ................................................................................................................................................ 26
Guidelines for National Emergency Medical Services (N.E.M.S) During 2019 Novel
Coronavirus Alert –January 2020 ........................................................................................................ 27
Background ............................................................................................................................................ 27
Case Definition for COVID-19 ............................................................................................................... 27
Response Guidelines ............................................................................................................................. 28
Reminder ................................................................................................................................................ 30
3
References .............................................................................................................................................. 30
STANDARD OPERATING PROCEDURES ............................................................................................... 32
FOR ............................................................................................................................................................. 32
COLLECTION, RECEIPT, PROCESSING AND TRANSPORT OF SPECIMENS CONTAINING RISK
GROUP 3 ORGANISMS INCLUDING COVID-19 ..................................................................................... 32
Preparation, Review and Approval Page ............................................................................................. 33
Document Version History ................................................................................................................... 33
Familiarization Page ............................................................................................................................. 34
Title ......................................................................................................................................................... 35
Intended Use .......................................................................................................................................... 35
Introduction ........................................................................................................................................... 35
Collection of Specimens For COVID-19 ................................................................................................ 35
Appropriate Specimen Types ........................................................................................................... 35
Requisition Form Requirements ...................................................................................................... 36
Instructions for Nasopharyngeal Swab or Oropharyngeal Swab Collection ................................ 36
Sputum collection .............................................................................................................................. 37
Urine collection .................................................................................................................................. 37
Infection Control Procedures During Specimen Collection ............................................................... 38
Specimen Collection and Transport to The Hospital Laboratory ...................................................... 38
Specimen Testing .................................................................................................................................. 39
Packaging and Transport of Specimens Outside of the Hospital ....................................................... 39
References .............................................................................................................................................. 43
Related Documents ............................................................................................................................... 43
Records ................................................................................................................................................... 44
Document Amendment Page ................................................................................................................ 45
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Preface
This Novel Coronavirus COVID-19 Preparedness document seeks to provide guidance for the Health
Sector preparedness and response in the event of the introduction of COVID-19 Disease into The
Bahamas. This plan will outline the steps required to prevent, detect, report, investigate and respond
to any potential case of COVID-19 Disease in a coordinated and timely manner.
Under the leadership of the Ministry of Health, COVID-19 preparedness meetings have convened and
will continue for the duration of this public health threat. It is anticipated that this document will be
reviewed and updated as guided by the evolution of COVID-19 Disease in the Region of the Americas,
the Caribbean sub-region and specifically, The Bahamas.
While this document seeks to guide preparedness and response activities for the country, it is
imperative that each health sector agency and relevant stakeholder agencies have preparedness
plans in place for specific application to their component of the implementation of a comprehensive
response.
The Government of The Bahamas has an established mechanism for the management and control of
disasters and emergencies through the National Emergency Management Agency (NEMA).
Preparedness and response for COVID-19 Disease is the responsibility of the Ministry of Health. The
COVID-19 Preparedness and Response Plan is a subset of the Influenza and other Vaccine-
Preventable Diseases Plan.
The following documents are relevant to the smooth implementation of this plan:
National Health Disaster Plan
Influenza and other Vaccine-Preventable Diseases National Emergency Management Agency
Plan
National Mass Casualty Plan
National Waste Management Plan – Environmental Health
COVID-19 Risk Communication Strategy – Ministry of Health
Environmental Health Communicable Disease Contingency Plan
Detention Centre Communicable Disease Contingency Plan
Ports Authority Communicable Disease Contingency Plan
Immigration Communicable Disease Contingency plan
PHA Communicable Disease Contingency plan
Grand Bahama Health Services Communicable Disease Contingency Plan
Community Health Clinics Communicable Disease Contingency Plan
Funeral Directors Communicable Disease Contingency Plan
Private Health Care Facilities Communicable Disease Contingency Plan (Doctors and Lyford
Cay, walk in clinics and medical centres)
International Health Regulations (2005)
Civil Aviation Communicable Disease Contingency Plan
Nassau Airport Development (NAD) Communicable Disease Response Plan
5
International Health Regulations (IHR 2005)
The International Health Regulations is a legally-binding agreement that significantly contributes to
global public health security by providing a new framework for the coordination of the management
of events that may constitute a public health emergency of international concern, and improves the
capacity of all countries to detect, assess, notify and respond to public health threats.
Figure 1: Reporting Within the International Health Regulations Framework
Under IHR 2005 state parties are required to have the capacity to: detect, assess, respond to, notify
and report Public Health threats and Public Health Emergencies of International Concern
(PHEIC) in an efficient and timely to the World Health Organization.
The International Health Regulations (2005) (IHR (2005)) have radically changed the international
notification requirements of States to WHO in the IHR (1969). As of 15 June 2007,which marks the
entry into force of the IHR (2005), WHO member states and non-member states parties that have
agreed to be bound by the new provisions (States Parties) will no longer be required to automatically
notify cases of cholera, plague and yellow fever to WHO. Notification is now based on the
identification within a state party’s territory of an "event that may constitute a public health
emergency of international concern (PHEIC)”. These changes in the IHR (2005) reflect the evolving
nature of the threats and speak to the need for countries to take an all-hazards approach to
preparedness and response.
In the event of a PHEIC, the national IHR Focal Point is required to notify WHO within 24 hours of the
assessment of the event. The decision on what to notify is clarified in the decision instrument below.
6
Figure 2: International Health Regulations Decisions Instrument
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Risk Communication and Community Engagement (RCCE) 1
Goals
• Communicate about preparedness measures and communicate the public health advice for
your country.
• Prepare to communicate about a first case in your country: what is unknown and about the
uncertainty of what is known.
• Assess national and subnational communication capacity (both persons and resources).
• Identify who will be the main actors and form partnerships with them.
• Plan for the activation and implementation of an RCCE plan.
• Identify and train emergency RCCE staff and potential surge staff on plans and procedures.
Action steps
Risk communication systems
• Ensure that the highest levels of government agree to include RCCE in preparedness and
response activities and are ready to release information to protect the public’s health in a
rapid, transparent and accessible manner.
• Review existing RCCE plans and consider whether adjustments are needed for an outbreak
of COVID-19 infection.
• Agree on procedures to ensure the timely release of information, such as clearance
procedures for messages and information products: keep clearance chains short.
• Prepare a budget for communication (including scale up).
• Set up an RCCE team and define members’ roles and responsibilities.
Internal and partner coordination
• Identify partners − such as other agencies, organizations, community planners and
healthcare workers − and their contact information (in the case of a COVID-19 outbreak
consider, for example, the ministries of agriculture and travel and tourism, as well as
hospital systems); should an outbreak occur, these partners should be notified and work
together as a multi-sectoral RCCE Rapid Response Team.
• Assess the communication capacity of all relevant partners: identify the typical target
audiences and channels of communication used by partners.
• Plan and agree on communication roles and responsibilities using standard operating
procedures (SOPs) (e.g., determine which agency will speak first on which issue, what
specific topics and audiences will be best addressed through which agency or partner, how
messaging will be aligned).
Public communication
• Review the roster of spokespeople at all levels; list their areas of expertise in the context of
a COVID-19 outbreak; and, if necessary, train them.
• Produce and pre-test message templates to announce the first case, action taken, public
health advice and follow-up communications.
• Identify key media; create and/or update a list of journalists and foster good relations with
the media by providing regular information on the evolution of the outbreak and your
country’s preparedness.
1
Risk communication and community engagement readiness and response to the 2019 novel coronavirus (2019-
nCoV): interim guidance
8
• Identify media and other communication channels and influencers and assess their
potential to reach the target audiences: use the channels and influencers that are trusted,
preferred and regularly used by the target audiences. In the context of COVID-19, it is
critical that health professionals are aware of public concerns and trained to provide public
health advice to people.
Community engagement
• Establish methods for understanding the concerns, attitudes and beliefs of key audiences.
• Identify the target audiences and gather information about their knowledge and behaviours
(e.g., who they trust, how they are likely to receive information, their daily habits, their
concerns).
• Engage through social media: proactively inform audiences and collect and answer all
questions.
• Engage through radio programs so that people can call in and ask questions.
• Identify community influencers (e.g., community leaders, religious leaders, health workers,
traditional healers, alternative medicine providers) and networks (e.g., women’s groups,
community health volunteers, youth associations, religious groups, unions, and social
mobilizers for polio, malaria, HIV) that can help with community engagement.
• Anticipate special information and engagement needs for people who are disabled or
illiterate.
Addressing uncertainty and perceptions and managing misinformation
• Be prepared to communicate about the first COVID-19 case before the full picture is known
by ensuring leaders agree to communicate with affected populations by addressing
populations’ concerns and questions while offering actions that can be taken to protect their
health.
• Establish a system for listening to public perceptions as well as for finding out about
rumours and misinformation, for example, by monitoring media and social media and by
gathering feedback from healthcare workers and hotlines; if necessary, establish systems
for responding to rumours, misinformation and frequently asked questions.
• Keep in mind to always establish dialogue in any activity you implement in order to
systematically collect and provide answer to all questions coming from the public.
Capacity building
• Consider what training will be needed for RCCE responders about what is known and
unknown about COVID-19, and current plans and procedures, as well as what subnational
preparation is needed for an RCCE response.
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Protocol on Management and Control
On 30 January 2020, The Bahamas implemented border control and quarantine measures for
travelers to The Bahamas as a component of its COVID-19 Emergency Preparedness and
Response Plan.
All travelers, who are not citizens or residents of The Bahamas, with a history of travel to
China within the previous 20 days are to be denied entry. Citizens and residents with a
history of travel to China within the previous 20 days are to be quarantined and
monitored for the development of symptoms for up to 14 days. These persons will be
monitored closely by public health department to determine whether possible exposure
while in China will result in illness. Should they become ill, they will me managed as per
clinical management WHO guidelines for cases of COVID-19.
Port Surveillance
The Port Surveillance system in the Ministry of Health requires that Medical Officers are on call for
Port Health and are required to be accessible 24 hours each day. There are clear guidelines and
procedures in the Ministry of Health which direct the response to port health concerns (see annex).
These guidelines and procedures will remain in effect in the event of the identification of a suspected
case of COVID-19 through Port Surveillance.
Persons with a travel history to China within the previous 20 days, who are not Bahamian residents
or citizens, will not be allowed entry to the Commonwealth of The Bahamas. Returning residents or
citizens who have a history of travel to the China within the previous 20 days will be allowed entry
to the country and be reviewed by the Port Health Team at the Port.
At the seaports, persons with a history of travel to China within the previous 20 days will not be
allowed to leave the cruise ship. Other persons on the ship may be granted free pratique after review
of the Maritime Health Declaration by the Port Health Officer.
The system is activated through contacting the on-call cells 376-3533 or 376-4705. A suspect case
of COVID-19 among returning residents and citizens will activate this system immediately.
Figure 3: Possible points of detection for a traveler with COVID-19 infection
Personnel at all points along the travel continuum should be alert and aware of the possible points
of introduction of COVID-19. They must also be prepared to properly follow IPC processes and
procedures (see annex).
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Surveillance Guidelines in Response to COVID-19
Targeted audiences
• Clinical personnel: doctors, nurses, health care workers (anybody in regular close contact
with the suspected/probable COVID-19 case).
• Hospital clinical laboratory staff and/or public health laboratories
• Ministry of Health and Hospital Administration
Overall objective
Strengthen surveillance and infection control measures in the country
Specific objectives
• Raise awareness on COVID-19 risks and good surveillance practices
• Provide case management and investigation
• Reduce the risk of transmission of COVID-19 infection (good infection control practices)
• Ensure appropriateness of clinical sample taking, transportation in-country, and overseas
shipment to reference laboratories
Case Definition
Surveillance activities should focus on the following case definition of COVID-19 infection:
Fever or signs/symptoms of lower respiratory illness (e.g. cough or shortness of breath), AND any
person, including healthcare workers, who has had close contact 2 with a laboratory-confirmed
COVID-19 patient within 14 days of symptom onset
OR
Fever and signs/symptoms of a lower respiratory illness (e.g. cough or shortness of breath), AND a
history of travel from Hubei Province, China within 14 days of symptom onset
OR
Fever and signs/symptoms of a lower respiratory illness (e.g. cough or shortness of breath)
requiring hospitalization, AND a history of travel from mainland China within 14 days of symptom
onset
2
Having cared for, having lived with, or having had direct contact with respiratory secretions and bodily fluids of a
person with 2019-nCoV infection
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Type of Cases Definition 3
Confirmed case – a person with laboratory confirmation of COVID-19 infection, irrespective of
clinical signs and symptoms.
Probable case – a suspect case for whom testing for COVID-19 is inconclusive or for whom testing
was positive on a pan-coronavirus assay.
Suspected cases
As per case definition
Comments
In addition to fever and respiratory symptoms, COVID-19 infection may be associated with other
symptoms including: headache, muscular stiffness, loss of appetite, malaise, confusion, rash, and
diarrhea.
All reports of a suspected case of COVID-19 should be made through the Ministry of Health,
Surveillance Unit. Contact numbers are as follows: 502-4790 or 397-1021 during regular
office hours. After 5pm or on weekends, please call 376-3533, 376-4705, or 376-3970.
Possible sources of reporting are:
• Ports of entry,
• Public healthcare providers,
• Private clinicians, and
• Tertiary level healthcare providers
The Surveillance Unit will be responsible for the initial review of all reports of a suspected
case. In the event that the established case definition for a suspected case is met, the COVID-19
Rapid Response Team will be notified immediately to conduct a thorough investigation and
apply necessary public health measures in conjunction with the office of the Chief Medical
Officer.
The COVID-19 Response Team shall be made up of:
• An Infection Disease Clinician
• An Epidemiologist/Port Health Officer
• A Surveillance Nurse
• An Infection Control Officer
3
http://carpha.org/Portals/0/articles/documents/nCoV_CHINA_EpiUpdate%203_270120.pdf
12
Functions of the Rapid Response Team Members
Infection Disease Clinician
The role of the Infection Disease Clinician will be to perform a thorough physical examination to
rule out other known causes of Acute Respiratory Syndrome and to order appropriate
investigation, management and follow up of the patient as per WHO guidelines (see annex).
Epidemiologist
The Role of the Epidemiologist is to co-ordinate the investigation, ascertain the epidemiological
link of the case to any other case(s) and to write a report of the investigation for dissemination
to appropriate authorities. The epidemiologist will be responsible for notification to appropriate
agencies.
Surveillance Nurse
The role of the surveillance nurse will be to liaise with the epidemiologist and to carry out
contact tracing and monitoring of the patient as per WHO guidelines See annex).
Infection Control Officer
The Role of the Infection Control Officer will be to oversee the collection, transportation of
necessary samples for laboratory investigation as per WHO guidelines (see annex).
Management of Cases 4
Management of Suspect Cases
• Clients meeting the criteria of a suspected case of COVID-19 should be triaged immediately
to designated examination rooms or wards
• Clients with suspected COVID-19 should be issued a surgical mask
• Obtain and record detailed clinical, travel and contact history including occurrence of acute
respiratory diseases in contact persons during the last 14 days
• Nasopharyngeal swab, serum sample, and urine sample should be taken to rule out COVID-
19 and influenza
Management of Contacts of Suspect Cases
• Provide advice on respiratory hygiene, avoidance of crowded areas and public
transportation, remaining at home until well
• Discharge with advice to seek medical care if respiratory symptoms worsen
4
Algorithm for the Management of Suspected 2019-novel coronavirus Cases in CARPHA Member States
13
Management of Probable Cases in conjunction with the Infectious Disease Unit 5
Hospitalize under isolation or in cohort with other COVID-19 cases
• Baseline bloods (FBC and Chemistry) should be drawn
• CXR to determine presence of uni- or bilateral infiltrates
Sampling and Testing 6
Send samples for laboratory investigation and exclusion of known causes of atypical pneumonia
• Viral nasopharyngeal swabs/aspirates (Universal Viral Transport Media, red capped swab)
• Blood for serology
• Collect two samples:
Acute – within the first week of illness
Convalescent – 2-3 weeks later
• Urine for serology
• Postmortem examination as appropriate
This should be coordinated through Surveillance unit and the PMH laboratory. Immediately refer
samples to the Laboratory refrigerated and transported with ice packs (4°C). If testing will occur
within 5 days, the sample can be stored at 4°C. If storage time prior to testing is >5 days, the sample
should be frozen and stored at -70°C.
Contact tracing 7
Contact tracing is essential in identifying and managing case contacts to prevent transmission to
additional individuals. This form of active surveillance is an integral component in preventing the
spread of COVID-19. Contact tracing is required for all persons having had contact with a suspect,
probable or confirmed case of COVID-19. Contact tracing will be undertaken by the Surveillance Unit
in the Ministry of Health following WHO Guidelines (see annex). Contact tracing is broken down into
three elements:
1. Contact Identification
A case contact is defined as any person having had contact with a COVID-19 case during the 14 days
preceding the onset of symptoms in at least one of the following ways categorized in the contact
identification list below:
• All persons who lived with the case (alive/dead) in the same households since onset of illness.
• All persons who visited the patient (alive/dead) either at home or in the health facility since
onset of illness.
• A baby who has been breastfed by a case.
• All places and persons visited by the patient since onset of illness e.g. traditional healer,
church, relatives, etc. All these places and persons should be visited and contacts identified.
5
Clinical management of severe acute respiratory infection when Novel coronavirus (2019-nCoV) infection is
suspected: Interim Guidance
6
Laboratory testing for 2019 novel coronavirus (2019-nCOV) in suspected human cases
7
Home care for patients with novel coronavirus (nCoV) infection presenting with mild symptoms and management
of contacts
14
• All health facilities visited by the patient since onset of illness and all health workers who
attended to the patient (alive/dead) without appropriate infection prevention and control
procedures.
• During the home visit, the contact tracing/follow-up teams should ask about persons who
might have been exposed to the patient (alive/dead) but were not identified and listed as
contacts through the above process.
The Surveillance Unit will systematically identify potential contacts following the completion of the
case investigation form for all suspected, probable and confirmed COVID-19 cases. This identification
process includes investigation into activities of the case and the activities and roles of persons
associated with the case since the onset of illness/symptoms. Home visitation is a required
component for contacts of confirmed cases of COVID-19.
Contacts should be classified as to their exposure and prioritized for high risk categories of contact.
This process should be verified and double-checked for consistency and completeness during the
home visit.
As part of contact tracing, the following information for each contact is to be collected:
• Name
• Address
• Relationship with the patient
• Date of last exposure to COVID-19
• Type of contact
2. Contact Listing
All persons considered to have had a significant exposure will be listed on the contact listing form
provided (see annex). The Surveillance Unit, along with local/public healthcare providers, will make
every effort to physically identify every listed contact, inform them of their contact status, the actions
that will follow and educate contacts on the importance of calling the Surveillance Unit at the first
sign of any of the symptoms of COVID-19.
3. Contact Follow-up
Contact tracing will consist of daily review of signs or symptoms of COVID-19 for each contact
gathered through daily visits or through live or remote means. For household visits of asymptomatic
contacts, the use of PPE by healthcare personnel performing the visit is not required.
The daily monitoring of contacts may be made through in-person visits or virtually if the system used
allows visualization of the individual (e.g. video chat). The contact should be instructed to telephone
the Surveillance Unit in the Ministry of Health immediately if symptoms occur at: Tel: 502-4790 or
502-4776, Monday through Friday during normal working hours OR Tel: 376-3533 or 376-4705
after normal working hours. Contact is only complete when you have spoken to the responsible
person in the Surveillance Unit.
15
Recommended safety precautions for contact tracing teams
Since COVID-19 cases are more likely to be discovered during contact follow-up, contact tracing
teams should take precautionary measures to protect themselves during home visits.
The following precautions will be taken during contact tracing visits by all members of the team:
• Avoid direct physical contact like shaking hands or hugging.
• Maintain a comfortable distance (more than 1metre) from the person.
• Avoid entering the residence.
• Avoid sitting on chairs offered to you.
• Avoid touching or leaning against potentially contaminated objects.
• Always have a good breakfast before home visits to resist the temptation of eating
or drinking while visiting contacts.
• Do not conduct home visits wearing personal protective equipment like masks,
gloves, or gowns.
• If you must take the contact’s temperature, put on disposable gloves.
• Have the contact turn around and take their temperature in the armpit.
• Avoid touching the patient and step back to wait for the thermometer.
• If the contact is visibly ill, do not attempt to take their temperature but notify your
supervisor immediately.
• As part of the overall safety of the Rapid Response Team, all members of the contact
tracing team should monitor their own temperature every morning.
Asymptomatic individuals identified as contacts must remain available to health authorities,
notifying health personnel of any change of location that may affect the health personnel’s ability to
carry out daily monitoring. For operational reasons, non-essential travel of contacts during the
monitoring period is discouraged.
Contacts that developed symptoms compatible with COVID-19 must be referred to Infectious Disease
Unit, PMH for medical assessment and further investigation. This should trigger further active search
for cases in both the community and at health facilities.
Contact tracing – non health sector partners
If the patient with illness compatible to COVID-19 develops symptoms while on an aircraft, contact
tracing must be made according to the Risk Assessment Guidelines for Infectious Diseases
transmitted on Aircraft (RAGIDA) protocol, which indicates the contact tracing should only include
passengers who were seated in direct proximity to the index case, i.e. only passengers who were one
seat away from the index case (+/- 1 seat in all directions). Additionally, all persons who reported
direct contact with the index case should be traced back. Crew members who provided in-flight
service in the section of the aircraft where the index case was seated should be included in the traceback,
as well as cleaning staff that cleaned the section and seat where the index case was seated. The
Surveillance Unit, through the Port Medical Officer, will liaise with airline crew and Agents for the
conveyance operator who will be responsible for obtaining the contact information from the airlines
arriving in The Bahamas.
Should the passenger become ill during the flight, contacts should be assessed in the designated areas
within the airport according to the airport contingency plan (domestic and international terminals).
16
When any international traveler in transit is among the identified contacts, the national authorities
should determine the least disruptive and most acceptable way to secure the follow up of the contact.
Continuation of international travel to the final destination should be preceded by communication to
national health authorities in the relevant country by the Office of the Chief Medical Officer or the
designate in the Ministry of Health.
When the Ministry of Health is informed by their counterparts in other countries, directly or through
PAHO/WHO, about the arrival in their jurisdiction of a contact of a COVID-19 case, responsibility for
the monitoring of the individual for 14 days after the date of last exposure to COVID-19 will be
assigned to the Surveillance Unit or healthcare providers responsible for that catchment area in the
Ministry of Health.
If a case of COVID-19, is diagnosed subsequent to the arrival and departure of the aircraft, then
consideration needs to be given to the lapse in time between the flight event and the incubation
period. The incubation period of COVID-19 is 2-10 days (accepted as 14 days). In order to find
potential cases, tracing passengers should only be considered if the flight took place within the
previous 14 days. Outside this time, a message to raise awareness among doctors and public health
professionals should be considered.
Contact tracing health care workers
Both health personnel involved in the direct care of a patient under investigation for COVID-19 or of
a confirmed case of COVID-19, as well as laboratory personnel, must be considered as a contact in
the event of unprotected exposure to potentially infectious body fluids or through sharps injury and
monitored for 14 days after the opportunity for exposure to contaminated material.
Management of Contacts of Suspected and Probable Cases
• Provide reassurance
• Record name and contact details
• Provide advice that in the event of fever or respiratory symptoms, to immediately report to
doctor/physician/health authority
• Do not report to work until advised by health authority
• Avoid public places until advised by health authority
• Minimize contact with family members and friends
• Implement the following Hospital Infection Control Measures
Care for Patients with Probable COVID-19: Health Care Setting Infection Control Measures 8
All health care facilities should have a preparedness and response plan which outlines infection
prevention and control advice for healthcare providers assessing possible cases of COVID-19.
WHO advises strict adherence with the barrier nursing of patients with COVID-19 using precautions
of airborne, droplet, and contact transmission.
8
Clinical management of severe acute respiratory infection when Novel coronavirus (2019-nCoV) infection is
suspected: Interim Guidance
17
Triage nurses should rapidly divert persons presenting to their health care facility with influenzalike
symptoms to a separate assessment area to minimize transmission to others in the waiting
room. Suspect cases should wear surgical masks until COVID-19 is excluded.
Patients with probable COVID-19 should be isolated and accommodated as follows in descending
order of preference:
• Negative pressure rooms with the door closed
• Single rooms with their own bathroom facilities
• Cohort placement in an area with an independent air supply and exhaust system.
If an independent air supply is not feasible, turning off air conditioning and opening windows for good
ventilation is recommended
Wherever possible, patients under investigation for COVID-19 should be separated from
those diagnosed with the syndrome.
Disposable equipment should be used wherever possible in the treatment and care of patients with
COVID-19. If devices are to be reused, they should be sterilized in accordance with manufacturers'
instructions. Surfaces should be cleaned with broad spectrum (bactericidal, fungicidal, and
virucidal) disinfectants of proven efficacy.
Patient movement should be avoided as much as possible. Patients being moved should wear a
surgical mask to minimize dispersal of droplets. NIOSH standard masks (N95), often used to protect
against other highly transmissible respiratory infections such as tuberculosis, are preferred if
tolerated by the patient. All visitors, staff, students and volunteers should wear a N95 mask on
entering the room of a patient with confirmed or suspected COVID-19. Surgical masks are a less
effective alternative to N95 masks.
Handwashing is the most important hygiene measure in preventing the spread of infection.
Gloves are not a substitute for handwashing. Hands should be washed before and after significant
contact with any patient, after activities likely to cause contamination, and after removing gloves.
Alcohol-based skin disinfectants formulated for use without water may be used in certain limited
circumstances until there is access to handwashing facilities.
Health care workers are advised to wear gloves for all patient handling.
Gloves should be changed between patients and after any contact with items likely to be
contaminated with respiratory secretions (masks, oxygen tubing, nasal prongs, tissues). Gowns
(waterproof aprons) and head covers should be worn during procedures and patient activities that
are likely to generate splashes or sprays of respiratory secretions.
Healthcare workers (HCWs) must wear protective eyewear or face-shields during procedures
where there is potential for splashing, splattering or spraying of blood or other body substances.
18
Health care workers are advised to wear masks.
Particulate filter personal respiratory protection devices capable of filtering 0.3um particles (N95)
should be worn at all times when attending patients with suspected or confirmed COVID-19.
Standard precautions should be applied when handling any clinical wastes.
All waste should be handled with care to avoid injuries from concealed sharps which may not have
been placed in sharps containers. Gloves and protective clothing should be worn when handling
clinical waste bags and containers. Where possible, manual handling of waste should be avoided.
Clinical waste must be placed in appropriate leak-resistant biohazard bags or containers, labeled,
and disposed of safely.
Laboratory Safety Guidelines for Handling Suspected Samples 9
Specimen may be processed for packaging and distribution to reference laboratories for further
testing in a containment Level 2 laboratory.
When handling theCOVID-19 specimens, the following should be implemented:
• The use of respirators which filter >90% of particles ranging from 0.5 um to 1.0 um e.g. N95
respirators from 3M.
• Safety glasses or eye shields as necessary
• Laboratory coats
• Gloves
• Manipulations that may produce aerosols should be carried out in a certified biological
safety cabinet (BSC)
• Centrifugation of blood should be carried out using sealed centrifuge cups and unloaded in a
BSC
• Any activities that bring hands into contact with mucosal surfaces such as eating, drinking,
smoking, or applying make-up are prohibited in the laboratory.
• Protective clothing must not be worn outside the work area and must be placed in separate
containers or laundry bags and autoclaved before being washed or discarded. Under no
circumstances must protective clothing be taken home to be laundered.
• Proper hand washing is required before leaving the laboratory.
Decontamination
• Commercially available household bleach solution containing 5.25% hypochlorite, when
diluted 1:10 is effective in routine decontamination of surfaces and instruments after
working with materials possibly infected with COVID-19.
• Contaminated items such as pipettes, disposable loops etc. should be immersed in
decontamination solution until autoclaving.
• Spills involving samples should be flooded with decontamination solution and soaked for
20-30 minutes before clean-up
9
Infection prevention and control during health care when novel coronavirus (nCoV) infection is suspected:
interim guidance
19
• Persons involved in the clean-up of spills should wear gloves, safety glasses, and a
laboratory coat or gown during the clean-up process.
• Respiratory protection should be considered for spills in which substantial aerosolization is
suspected when handling the samples.
Waste Disposal
• All infectious waste must be placed in autoclavable pans or bags for decontamination.
• Disinfectant solution must be placed in discarded pans to begin the decontamination
process.
• All infectious waste must be autoclaved and/or incinerated before disposal
• Waste should be autoclaved as close to the point of generation as possible.
• Biological indicators must be used to monitor the effectiveness of the autoclaving process.
Waste may also be autoclaved centrally (away from the lab) but it must be packaged in leakproof
bags and containers and must be properly transported to the central autoclave.
• After autoclaving, all waste should be incinerated for complete destruction.
• All waste handlers must be properly trained to handle infectious laboratory waste.
Plan for Public and Private Primary Care Clinics
Plan for Tertiary Hospitals (Emergency Department and Urgent Care):
Ensure triage, early recognition, and source control 10
Clinical triage includes a system for assessing all patients at admission allowing early recognition of
possible COVID-19 infection and immediate isolation of patients with suspected infection in an area
separate from other patients (source control).
To facilitate the early identification of cases of suspected COVID-19 infection, healthcare facilities
should:
• Encourage HCWs to have a high level of clinical suspicion;
• Establish a well-equipped triage station at the entrance of health care facility, supported by
trained staff;
• Institute the use of screening questionnaires according to the updated case definition, and
• Post signs in public areas reminding symptomatic patients to alert HCWs.
The promotion of hand hygiene and respiratory hygiene are essential preventive measures.
10
Infection prevention and control during health care when novel coronavirus (nCoV) infection is suspected:
interim guidance
20
Once a person meets the criteria for a suspected case, they should immediately be masked and
placed in a designated isolation room/area. The Surveillance Unit should be notified and the case is
not to be removed from the isolation area/room till review by the Surveillance Unit staff.
Plan for designated remote field hospital
A remote field hospital represents the ideal quarantine facility. Plans for the acquisition/erection of
such a facility are ongoing.
Management of Suspected Cases in Quarantine
If a person in quarantine develops symptoms suggestive of COVID-19 infection, the client remains
masked and in isolation. The COVID-19 Rapid Response is informed and the client assessed at the
quarantine site. Once their investigation is complete, they will determine if the case can remain
under ‘home care’ or requires isolation and treatment at a tertiary level institution.
Isolation (patient placement)
• A possible case should be managed in negative pressure single room if available. If this
is not possible then a single room with ensuite facilities should be used. Room doors
should be kept closed
• Positive-pressure single rooms must not be used
• The nature of the area adjoining the side room should be considered to minimize the
risk of inadvertent exposure (such as high footfall areas, confused patients, vulnerable
patient groups)
• If on a critical care unit, the patient should be nursed in a negative-pressure single/side
room where available, or, if not available, a neutral-pressure side room with the door
closed
• If there is no ensuite toilet, a dedicated commode (which should be cleaned as per local
cleaning schedule) should be used with arrangements in place for the safe removal of
the bedpan to an appropriate disposal point
• Avoid storing any extraneous equipment in the patient’s room
Anterooms and putting on and removing PPE
Ideally an isolation room as above with an anteroom should be used.
Anterooms also have the potential to become contaminated and should be regularly
decontaminated as per existing IPC guidelines.
The staff is to progress through ‘dirty’ to ‘clean’ areas within the anteroom as they remove
their PPE and wash hands after they leave the patient room. To this effect, movements within the
anteroom should be carefully monitored and any unnecessary equipment should not be kept in this
space.
21
A buddy system to observe for inadvertent contamination will be used, especially during high risk
procedures and PPE removal.
In the event that no anteroom/lobby exists for the single room used for COVID-19 patients, local
infection prevention and control teams (IPCT) will need to outfit alternative ways of
accommodating these recommendations to suit local circumstances.
Notices about infection risks
Written information will be placed on the isolation room door indicating the need for isolation,
including the infection prevention and control precautions which must be adhered to prior to
entering the room. Patient confidentiality will be maintained.
Entry records
Only essential staff should enter the isolation room.
A record should be kept of all staff in contact with a possible case, and this record will be accessible
to occupational health should the need arise.
Staff considerations
The use of bank or agency staff should be avoided.
Staff involved in care of possible cases should be given emergency contact details if they
develop COVID-19 compatible symptoms while away from the hospital. Further details of this and
other requirements for managing healthcare contacts by the employer will be provided by Ministry
of Health Disease Surveillance Unit.
Visitors
Visitors will be restricted to essential visitors only, such as parents of paediatric patients or an
affected patient’s main carer. This will be subject to a local risk assessment having been performed.
Personal protective equipment must be made available to visitors, including instruction and
supervision of correct usage and donning and doffing.
The hospital must be mindful of its responsibilities to persons who are not employees for safety in
the institution and health hazards
Personal Protective Equipment (PPE)
The following PPE is to be worn by all persons entering the room where a patient is being isolated
(either before definitive assessment, or once assessed as a possible case):
• Long sleeved, fluid-repellent disposable gown – wearing scrubs underneath obviates
problems with laundering of uniforms and other clothing
• Gloves with long tight-fitting cuffs
22
• NIOSH approved N95 mask/ FFP3 respirator conforming to EN149 must be worn by all
personnel in the room. Fit testing must be undertaken before using this equipment and a
respirator should be fit-checked every time it is used
• Eye protection, such as single use googles or full-face visors, must be worn (note
prescription glasses do not provide adequate protection)
The PPE described above must be worn at all times when in the patient’s room
Hand hygiene
This is essential before and after all patient contact, removal of protective clothing and
decontamination of the environment.
Use soap and water to wash hands or an alcohol hand rub if hands are visibly clean.
Rings (other than a plain smooth band), wrist watches and wrist jewellery must not be worn by
staff.
Aerosol generating procedures
Procedures that produce aerosols of respiratory secretions, for example bronchoscopy, induced
sputum, positive-pressure ventilation via a face mask, intubation and extubation, and airway
suctioning carry an increased risk of transmission. Where these procedures are medically
necessary, they should be undertaken in a negative-pressure room, if available, or in a single room
with the door closed at the remoted, isolated health care facility- Princess Margaret Hospital is not
equipped to house patients who need aerosol generating procedures.
Only the minimum number of required staff should be present, and they must all wear personal
protective equipment as described above. Entry and exit from the room should be minimized
during the procedure.
If aerosol generating procedures are undertaken in the patient’s own room, the room should be
decontaminated 20 minutes after the procedure has ended.
If a different room is used for a procedure it should be left for 20 minutes, then cleaned and
disinfected before being put back into use.
Clearance of any aerosols is dependent on the ventilation of the room. In hospitals, rooms
commonly have 12-15 air changes per hour, and so after about 20 minutes there would be less than
1 per cent of the starting level (assuming cessation of aerosol generation).
If it is known locally that the design or construction of a room may not be typical for a clinical space,
or that there are fewer air changes per hour, then the local IPCT would advise on how long to leave
a room before decontamination.
23
Equipment
• Re-useable equipment should be avoided if possible; if used, it should be decontaminated
according to the manufacturer’s instructions before removal from the room
• Use dedicated equipment in the isolation room. Avoid storing any extraneous equipment in
the patient’s room
• Dispose of single use equipment as per clinical waste policy inside room
• Ventilators should be protected with a high efficiency filter, such as BS EN 13328-1
• Closed system suction should be used
• Disposable crockery and cutlery may be used in the patient’s room as far as possible to
minimise the numbers of items which need to be decontaminated
Environmental decontamination
There is evidence from other coronaviruses of the potential for widespread contamination of
patient rooms/environments. Effective cleaning and decontamination, therefore, is vital.
Cleaning and decontamination should only be performed by staff trained in the use of the
appropriate PPE.
Institution to review if this needs to be trained clinical staff rather than domestic staff.
After cleaning with neutral detergent, a chlorine-based disinfectant should be used, in the form of a
solution at a minimum strength of 1,000ppm available chlorine.
The main patient isolation room will be cleaned according to reference guidelines and following
aerosol generating procedures or other potential contamination.
There will be more frequent cleaning of commonly used hand-touched surfaces and of
anteroom/lobby areas (at least twice per day).
To ensure appropriate use of PPE and that an adequate level of cleaning is undertaken which is
consistent with the recommendations in this document, cleaning of the isolation area will be
undertaken separate to the cleaning of other clinical areas.
Dedicated or disposable equipment must be used for environmental decontamination. Reusable
equipment must be decontaminated after use with a chlorine-based disinfectant as described
above.
Linen
Bag linen inside patient isolation room in accordance with procedures for infectious linen.
Unbagged linens should not be carried through the ward or other clinical area.
Waste
Large volumes of waste may be generated by frequent use of PPE. Advice from the local waste
management team should be sought prospectively on how to manage this.
24
Dispose of all waste as clinical waste.
Waste will be quarantined until testing results are known. If the patient is confirmed to
have COVID-19, national and local guidelines will advise on waste disposal and transportation.
Waste from a confirmed case must be disposed of as per local guidelines.
If ambulant, the patient can use the ensuite bathroom. If bedpans are used, the excreta should
solidified using superabsorbent polymer gel granules and then disposed of as clinical waste. The
use of these granules must be strictly controlled as per local guidelines. Communal facilities must
not be used.
Specimens
• All specimens and request forms should be marked with a biohazard label.
• The specimen should be double bagged in the isolation room by a staff member wearing
recommended PPE.
• Specimens should be hand delivered to the laboratory by someone who understands the
nature of the specimens and the lab must be communicated with.
• Pneumatic tube systems must not be used to transport specimens.
• Transport of samples between laboratories should be in accordance with international
guidelines for hazardous specimens.
• Specimens are to be sent to local, regional, or international laboratory with capacity for
identifying COVID-19 in nasopharyngeal, serum, and urine samples.
For Further information please contact:
Surveillance Unit,
Ministry of Health
Meeting Street
Nassau, Bahamas
Tel # (242) 502-4790 or (242) 397-1021
25
Addendum
26
Guidelines for National Emergency Medical Services (N.E.M.S) During 2019 Novel
Coronavirus Alert –January 2020
Background
On January 30 th , 2020 The World Health Organization declared the outbreak of the 2019 Novel
Coronavirus (COVID-19) as a Public Health Emergency of International Concern. The outbreak
causing respiratory disease/pneumonia is said to have originated in a Seafood and Wild Animal
Market in Wuhan City, Hubei Province, China in December 2019. Coronaviruses (CoV) are zoonotic,
meaning that they are transmitted between animals and humans. Coronaviruses are a large family
of viruses that cause illnesses ranging from the common cold to more severe diseases such as
Middle East Respiratory Syndrome (MERS-CoV) and Severe Acute Respiratory Syndrome (SARs-
CoV). A novel coronavirus is a new strain that has not previously been identified in humans.
Common signs of COVID-19 infection include fever, cough, shortness of breath and breathing
difficulties. It is important to note that fever may not be present in all patients such as those who
are immunocompromised, the very young, the elderly or those taking fever-lowering medications.
In more severe cases of COVID-19, infection can cause pneumonia, severe acute respiratory
syndrome, kidney failure and death. According to available evidence, there is transmission from
person to person. COVID-19 is highly infectious and is spread via droplet, contact, and airborne
transmissions. The incubation period is up to 14 days and transmission of the virus may occur
during the incubation period prior to symptom onset. At present, there are no vaccines and
treatment of COVID-19 is mostly supportive with emphasis on avoidance of transmission. The
number of confirmed cases is in the thousands with hundreds of deaths. In The Bahamas, to date,
there are no suspected, reported or confirmed cases of COVID-19.
Emergency Medical Services (E.M.S.) personnel, however, must exercise a high degree of suspicion
for potential cases of COVID-19.The identification of a suspect or probable case must take into
account (1) clinical manifestations as noted above, (2) travel history to mainland China within
the last 14 days (two weeks) prior to the onset of symptoms and (3) possible exposure history.
As a precautionary measure, persons returning to the country after travel to affected areas will
remain in quarantine/isolation for a maximum of 20 days.
Case Definition for COVID-19
Fever or signs/symptoms of lower respiratory illness (e.g. cough or shortness of breath), AND any
person, including healthcare workers, who has had close contact 11 with a laboratory-confirmed
COVID-19 patient within 14 days of symptom onset
OR
11
Having cared for, having lived with, or having had direct contact with respiratory secretions and bodily fluids of a
person with 2019-nCoV infection
27
Fever and signs/symptoms of a lower respiratory illness (e.g. cough or shortness of breath), AND a
history of travel from Hubei Province, China within 14 days of symptom onset
OR
Fever and signs/symptoms of a lower respiratory illness (e.g. cough or shortness of breath)
requiring hospitalization, AND a history of travel from mainland China within 14 days of symptom
onset
Response Guidelines
In the Bahamas, any suspected case is treated in the tertiary care institution, not home
isolation. Asymptomatic travelers with unknown exposure history are managed with
“home-based isolation”
Most cases of COVID-19 are expected to be cases that can be managed with home-based
isolation and would not require transport to a tertiary level institution 12
When the Dispatch Units of N.E.M.S. receives a call of a patient complaining of respiratory
illness and/or fever, the Dispatch call taker should confirm the details of the travel history
and symptomology, ensuring the client meets criteria of a suspect or probable case of
COVID-19. This is done by asking the following:
o The Dispatcher should ask the following questions during the caller interrogation
process:
• Does the patient have a fever, cough or difficulty breathing?
• Have they traveled from China in the last 14 days?
• Have they had close contact with a person who recently traveled from China?
• Have they had contact with a person confirmed or suspected to have COVID-
19?
o This is further confirmed by EMS personnel assessing the patient at the site
• The client is assessed for the presence/or absence of fever, cough, shortness
of breath, and dyspnea
• Vitals to critically note include temperature, respiratory rate, heart rate, and
oxygen saturation
The presence of these, along with a history of recent travel to
mainland China, a strongly suggestive of a suspect COVID-19 case and
should be relayed to the Dispatcher
The Dispatcher should regard the patient as a suspect COVID-19 if the answer is YES to
travel to China within the past 20 days and has symptoms suggestive of COVID-19 infection,
as outlined above.
The Dispatcher should immediately contact the receiving facility, which has an identified
isolation area and notify a representative of the Surveillance Unit of the Ministry of Health
12
Home care for patients with suspected novel coronavirus (nCoV) infection presenting with mild symptoms and
management of contacts Interim guidance 20 January 2020; WHO/nCov/IPC_HomeCare/2020.1
28
and/or Port Health Officer to advise of the probable/suspected case of COVID-19. The
Ministry of Health Surveillance Unit can be reached at 502-4790, 502-4776 or 397-1021
(New Providence) OR 350-6700 ext. 2353 or 359-4541 (Grand Bahama) Monday-Friday
during business hours and at 376-3533 or 376-4705 after normal working hours.
The Dispatcher should alert the responding crew that the symptoms are consistent with
COVID-19 and should be managed as a suspected case. For the purpose of confidentiality and
patient comfort, this may be communicated by stating “ID ALERT” for infectious disease alert.
The Dispatcher should give notice by radio to remind the crew to utilize appropriate personal
protective equipment (PPE) (see below).
The Dispatcher should call ahead to advise the receiving healthcare facility and medical team
of the imminent transport of a suspected COVID-19 case to allow for appropriate preparation
and to receive information on the specific site of isolation for the patient and any further
advice from the receiving medical team.
The EMS crew dispatched to the scene should initiate standard droplet, contact and airborne
precautions by donning the appropriate personal protective equipment (PPE) which consists
of a disposable gown (long-sleeve, fluid impermeable), disposable N-95 mask (fit-tested for
good seal, beard not recommended), goggles/disposable face shield (providing coverage of
front and sides of the face) and gloves.
A surgical mask should be placed over the patient’s nose and mouth by the EMS crew if not
previously done.
The patient should receive routine monitoring and care during transport as required.
Prehospital care includes fever management (cooling, acetaminophen, etc.), IV therapy,
maintaining the airway, and adequate oxygenation. EMS crew should use caution with high
risk exposure procedures that produce aerosols such as suctioning, intubation and CPR. Crew
should refrain from touching eyes, nose or mouth with potentially contaminated gloved or
bare hands.
While en route, E.M.S. personnel should contact a senior physician at the receiving healthcare
facility by radio or telephone to give a status update on the suspected COVID-19 case, to
advise of the estimated time of arrival and confirm the specific site for patient isolation. For
the purpose of confidentiality and patient comfort, this may be communicated by stating “ID
ALERT” for infectious disease alert.
Upon completion of the transport, the EMS crew should properly doff and dispose of PPE by
placing them in a red biohazard bag. Before removing respiratory protection, crew should
remove gloves, clean hands using 60%-95% alcohol-based hand sanitizer (ABHS) or soap and
water for at least 20 seconds then remove eye and respiratory protection. Hands should be
thoroughly washed again.
EMS Crew should perform hand hygiene using ABHS or soap and water before and after all
patient contact, contact with potentially infectious material, and before putting on and upon
removal of PPE. If hands are visibly soiled, use soap and water before returning to ABHS.
29
EMS crew should clean and disinfect all surfaces which the patient is in contact, the interior
of ambulance, and all patient care equipment (monitors, cables, BP cuffs, stethoscopes, etc.)
with a hospital grade disinfectant. A 1:10 solution of bleach will work if there is any
uncertainty. PPE should be used during cleaning. If possible, dedicated medical equipment
should be used for patient care.
ALL disposable items and medical waste should be deposited in red bio-hazard bags which
are disposed of into biohazard waste containers. If utilized, as per usual, safe handling (no
recapping) and disposal of needles in biohazard sharps containers must be done.
Reminder
If a suspected case is encountered or if you have any questions, please contact:
1. The Surveillance Unit of the Ministry of Health at 502-4790 or 397-1021,
2. PMH Infection Control Unit at 322-2861 ext. 2613 or 2711
References
1. Coronavirus – World Health Organization
www.who.int › Health topics
2. EMS Considerations for Coronavirus
1/28/2020 National Association of EMS Physicians | NAEMSP
https://naemsp.org/home/news/ems-considerations-for-coronavirus/ 2/3
3. Update and Interim Guidance on Outbreak of 2019 Novel Coronavirus
www.mass.gov › clinical-advisory › update-and-interim-guidance-on-..
4. Infection Control: Novel Coronavirus 2019 (2019-nCoV |CDC
www.cdc.gov › coronavirus › 2019-nCoV › hcp › infection-control
5. A Novel Coronavirus Overview for EMS|EMS World
www.emsworld.com › article › novel-coronavirus-overview-ems
6. Infection prevention and control during health care when novel coronavirus (2019-nCoV) infection
is suspected
Interim guidance 25 January 2020
30
WHO/2019-nCoV/IPC/v2020.2
7. Novel Coronavirus (2019-nCoV) Update - JEMS
www.jems.com › 2020/01/27 › novel-coronavirus-2019-nCoV-update
8. Wuhan Coronavirus: What EMS Providers Need To Know
www.ems1.com › infectious-diseases › articles › rapid-response-wuha...
9. Interim Infection Control Guidance for Prehospital Emergency Medical Services
www.doh.wa.gov › Portals › Documents › InfectionControlforPrehos...
10. EMS Policy Statement – 20-02: 2019-nCoV”Wuhan Coronavirus
www.health.ny.gov › professionals › ems › pdf
31
STANDARD OPERATING PROCEDURES
FOR
COLLECTION, RECEIPT, PROCESSING AND TRANSPORT OF SPECIMENS CONTAINING RISK
GROUP 3 ORGANISMS INCLUDING COVID-19
32
Preparation, Review and Approval Page
TITLE: COLLECTION, RECEIPT, PROCESSING AND
TRANSPORT OF SPECIMENS CONTAINING
RISK GROUP 3 ORGANISMS INCLUDING COVID-19
Doc Control #: PMHLAB-MICR-SOP-086-01
SECTION:
Medical Microbiology
VERSION: 01
APPROVED BY: Signature/Date EFFECTIVE DATE: FEBRUARY 3 rd 2020
REVIEWED BY: Signature/Date
PREPARED BY:
Dr. Jessica Edwards
SUPERSEDES: N/A
Document Version History
Version
Number
Revision
Date:
Revised By:
Brief description of revision:
(write in or type in)
33
Familiarization Page
Document control #
Document control title
PMHLAB-MICR-SOP-086-01
Collection, Receipt, Processing and Transport of Specimens
Containing Risk Group 3 Organisms Including
COVID-19
By signing this page, members of staff and management confirm they have read this SOP and
promise to implement the procedures contained within.
Name Title Date Signature
(staff member)
34
Title
Collection, Receiving, Processing and Transport of Specimens Containing Risk Group 3 Organisms
Including COVID-19
Intended Use
This SOP was developed to guide laboratory users and personnel on the steps required for
collecting, processing, packaging and transporting of specimens containing risk group 3 organisms,
including COVID-19, to be investigated.
Introduction
From time to time there have been global outbreaks of risk group 3 organisms such as
Chikungunya, West Nile Virus and Coronaviruses. A new strain of coronavirus was detected on
January 2020, after several persons were identified with an unusual type of pneumonia.
Coronaviruses (CoV), so named for their “crown-like” appearance, are a large family of viruses, the
Coronaviridae family, genus Betacoronavirus. Coronaviruses are enveloped single stranded,
positive sense RNA virus. The Coronaviruses have the longest genome of the RNA viruses. The
novel Coronavirus is closely associated with two other respiratory coronaviruses, the Severe Acute
Respiratory Syndrome (SARS - CoV) in 2003 and Middle East Respiratory Syndrome (MERS- CoV)
in 2012. Researchers have now confirmed that though the original source of the virus has not been
identified, transmission of the virus occurs from person to person through respiratory droplets.
Infections are purported to spread during the incubation or in asymptomatic patients. Persons may
have mild illness, but the illness may progress to severe acute respiratory distress syndrome and
even death. Diagnosis of this infection is based on the detection of viral RNA in clinical specimens,
namely respiratory samples, thus real time RT PCR is the method of choice. There are no test
methods available at present at PMH and therefore, specimens need to be transported to a
reference lab, either locally, regionally or to the United States for confirmation. The specimen
collection, processing and transport procedures herein should be strictly followed when handling
these types of organisms.
Collection of Specimens For COVID-19
Clinical specimens should be collected from any patient under investigation for COVID-19 as
defined by the WHO surveillance reference, 2020. Rapid collection and testing is a priority and
although testing of other respiratory viruses will be included in the initial workup.
Appropriate Specimen Types
The main specimen required for the initial workup listed in order of priority:
a. Lower Respiratory specimens including: bronchoalveolar lavage, tracheal aspirates, and
sputum
b. Upper Respiratory Tract specimens - nasopharyngeal or oropharyngeal aspirates or
washes, nasopharyngeal or oropharyngeal swabs
o Swab specimens should be collected only on swabs with a synthetic tip (such as
polyester or Dacron®) with aluminium or plastic shafts. Swabs with calcium
alginate or cotton tips with wooden shafts are not acceptable.
c. Serum (red top tube or serum separator tube)
d. Urine may also be collected (sterile urine collection cup
35
See Table 1 below for other specimen options available.
Table 1: Specimen collection guidelines for COVID-19
*
Note: *Transport temperature to PMH Lab from outside of PMH.
Samples currently being tested at the CDC include: Sputum, Nasopharyngeal or Oropharyngeal
swabs. Additional samples that might be collected will be stored until further notice.
Requisition Form Requirements
To order a COVID-19 workup, physicians need to request a viral respiratory screen.
1. Patient demographics: Name, date of birth, medical record number, physician’s name
2. Date and time of sample collection
3. Anatomical site and location of specimen collection
4. Tests requested
5. Clinical symptoms and relevant patient history
Instructions for Nasopharyngeal Swab or Oropharyngeal Swab Collection
36
Nasopharyngeal Swab
• Sterile Dacron/nylon swab • Viral transport media tube (should contain 1-3 ML of sterile viral
transport medium)
1. Tilt patient’s head back 70 degrees.
2. Insert swab into nostril. (Swab should reach depth equal to distance from nostrils to outer
opening of the ear.) Leave swab in place for several seconds to absorb secretions.
3. Slowly remove swab while rotating it. (Swab both nostrils with same swab.)
4. Place tip of swab into sterile viral transport media tube and snap/cut off the applicator
stick. 2 dry sterile polyester swabs (aluminum or plastic shafts preferred)
Oropharyngeal and Nasopharyngeal Swab
• Viral transport media tube (should contain 1-3 ML of sterile viral transport medium)
1. Tilt patient’s head back 70 degrees.
2. While gently rotating the swab, insert swab less than one inch into nostril (until resistance
is met at turbinates).
3. Rotate the swab several times against nasal wall and repeat in other nostril using the same
swab.
4. Place tip of the swab into sterile viral transport media tube and cut off the applicator stick.
5. For throat swab, take a second dry polyester swab, insert into mouth, and swab the
posterior pharynx and tonsillar areas. (Avoid the tongue.)
6. Place tip of swab into the same tube and cut off the applicator tip.
Sputum collection
1. Have a sterile specimen cup or sputum cup
2. Ask patient to rinse out their mouth with water
3. Take a deep breath and cough directly into the specimen cup
4. Screw cover onto cup and label container
5. Place in hazard bag
Urine collection
1. Wipe urethra with clean cloth or towelette
2. Allow urine to collect in a clean catch urine in sterile specimen container
3. Label container
4. Urine should be placed in the biohazard bag
37
Infection Control Procedures During Specimen Collection
Ensure that Health Care workers (HCWs) who collect specimens follow the following guideline and
use the adequate PPE: Infection prevention and control during health care when novel coronavirus
(COVID-19) infection is suspected.
HCWs performing aerosol-generating procedures (i.e. aspiration or open suctioning of respiratory
tract specimens, intubation, cardiopulmonary resuscitation, bronchoscopy) should use additional
precautions such as:
1. Respirators (NIOSH-certified N95, EU FFP2 or equivalent, or higher level of protection).
When putting on a disposable particulate respirator, always check the seal/fitness. Be
aware that the presence of facial hair (e.g. beard) may prevent a proper respirator fit for the
wearer. In some countries, a powered air purifying respirator (PAPR) is utilized instead of a
respirator.
2. Eye protection (i.e. goggles or a face shield).
3. Clean, long-sleeved gown and gloves. If gowns are not fluid resistant, a waterproof apron
should be used for procedures where it is expected that fluid might penetrate the gown
Perform procedures in an adequately ventilated room: at a minimum natural ventilation with at
least 160l/s/patient air flow, or negative pressure rooms with at least 12 air changes per hour and
controlled direction of air flow when using mechanical ventilation.
Limit the number of persons present in the room to the minimum required for the patient’s care
and support.
Follow WHO guidance for steps of donning and doffing PPE. Perform hand hygiene before and after
contact with the patient and his or her surroundings and after PPE removal.
Waste management and decontamination procedures: Ensure that all materials used are disposed
appropriately. Disinfection of work areas and decontamination of possible spills of blood or
infectious body fluids should follow validated procedures, usually with chlorine-based solutions.
Specimen Collection and Transport to The Hospital Laboratory
Ensure that personnel who transport specimens are trained in safe handling practices and spill
decontamination procedures.
State the full name, registration number and date of birth of the suspected case clearly on the
specimen containers.
Complete the required CDC investigation forms:
1. Person Under Investigation form
2. 50.34 form
3. Ministry of Health Influenza investigation form.
38
BEFORE transport of specimen to Princess Margaret Hospital Microbiology lab, notification of Dr
Jessica Edwards (Microbiologist) or Mr Allison Scavella (Microbiology Supervisor) for further
referral is required.
Deliver all specimens by hand. Do not use the pneumatic-tube systems to transport
specimens within the hospital/institution.
Specimens should be placed in a durable, leak-proof secondary container for transport within a
facility. To reduce the risk of breakage or leaks, samples should be hand delivered to the lab and
received by the institution identified lab personnel.
Specimens being locally transported to the PMH lab should be packaged in a leakproof secondary
container with ice packs, then place into a rigid outer package.
Specimen Testing
Respiratory specimens should be walked down to the lab and be given to a pre-identified
Microbiology staff member. The specimen will be immediately placed in the respiratory bin of the
Microbiology refrigerator at 2 - 8°C. Processing of the nasopharyngeal or oropharyngeal specimens
will begin within two hours of receipt of the specimen. A routine viral screen including the
influenza screen and RSV will be done and reported within one hour (see SOP). A positive viral
respiratory result does not preclude additional work-up for COVID-19. Because coinfection is
possible, specimens will also be sent to the CDC or the National Reference Lab for confirmation of
presence of COVID-19 by RT-PCR.
From the 3mL VTM tube, aliquot 0.5ml of VTM into a separately labelled tube to be transferred to
the National Reference Lab. Aliquot 2.0mL into another empty labelled sterile tube which will be
transferred to the CDC. The remaining 0.5mL will be stored in the -70C freezer in the Microbiology
lab. Urine will be stored at -70°C for future use.
Contact the Surveillance unit of the Ministry of Health for a special SU number for tracking to
accompany the appropriately completed surveillance form which will be transported to the
National Reference Lab. The appropriate CDC Person Under Investigation form and the 50.34
must be filled out to accompany the specimens to the CDC.
Packaging and Transport of Specimens Outside of the Hospital
In accordance with the IATA regulations, the package should be packed accordingly for Category B
biological specimens and shipped to both the CDC and the National Reference Lab.
Specimens should be stored and shipped at 4°C using ice packs or they may be frozen. Shipped
specimens will be triple packaged according to International Air Transport Association (IATA)
standards for Category B biological material as in illustrated in Figure 1 below.
For patients outside of New Providence and Grand Bahama, refer to the Department
of Public Health for registration, collection and transport protocols.
39
Figure 4: Triple packing method for Category B specimens
40
Figure 5: Information Sequence from AED or Outside Sources
Suspected case identified in A&E or Outside the PMH in accordance with
WHO case definitions
Inform Surveillance Unit of the Ministry of Health, 242-376-3533 or
242-376-4705 or 242-376-3809
Inform Hospital Administration, Infection Control and Laboratory Director
Notify Microbiology lab focal point (ext. 2246 or 2427) or call 242-
525-7200 or 242-465-2139, of the specimen collection and await
instruction on the name of the Microbiology Technologist to whom
the specimen should be handed
For A&E: Order in LIS under VIRS and specify COVID-19 in specimen
description. Print duplicate labels. Collect specimen: nasopharyngeal,
oropharyngeal or sputum, serum and urine. Ensure proper labelling of
specimen and complete the appropriate forms available in A&E. Place
one label on specimen and the other in the pocket of biohazard bag.
Outside specimens will be ordered in the lab.
Place specimen in a biohazard bag, place in a secondary secured
container and walk specimen and forms down to the lab. Hand specimen
to the identified Microbiology staff member and sign receipt log.
* DO NOT place specimen in pneumatic chute
41
Figure 6: Algorithm for Receiving, Processing and Transporting Specimens in PMH Lab
Microbiology focal point informed of specimen collection from PUI and
Microbiology Technologist informed of the case to receive the specimen
Specimens will be received in hand by Technologist and placed in the
respiratory bin in the 2 to 8℃ refrigerator
Contact CDC (770-488-7100) with PUI detailed information; email
address: eocevent185@cdc.gov). Subject line should read: nCoV PUI
Form
Receive specimen in the LIS by accessioner for Microbiology or Central
Accessioning including specimens received from outside sources
Respiratory specimen processing should be performed in the TB Lab.
Aliquot 0.5ml of VTM/respiratory fluid into a labelled, sterile cryotube and
aliquot 2.0ml of VTM/respiratory fluid into a separate sterile tube. Blood
will be spun down. Serum and urine will be stored in the -70℃ freezer.
Process the remaining
specimen for Influenza and
RSV and place remaining
volume in -70℃
Package specimen containing 0.5ml for
National Reference lab and contact Dr.
Martin for package pick up from
Microbiology lab. Package specimen
containing 2.0ml for CDC and contact
DHL for CDC package pick up.
Report influenza/RSV results
to Clinician and MOH*.
Contact CDC to provide tracking details
Note: *For PUIs testing positive for another respiratory virus, after clinical evaluation and consultation with Public Health
Authorities and Infectious Disease Specialist, they may no longer be considered a PUI.
42
References
1. WHO, Laboratory testing for 2019 novel coronavirus ( 2019-nCoV) in suspected human
cases, January 2020 (https://www.who.int/docs/default-source/coronaviruse/20200117-
interim-laboratory-guidance-version-final.pdf) PMHLAB-REF-0776
2. CDC, Interim 2019 novel coronavirus (2019-nCoV) patient under investigation (PUI) form,
CDC, January 2020
(https://www.cdc.gov/coronavirus/2019-nCoV/downloads/pui-form.pdf)
PMHLAB-REF-0774
3. CDC, Influenza Specimen Collection
(https://www.cdc.gov/flu/pdf/freeresources/healthcare/flu-specimen-collectionguide.pdf)
PMHLAB-REF-0777
4. CDC, Interim Guidelines for Collecting, Handling and Testing Clinical Specimens from
Patients Under Investigation (PUIs) for 2019 Novel Coronavirus (2019-nCoV), February
2020 (https://www.cdc.gov/coronavirus/2019-nCoV/lab/guidelines-clinicalspecimens.html)
PMHLAB-REF-0778
5. CDC, Biosafety in Microbiological and Biomedical Laboratories (BMBL) 5th Edition,
December 2009
(https://www.cdc.gov/labs/BMBL.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%
2Fbiosafety%2Fpublications%2Fbmbl5%2Findex.htm)
PMHLAB-REF-0779
6. CDC Specimen Submission Form: Specimens of Human Origin
(https://www.cdc.gov/laboratory/specimen-submission/form.html)
PMHLAB-REF-0775
7. Lawrence Berkeley National Laboratory, Environmental, Safety and Health (ESH) Manual
(PUB-3000), Chapter 26 Biosafety, Appendix B. Pathogen and Toxin Lists, Revised March,
2019. (https://www2.lbl.gov/ehs/pub3000/CH26/CH26_Appx_B.html)
PMHLAB-REF-0780
Related Documents
Examination by Referral Laboratories (QMM Section 5.0)
External Services and Supplies (QMM Section 6.0)
Advisory Service (QMM Section 7.0)
Preventive Actions (QMM Section 11.0)
Pre-examination Procedures (QMM Section 19.0)
Examination Procedures (QMM Section 20.0)
Post-examination Procedures & Reporting Results (QMM Section 22.0)
Clinician User Manual (DPLM-PMHLAB-USER-SOPM-002)
Safety Manual (DPLM-PMHLAB-SAFE-SOPM-004)
43
Specimen Acceptability (PMHLAB-QUAL-SOP-002)
Retention Time and Storage for Specimen and Records/Results (PMHLAB-QUAL-SOP-004)
Suppliers and Service Providers (PMHLAB-QUAL-SOP-013)
Risk Management Policy and Procedure (PMHLAB-QUAL-SOP-015)
Quality Control Management Protocol (PMHLAB-QUAL-SOP-033)
Non-conformances, Root Cause Analysis, Corrective Action and Preventative Action
(PMHLAB-QUAL-SOP-066)
Specimen Packaging and Shipping (PMHLAB-QUAL-SOP-0102)
Referral Laboratory Process (PMHLAB-MG-SOP-021)
Result Reporting, Critical Results and Corrected Report (PMHLAB-MG-SOP-030)
DPLM Risk Rating Table (PMHLAB-QUAL-LCK-0211)
Root Cause Analysis, Corrective Action and Preventative Action Flow Chart (PMHLAB-
QUAL-LCK-0213)
Pre-Analytical Procedures in Microbiology (PMHLAB-MICR-SOP-001)
Bio-safety Procedures (PMHLAB-MICR-SOP-002)
Guidelines for In Land Transportation (PMHLAB-MICR-SOP-014)
Reporting of Critical and Urgent Results (PMHLAB-MICR-SOP-025)
Protocol for Testing and Referring specimens to Reference Laboratories for analyses
(PMHLAB-MICR-SOP-030)
Quality Control in Microbiology (PMHLAB-MICR-SOP-031)
Medical Microbiology Workflow (PMHLAB-MICR-SOP-035)
BD Directigen RSV (PMHLAB-MICR-SOP-047)
Veritor Plus System For Rapid Detection of Flu A+B (PMHLAB-MICR-SOP-085)
Records
Reference Laboratory/Courier Tracking Log (PMHLAB-QUAL-LCK-031)
Biological Substance, Category B - UN3373 Shipping Checklist (PMHLAB-QUAL-LCK-
0159)
Risk Management Plan (PMHLAB-QUAL-LCK-0188)
Proforma Invoice form (for Shipping specimen) PMHLAB-QUAL-LCK-0202
USA Customs Letter (Category B) PMHLAB-QUAL-LCK-0203
Commercial Invoice (for Shipping specimen to CARPHA) PMHLAB-QUAL-LCK-0204
Surveillance Specimen Log (PMHLAB-QUAL-LCK-0205)
Referral Laboratory Results Tracking Form (PMHLAB-MG-LCK-001)
Approved Reference Laboratories (PMHLAB-MG-LCK-021)
Pathology and Laboratory Approved Vendor & Service Provider List PMHLAB-INV-
LCK-006
Reference Laboratory Tracking Chart (PMHLAB-MICR-LCK-013)
Microbiology Critical/Urgent Report Communication Log (PMHLAB-MICR-LCK-017)
List of Notifiable Diseases (PMHLAB-MICR-LCK-0188)
Viral Respiratory Infection Work Card (PMHLAB-MICR-LCK-0189)
44
Log of Received Specimens During a Period of Public Health Emergency of International
Concern (PHEIC) PMHLAB-MICR-LCK-0207
Interim 2019 novel coronavirus (2019-nCoV) patient under investigation (PUI) form
(PMHLAB-REF-0774)
CDC Specimen Submission Form: Specimens of Human Origin (PMHLAB-REF-0775)
Document Amendment Page
Document Control Title: Collection, Receipt, Processing and Transport of Specimens
Containing Risk Group 3 Organisms Including 2019-nCoV
Number Date Page # Amendment Authorized by
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
The amendment must be authorized by the section head
The amendment must be underlined and an asterisk written in the margin alongside the
change
Ten or less minor amendments can be made before the procedure is revised.
Major changes must result in the immediate review of the procedure.
45