26.02.2020 Views

Novel Coronavirus Preparedness and Response Plan- fbg-2

Create successful ePaper yourself

Turn your PDF publications into a flip-book with our unique Google optimized e-Paper software.

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

4


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

7


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.

9


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).

10


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

11


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

Hooray! Your file is uploaded and ready to be published.

Saved successfully!

Ooh no, something went wrong!