Screening and Management of COVID-19 at Primary Care

Introduction

COVID-19 is an infection with its own uniqueness. This virus is the seventh member of the family of coronaviruses that infect humans^{1, 2}. Earlier on, many would have dismissed it as a type of infection with a low rate of fatality compared to the previous two coronavirus infections, SARS-CoV and MERS-CoV. This situation could not be far from the truth with the reported fatality rate hovering around 1 to 2%¹. When compared to the fatality rates of SARS-CoV and MERS-CoV at 10 and 35 %¹ respectively, the difference is obvious.

What makes COVID-19 deadly is its infectivity. The spread is so overwhelming and devastating, requiring lockdown to contain the transmission. It has been proven transmission by the asymptomatic carrier with normal chest findings clinically and normal chest computed tomography³. Because of the rapid and massive increase in the number of people infected, the total number of deaths related to COVID-19 is high, despite the low fatality rate. Based on an early report from Hubei Province, China, the median incubation period was estimated to be 5.1 days. The symptoms will develop within 11.5 days for those who are symptomatic, with a small portion developing symptoms after 14 days of active monitoring or quarantine⁴.

The threat of COVID-19 forces some health facilities to set up special clinics to screen all patients coming for treatment. This is what happens in government facilities in Malaysia. These special clinics were established and operated at the very front of the outpatient clinics under tents and makeshift facilities. All patients coming for treatment at any outpatient clinics were screened for risks of COVID-19. Patients with risks of COVID-19 were handled at the clinic. Those found to have no risk of COVID-19, but manifesting signs and symptoms of other respiratory tract infection, including conjunctivitis, will be referred to the green zone clinic, located next door. The patient will be further assessed at the green zone and managed accordingly.

The idea of setting up a separate screening clinic is to prevent any form of infections from breaching the outpatient clinic set up and hospital in general. It also serves to provide a one-stop centre for outpatient management of patients with Acute Respiratory Infection (ARI) who might be at risk of COVID-19. It enables early diagnosis and initiation of treatment for possible COVID-19 infection. The use of Personal Protective Equipment is to be practised based on WHO recommendations⁵.

Management of PUI as an outpatient

All patients who present to any health facilities should be screened for suspected COVID-19 at triage, using Case Definition for Person Under Investigation (PUI), as practised by Ministry of Health, Malaysia (MOH)⁶. MOH came up with the recommendations guided by the World Health Organisation (WHO)^{7, 8}. Another source of information is the Centre for Disease Control and Prevention (CDC)⁹. As stated earlier, this special area specifically set up to cater for COVID-19. Patients should be able to come directly and to be assessed there. At the special clinic, a dedicated team manned the clinic.

During the assessment, the most important decision is to decide whether that patient fulfils the PUI criteria or not. If the patient fulfilled the criteria, the next action is to determine whether the patient is stable to be treated as an outpatient or requires admission. If admission is required, then a proper arrangement is made, based on the guidelines provided. Further investigation will be done at the admitting hospital. A designated ambulance is used to transport the patient to admitting hospital.

If PUI does not need admission, then sampling for COVID-19 will be done as an outpatient. If the sampling can be done onsite, then it will be done accordingly. If the sampling is not offered at the site, the patient should be referred to the sampling clinics, as listed. A decision is made whether PUI is suitable for home quarantine or not and advised accordingly.

Clinic Set up

If possible, there should physical barriers separating healthcare worker and patients to reduce exposure to the COVID-19 virus, such as glass or plastic windows. Tissues and surgical mask with a no-touch bin for disposal of tissues or biohazard bag should be available and strategically located. Area for hand washing or alcohol-based sanitizer should be prepared too.

There should be a dedicated person to clean high touch areas like the chair, table and couch at waiting and triage areas after patient leaves the area. Cleaning is required in the event of spillage or any other emergency. The waiting area should be well ventilated with separation of at least 1 - 2m between patients in the waiting rooms⁹. A surgical mask is offered to the patient as a safety measure.

Case Definition of COVID-19.

Screening for COVID-19 is not as simple as doing screening for any other diseases. There are specific criteria for COVID-19, and they keep changing based on the latest information and need to ensure no case are missed. These criteria are based on the latest guideline from the Ministry of Health, 25th March 2020.

Patients presenting with symptoms of acute respiratory infection are considered ARI patients. They can be present with any specified symptoms of sudden onset respiratory infection: shortness of breath, cough or sore throat, regardless of whether they have a fever or not. Basically, fever is not one of the must-have criteria.

Other important criteria are the history of travelling to or residing in a specified foreign country, having close contact with a confirmed case of COVID-19 or attending an event associated with known COVID-19 outbreak within 14 days before the onset of illness. Having fulfilled the criteria, the patient is treated as Person Under Investigation (PUI) and will be further managed accordingly. Those who later confirmed to have positive laboratory result is considered as a Confirmed Case of COVID-19.

One of the criteria is close contact. It is very important information to be determined to ensure we are not missing any patients with risk and at the same time to avoid unnecessary investigation. Close contact is defined as:

1. Healthcare-associated exposure without appropriate PPE. This includes providing direct care for COVID-19 patients, working with health care workers infected with COVID-19, visiting patients or staying in the same close environment of a COVID-19 patient.
2. Working together in close-proximity or sharing the same classroom environment with a COVID-19 patient.
3. Travelling along with COVID-19 patient.
4. Living in the same household as a COVID-19 patient.

Management of Person under Investigation: Admission

Not all patients require admission, and in fact, many of the patients are healthy except for the respiratory symptoms. Clearly, any PUI COVID-19 who is clinically ill requires admission. Any patient with uncontrolled medical conditions or with immune-compromised status needs to be admitted. The other group is pregnant women and those with extremes of age which is < 2 or > 65 years old.  Patients who are confirmed by the laboratory results are also admitted, regardless of whether they are symptomatic or not. The rest, while waiting for investigation results, are strictly advised for home surveillance or quarantine. Those who are not suitable for home surveillance are to be considered for admission in quarantine station^{6, 7, 8}.

Home surveillance

One of the most important aspects of dealing with COVID-19 is preventing the spread of disease or stopping infection transmission⁶. While waiting for the results to be ready, home surveillance or quarantine is very important. And above that, because of the incubation period, a 2-week quarantine is advised. The patients need to be given clear information regarding the importance of this measure. It is very important, too, to fully assess the suitability of the home condition for that matter.

Ideally, it should be a separate bedroom with en-suite bathroom, but if it is not possible, they can share a common bathroom with frequent disinfection. Understandably they should have access to food and other necessities including face mask, glove and disinfectant at home. They should be able to seek medical care if necessary and return with their own private transport.

A piece of very important advice for home surveillance is disease transmission itself, especially to the high-risk household members^6,10. They should be able to stay away, at least 2 meters apart from the high-risk household members. The high-risk members are people > 65 years old, young children <2 years, pregnant women and those who are immunocompromised or who have chronic lung, kidney, heart disease. 

Patients under home surveillance should be contactable at all time. They should strictly stay at home during the self-monitoring period and limit the visitors coming to the house. All visitors coming to the house, their names should be kept in a list for a possible communication in future.

Practising good cough etiquette sounds mundane advice. However, it is very important. The patients are always advised to wear a face mask when symptomatic. If not wearing a mask, it is important to close mouth and nose with tissues when coughing and sneezing. Immediately throw away the tissues into a closed dustbin and wash the hands with soap or use hand sanitizer.

At home, patients should observe social distancing with healthy person by keeping at least a 1m distance. Always wear a face mask when going out of the room and avoid contact with others as much as possible. All windows in the house should be open to ensure good ventilation. Another advice is not to share utensils, tableware and personal hygiene items. A very important reminder is to seek medical treatment immediately in the event of worsening of symptoms.

Protection of Healthcare Worker

In managing patient suspected of having COVID-19, a strict infection prevention and control measures should be taken⁵. General measures suggested are:

1. Place patients at least one meter away from other patients or health care workers. Clinics should have an isolation area for patients.
2. Ensure strict hand hygiene for all clinic staffs and suspected patient.
3. Provide surgical mask to patients if not contraindicated.
4. Personal protective equipment should be worn at all time.
5. After the encounter, ensure proper disposal of all PPE that has been used.
6. Decontamination of the isolation area and equipment used should be done.

In a case that a group of suspected PUI presented to any healthcare facilities in a specific vehicle, they should be contained in that vehicle until being evaluated by a dedicated team. This serves to minimize exposure to healthcare workers and other patients.

Health Alert Card

Those patients coming back from overseas or affected areas sent for home surveillance are given Health Alert Card. The card should be kept for the next 14 days after returning home. It acts as a reminder for the patient to monitor his/her body temperature to look out for fever (≥38.0C) and symptoms of cough with breathlessness. If the patient were to develop any symptoms or not feeling well, he/she should seek immediate medical treatment at the nearest healthcare facility.

It also reminds patient to practice good personal hygiene. Patient should cover mouth and nose using a tissue when coughing or sneezing. The tissue is thrown in the trash afterwards. Next, patient should wash hands with soap and water or use hand sanitizer regularly. The card also reminds patient of other general advice: to always practice cough etiquette, use face mask whenever being in public or having close contact with people and to always maintain good personal hygiene and cleanliness.

The Health Alert Card is also for the benefit of healthcare workers, who were to see the patient subsequently. It should alert the doctor or nurse that the person who is presenting this Health Alert Card had recently travelled or returned from affected countries with active transmission (within the past 14 days). If the person presents with fever (≥38.0C), pneumonia or severe respiratory infection with breathlessness, they should refer the patient to the nearest hospital immediately. 

Sampling Procedure

Sampling procedure depends on the set up of the sampling area^{5, 6}. If the set up provides a total barrier between the patient and medical staff, only minimal PPE needed. A Full set PPE is required if there is no barrier available. Full PPE set includes:

1. Headcover
2. Face shields
3. Mask N95
4. Double glove
5. Isolation gown (Level 4-5)
6. Plastic gown
7. Boot cover

The sampling process itself requires a proper set for sampling. They are Nasopharyngeal swab (NPS) or Oropharyngeal swab (OPS) and Viral Transport Medium (VTM) and triple packaging set for transportation of samples. Biohazard waste is another must.

References

1. Petrosillo N, Viceconte G, Ergonul O, Ippolito G, Petersen E. COVID-19, SARS and MERS: are they closely related? 2020. Clin Micro Infection. 26(6):729-734.

DOI: 10.1016/j.cmi.2020.03.026

2. Zhu N, Zhang D, Wang W, Li X, Yang B, Song J, Zhao X, Huang B, Shi W, Lu R, Niu P, Zhan F. 2020. A Novel Coronavirus from Patients with Pneumonia in China, 2019. N Engl J Med. 382:727-733.

DOI: 10.1056/NEJMoa2001017

3. Bai Y, Yao L, Wei T, Tian F et al. Presumed Asymptomatic Carrier Transmission of COVID-19. 2020 JAMA. 323(14):1406-1407. DOI:10.1001/jama.2020.2565

4. Lauer SA, Grantz KH, Bi Q, Jones FK, Zheng Q, Meredith HR, Azman AS, Reich NG, Lessler J. 2020. The Incubation Period of Coronavirus Disease 2019 (COVID-19) From Publicly Reported Confirmed Cases: Estimation and Application. Annals of Internal Medicine

5. Rational use of personal protective equipment (PPE) for coronavirus disease (COVID-19): interim guidance, 19 March 2020. World Health Organization [Accessed on 2020 May 10]

6. Guidelines COVID-19 Management No.5/2020 update on 24 March 2020

7. World Health Organisation (WHO). Coronavirus disease (COVID-19) outbreak. Available at: https://www.who.int/emergencies/diseases/novel-coronavirus-2019 (Accessed 6 May 2020).

8. World Health Organisation (WHO). Getting your workplace ready for COVID-19. 3 Mac 2020. Available at: https://www.who.int/docs/defaultsource/coronaviruse/getting-workplace-ready-for-covid19.pdf?sfvrsn=359a81e7_6 (Accessed on 6 May 2020)

9. Center for Disease Control and Prevention  (CDC).  Coronavirus  Disease  2019 (COVID-19). Environmental Cleaning and Disinfection Recommendations.   6  March 2020. Available at: https://www.cdc.gov/coronavirus/2019ncov/community/organizations/cleaning-disinfection.html (Accessed on 11 May 2020)

10. Dalton, Craig and Corbett, Stephen and Katelaris, Anthea, Pre-Emptive Low-Cost Social Distancing and Enhanced Hygiene Implemented before Local COVID-19 Transmission Could Decrease the Number and Severity of Cases. (May 5, 2020). Available at SSRN: https://ssrn.com/abstract=3549276