Interim Guidance For Care Of Pts With Covid 19 In Liberia
INTERIM GUIDANCE ON CLINICAL CAREFOR PATIENTS WITH COVID-19 INLIBERIA(Version One)Ministry of Health and National Public Health Institute ofLiberia (NPHIL)June 1, 2020
Table of ContentsPREFACE . vAcknowledgement . viAbbreviations . viii1OVERVIEW OF COVID-19 . 12LABORATORY INVESTIGATION OF PATIENTS WITH COVID-19 . 332.1Recommended samples for diagnosis . 32.2Laboratory confirmation of COVID-19 Diagnosis . 32.3Who should get tested? . 42.4Supplementary Laboratory testing. 4CLINICAL MANAGEMENT . 53.1Principles of Clinical Management . 53.2CLINICAL ASSESSMENT . 63.2.1COVID-19 screening at facilities . 63.2.2Outbreak Case definition: . 73.2.3Initial management at the facility of a suspected, probable or confirmed case . 83.2.4Initial management of a high-risk contact at the health facility . 83.2.5Transfer of suspected, probable and confirmed patients to the CITU . 93.2.6CITU Triage and Severity Scoring . 113.3MANAGEMENT OF MILD CASES . 113.3.1Clinical features . 113.3.2Treatment . 123.4MANAGEMENT OF MODERATE DISEASE . 133.4.1Clinical Features . 133.4.2Management . 133.5MANAGEMENT OF SEVERE CASES . 143.5.1Overview . 153.5.2Clinical features . 153.5.3Management . 153.6MANAGEMENT OF CRITICAL CASES . 20ii
3.6.1Overview . 203.6.2Clinical features . 213.6.3Principles of Clinical Management . 213.743.7.1Hypoxemic Respiratory Failure and Acute Respiratory Distress Syndrome (ARDS) . 283.7.2SEPSIS AND SEPTIC SHOCK. 303.8MANAGEMENT OF OTHER SYMPTOMS . 333.9MANAGEMENT OF CO-MORBIDITIES . 363.10MANAGEMENT OF SPECIAL POPULATIONS . 363.10.1PREGNANT WOMEN . 373.10.2COVID-19 IN CHILDREN . 403.10.3ELDERLY . 513.10.4COVID-19 IN PEOPLE WITH HIV. 51DISCHARGE CRITERIA AFTER COVID-19 . 524.156CRITICAL COVID-19: MANAGEMENT OF COMPICATIONS . 28Discharge from CITU when COVID-19 test is Accessible . 524.1.1Clinical Discharge Criteria . 534.1.2Laboratory Discharge Criteria . 544.2Discharge from CITU when COVID-19 test is NOT accessible . 544.3Recommendations for Follow Up . 55OTHER CONSIDERATIONS . 565.1Rational Use of Antimicrobials . 565.2Other Drug considerations . 565.2.1ACE inhibitors (ACEIs) and angiotensin receptor blockers (ARB). 565.2.2Opioid analgesics . 56Mental Health and PSYCHOSOCIAL CARE . 576.1Psychosocial care for patients . 576.1.1Overview . 576.1.2Management . 576.1.3Hierarchy of mental health and psychosocial support including . 586.26.2.1RESPITE CARE FOR STAFF IN THE CITU . 59Daily screening . 59iii
6.2.2Accidental Exposure to droplets contaminated with SARS-CoV-2 while at work or going to orreturning home . 596.2.3Healthcare personnel (HCP) returning to work after COVID-19 diagnosis . 607INFECTION PREVENTION AND CONTROL when covid-19 is suspected . 618Quarantine of HIGH-RISK contacts. 758.1Pre-commissioning assessment . 768.1.18.2Criteria for selecting a POC . 77Monitoring of high-risk contacts . 798.2.1Baseline Assessment. 798.3COVID testing for high risk contacts . 818.4Criteria for Discharge from Precautionary Observation (Figure 6) . 818.4.1Criteria for discharge from POC when covid-19 testing is accessible . 818.4.2Criteria for discharge from the POC when COVID-19 testing is not accessible . 828.4.3Follow-up after discharge . 828.59Low risk contacts . 82COVID-19 RESEARCH as part of RESPONSE. 839.1Research as part of Response . 839.2Clinical Trial Therapeutics and Vaccines . 8610References. 88List of FiguresFIGURE 1: COVID-19 PATIENT FLOW THROUGH THE HEALTH CONTINUUM . 6FIGURE 2: SCREENING ALGORITHM FOR COVID-19 IN ADULTS . 10FIGURE 3: EMERGENCY CARE OF COVID-19 IN ADULTS IN LOW RESOURCE SETTING . 12FIGURE 4: SELF PRONE POSITION . 26FIGURE 5: SCREENING ALGORITHM FOR COVID-19 IN CHILDREN UNDER FIVE. 44FIGURE 6: COVID-19 TEST-BASED DISCHARGE CRITERIA . 53FIGURE 7: COVID-19 NON-TEST-BASED DISCHARGE CRITERIA . 54FIGURE 8: WHO MY FIVE MOMENTS OF HAND HYGIENE . 64FIGURE 9: PRECAUTIONARY OBSERVATION FOR TRAVELERS WHO ARE HIGH RISK CONTACTS. 76FIGURE 10: COVID-19 RESEARCH GOVERNANCE STRUCTURE . 84iv
PREFACEThis is the first interim guidance for the management of COVID-19 in Liberia. The document isintended for use by all clinicians involved in the care of patients when COVID-19 is suspectedor confirmed. The recommendations in this guidance are derived from three main sources:-Review of clinical guidance from the World Health Organization (WHO), the UnitedStates Centers for Disease Control (USCDC), US Expert Panel COVID-19 TreatmentGuidelines, and experiences from other countries (e.g. China, Nigeria, Ghana, etc.)-Review of data in peer-reviewed journals obtained from PubMed and Medline.-Experiences of experts and clinicians who have treated a number of COVID-19 patients.Inappropriate prescribing is unethical and can cause harm for patients. It occurs whenmedicines are not prescribed in accordance with guidelines that are based on scientificevidence to ensure safe, effective, and economic use. This interim guidance addresses a criticalgap and will undergo frequent revisions and updated as new evidence becomes available andthe country enhances capabilities for critical care. Clinicians are advised to reference the belowsources to address clinical issues where no recommendation was provided in this guidance:a. WHO Interim Guidance for Clinical Management of COVID-19, May 27, 2020.b. US Expert Panel COVID-19 Treatment Guidelines.c. Second Edition Liberia National Therapeutic Guidelines, 2017d. Liberia National IPC Guidelines, 2020e. Other clinical guidelines where relevant [e.g. WHO Hospital Care for Children, LiberianGuidelines (HIV, TB, Malaria, etc.), WHO Oxygen therapy for children (2016), WHOManagement of complications of pregnancy, labor and delivery, etc.].f. WHO: Addressing Mental Health Psychosocial Aspects of COVID-19 version 1.5.g. mhGAP Humanitarian Intervention Guide.For queries regarding any recommendation in this guidance, please contact:Dr. Jerry Fahnloe Brown, Chief Executive Officer (CEO), John F. Kennedy Medical CenterCase Management Lead, COVID-19 National Incidence Management SystemEmail: fahnloe@gmail.comv
ACKNOWLEDGEMENTThe National Incidence Management System for the COVID-19 pandemic response in Liberia isvery pleased for the development of the Interim Guidance on Clinical Care for Patients withSuspected and Confirmed COVID-19 in Liberia by the National Case Management Pillar. We arepleased with the active participation of our national and international partners whocontributed in various ways to the development of this guidance. We are especially grateful tothe World Bank Financial support for the validation workshop and printing of the document.We also specifically want to extend our appreciation to the IMS Case Management InterimGuidance Technical Committee and the following institutions and individuals:Case Management Interim Guidance Technical Committee:1.2.3.4.5.6.Dr. Jerry F. Brown, Case Management LeadDr. Phiona NakyeyuneDr. Julius GilayenehDr. Momo TegliDr. Wahdae-Mai Harmon GrayDr. Keith L. Gray7.8.9.10.11.Dr. Thelma NelsonDr. Heounohu Romello HessouDr. Moses MassaquoiDr. Mukhtar Adeiza–Committee Co-ChairDr. Soka Moses–Committee ChairPrincipal Contributors:1. Dr. Jerry Fahnloe Brown, Case Management Pillar Lead; CEO, (JFKMC)2. Dr. J. Soka Moses, PREVAIL; Ministry of Health (MOH); UL School of Public Health (ULSPH)3. Dr. Mukhtar Adeiza, Consultant Infectious Diseases (CID), Internal MedicineDepartment (IMD), John F. Kennedy Medical Center (JFKMC) & Office of Global Health,Internal Medicine Department, Yale School of Medicine (Yale)4. Dr. Heounohu Romello Hessou, Medical Coordinator, 14-Military COVID-19 Treatment Unit5. Dr. Thelma Nelson, National Public Health Institute of Liberia (NPHIL), CM Admin.6. Dr. Moses Massaquoi Clinton Health Access Initiative (CHAI)/CM Research Lead7. Dr. Bennetta C. Andrews, Liberia College of Physicians & Surgeons (LCPS)8. Dr. Momo Tegli, Case Management; MOH, ULSPH, CM9. Dr. Wahdae-Mai Harmon Gray, CM, MOH, ULSPH10. Dr. Phiona Nakyeyune, Fidelity Health Care Services Inc. (FHCS)/CM11. Dr. Numeine Enders, JFKMC, LCPS12. Dr. Keith L. Gray, National AIDS Control Program (NACP), MOH13. Dr. Nicole Cooper, Jamale Medical Solutions (JMS), Health Federation of Liberia (HFL)14. Dr. Lekiley L. Tehmeh, MOH, IPC Pillar15. Dr. Janice Cooper, Carter Centervi
16. Caroline Gotche, MSC. Dr. Med. Univ.17. Dominik Vogel, Dr. Med. Univ.18. Dr. Moses Ziah, 14-Military COVID-19 Treatment UnitValidation Meeting (May 9-10, 2020)1.2.3.4.Dr. Jerry Brown, IMS CM Lead/CEO, JFKMCDr. Gorbee Logan, Asst Minister, MOHDr. Mukhtar Adeiza, CIDIMD, JFKMC/YaleDr. J. Soka Moses, PREVAIL, MOH, ULSPH5. Dr. Heounohu R. Hessou, JFKMC/14Military Hospital (14-Military)6. Dr. Wahdae-Mai Harmon-Gray,CM/ULSPH/MOH7. Dr. Thelma Nelson, NPHIL, CM8. Dr. Bennetta C. Andrews, LCPS9. Dr. Desmond Williams, US CDC10. Dr. Louis Ako Egbe, WHO11. Dr. Emmanuel Ekyinabah, LiberiaMedical & Dental Association (LMDA), JFKMC12.13.14.15.16.17.18.Dr. Nicole Cooper, JMS, HFLDr. Janice Cooper, Carter CenterDr. T. Juleo Karr, CM/14-MilitaryDr. Hawa Adoley Koon, LCPS /JDJ Hosp.Dr. Moses Massaquoi CHAI/CMDr. Numeini Enders, JFKMC/LCPSDr. Moses Ziah, JFKMC/14-Military19. Dr. Keith L. Gray, NACP/CM20. Dr. Deddeh E. Supuwood,Montserrado County Health Team21. Dr. Momo Tegli, CM/ULSPH/MOH22. Mr. Isaac S. Morlu, Physician AssistantsAssociation of Liberia/PREVAIL23. Dr. Ibrahim Ajami, CM/14-Military24. Dr. Richard Doe, CM/14-Military25. Dr. Phiona Nakyeyune, (FHCS)/CM26. Mrs. Tarlor M. Quiwonkpa, ChiefNursing/Midwifery Officer, RL, MOH27. Mrs. Bentoe Tehoungue, Director,Family Health Division, MOH28. Dr. Annette Brima-Davis, FHD, MOH29. Dr. Rick Sacra, ELWA Hospital30. Ms. Masmina Sirleaf, HFL31. Ms. Diana Smith, MOH32. Mr. Augustine Koryon, GIZ33. Dr. Rebecca Cooke, PIH34. Ms. Vivian Mussah, NPHILContributors1.2.3.4.5.6.Dr. Julius Gaylayeneh, National Malaria Control Program (NMCP)/CMMr. Philip Bemah, NPHIL, IPC PillarDr. Roseda E. Marshall, JFKMC/LPGMC/LCPSDr. Readon IdehDr. Sia Wata Camanor, JFKMCDr. Louis Ako Egbe, WHODr. Wilhemina JallahCOVID-19 National Incidence Management System (IMS) ChairMinister of Health, Republic of Liberiavii
ABBREVIATIONSAFEM: African Federation of Emergency MedicineIMS:Incidence Management SystemAIDS:AcquiredINR:International Normalized RatioARDS:Acute Respiratory Distress SyndromeIPC:Infection Prevention and ControlAVPU:Alert, Voice, Pain, UnresponsiveLDH:Lactate dehydrogenaseBid:twice dailyMAP:Mean Arterial PressureBiPAP: Bilevel Positive Airway PressureMERS:Middle Easter Respiratory SyndromeBP:Blood pressureNIV:Non-Invasive ventilationCBC:Complete Blood CountNPHIL: National Public Health Institute of LiberiaCDC:US Center for Disease Control & PreventionNSAID: Non-steroidal anti-inflammatory drugsCITU:COVID-19 Isolation & Treatment UnitO2:OxygenCM:Case Management PillarPEEP:Positive End Expiratory pressureCoV:CoronavirusPHEIC: Public Health Emergency of 19: Coronavirus Disease 2019COPD:Chronic obstructive pulmonary diseasePOC:Precautionary Observation CenterCPAP:Continues Positive Airway PressurePOE:Port of EntryCpm:Cycles per minutePPE:Personal Protective EquipmentCRP:C-reactive ProteinPREVAIL:Partnership for Research on Vaccines &CS:Caesarean sectionCXR:Chest X-rayRR:Respiratory RateECG:ElectrocardiogramSARS:Severe Acute Respiratory SyndromeEMS:Emergency Medical ServiceSARS-CoV-2: 2019 Coronavirus Type 2FFP2:Fine Filtration ParticulateSOB:Shortness of breathFiO2:Fraction of Inspired oxygenSOPs:Standard Operating ProceduresGI:GastrointestinalSPO2:Oxygen saturation in arterial bloodHb:HemoglobinTid:Three times a dayHBA1C: Hemoglobin A1C or Glycated HbTB:TuberculosisHBV:Hepatitis B VirusWHO:World Health OrganizationHCW:Health care workers.HCV:Hepatitis C VirusHDU:High dependency unitInfectious Diseases in LiberiaHFNO: High Flow Nasal OxygenHIV:Human Immunodeficiency virusHR:Heart rateICU:Intensive Care UnitIL-6:Interleukin 6viii
1 OVERVIEW OF COVID-19COVID-19 is predominantly a respiratory illness transmitted through contact with infectiousrespiratory droplets or direct physical contact with an infectious person or contaminated surface.An infected person who is asymptomatic can transmit the virus.There is no cure and the treatment depend on supportive care. Early detection, isolation, anddiagnosis of infected persons and quarantine of their close contacts is key. This requires ac
sources to address clinical issues where no recommendation was provided in this guidance: a. WHO Interim Guidance for Clinical Management of COVID-19, May 27, 2020. b. US Expert Panel COVID-19 Treatment Guidelines. c. Second Edition Liberia National Therapeutic Guidelines, 2017 d. Liberia National IPC Guidelines, 2020 e.
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