COVID-19

STANDARD OPERATING
PROCEDURES & GUIDELINES

(FEBRUARY 2020)
List of Contributors

Primary Authors
Dr Haroon Jahangir Khan Director General Health Services Punjab
Dr Shanaz Naeem Director Health Services CD &EPC
Dr Somia Iqtadar Associate Professor Medicine KEMU
Dr Jamshaid Ahmed Head of WHO Office Punjab
Mr. Usman Ghani Additional Director Health Education

Section B: Surveillance and Response

Dr Muhammad Saeed Ahmad Technical Advisor to DG Health
Dr Irfan Ahmed NPO WHO Surveillance
Dr Ahmed Shafique TSO JSI, PDSRU
Dr Mohsen Watto TSO FELTP
Dr Sarmad Wahaj Manager IT EP&C
Mr. Shamas ul Islam Senior Program Manager PITB
Mr Rana Muhammad Hassan Program Manager PITB

Section C: Clinical Management

Dr Javed Magsi Associate Professor of Pulmonology AIMC
Dr Asif Hanif Assistant Professor pulmonology KEMU

Section D: Laboratory Sample Collection and Transportation

Professor Dr Sidra Saleem Head of Microbiology Department University of Health Sciences

Section E: Infection Prevention and Control

Dr Summia Khan Demonstrator Institute of Public Health PH Lahore
Dr Huda Sarwar Demonstrator Institute of Public Health PH Lahore

Reviewed BY
Professor Dr Javed Akram Vice Chancellor University of Health Sciences
Brig (R) Dr Waheed ul Zaman Professor of Pathology Cughtai Lab
Dr Muhammad Saqib Saeed Professor of Pulmonology KEMU
Message by Sardar Usman Ahmad Khan Buzdar
Chief Minister Punjab
Government of the Punjab, in accordance with the vision of Honorable Prime
Minister, Islamic Republic of Pakistan, Mr. Imran Ahmed Khan Niazi, is leaving no
stone unturned to provide best and quality assured healthcare services at the
door step of masses. These endeavors are not merely limited to establishment
of new health facilities across the Province and revamping of existing healthcare
infrastructure but also strengthening the systems for preparedness by plugging
the gaps and lacunas faced in emergencies and epidemics that endanger the
health of the people.
The recent outbreak of COVID-19 in China during December 2019, has posed a
new challenge for Government of the Punjab for Provincial Health system. This
scenario is compounded by the fact that a huge number of people continue to
commute between two brotherly countries. There was a great likelihood of
transmission of virus to Pakistan. Since Punjab has the largest number of airports
and other entry points, so a major responsibility lied on Government to stop the
transmission and safeguard the lives of people.
I appreciate the coordinated efforts of all Government Departments especiall y
the Primary & Secondary Healthcare Department and Specialized Healthcare &
Medical Education, for taking preemptive measures to take on the challenge
including establishment of screening counters at port of entries and dedicated
units in specific hospitals, to receive and treat the suspected patients. It is the
result of all such measures / steps that were taken so far and by the Grace of
Almighty Allah, presently not a single confirmed patient of COVID-19 is reported
in the country.
Development of SOPs regarding clinical management, case response,
surveillance protocols, sampling guidelines and screening at point of entry for
the suspected patients of COVID-19 is another praiseworthy step by the Primary
& Secondary Healthcare Department, which would define roles and
responsibilities of all stakeholders and facilitate healthcare providers to take
informed decisions to reduce the risk of mortalities as well as transmission of
virus.
May Allah help and guide us to serve our people with utmost dedication and
professional excellence.
Message by Dr Haroon Jehangir Khan
Director General Health Services Punjab
Table of Contents
Section-A: Introduction 1
Background 1
Objectives of this Document 1
Section-B: Surveillance and Response 3
Case Definition 5
Epidemiology 5
Alert/ Outbreak Thresholds 6
Surveillance Protocols 6
Laboratory Diagnosis 7
Contract Tracing and Management 7
Roles and Responsibilities for PDSRU 8
SOPs for DHA-RRTs 9
Section-C: Clinical Management Guidelines 14
Scope of this Section 14
Clinical Case Definition 14
Case Identification 14
Patient Flow Chart 15
Initial Assessment and Patient Management 16
Management of Clinical Syndromes Associated with COVID-19 Infection 16
Uncomplicated Illness 16
Mild Pneumonia 17
Severe Pneumonia 17
Acute Respiratory Distress Syndrome 18
Sepsis 19
Septic Shock 19
Special Consideration of Pregnant Patient 20
Section-D: Laboratory Sample Collection and Transportation 24
Material and Equipment for Specimen Collection 24
Safety Procedures During Sample Collection and Transport 24
Infection Prevention Measures 25
Specifics for Transport of Samples to Laboratory 26
Sample Collection and Transportation Protocols 26
Section- E: Infection Prevention and Control 30
Standard Precautions 30
Transmission Based Precautions 30
Visitor Protocol for Infection Prevention and Control Precautions 31
SOPs for Suspected Patient Transfer 32
Managing Bodies of Deceased COVID-19 Patient 32
Recommendation for Public 32
Section- F: Annexures
Annex 1: COVID-19 Process Flow Chart 35
Annex 2: Patient Reporting Form 36
Annex 3: Contact Tracing and Line Listing Template 38
Annex 4: Lab Request Form COVID-19 41
Annex 5: Hand Hygiene 42
Annex 6: Burial Protocols of Deceased Died Due to COVID-19 Infection 43
Annex 7: Contact Details of COVID-19 Focal Points in Punjab 45
 section-a
Introduction
section-a
Introduction

Background
On 31st December 2019, cases of pneumonia of unknown etiology (unknown cause) were detected in Wuhan City,
Hubei province of China. 31 st December 2019 through 3rd January 2020, a total of 44 cases of pneumonia of
unknown etiology were identified. During this reported period, the causal agent was not identified. On 11 th and
12th January 2020, National Health Commission (NHC) China reported that the outbreak is associated with
exposure in one of the seafood and livestock markets in Wuhan City. The Chinese authorities identified a new
type of coronavirus on 7th January 2020. On 12th January 2020, China shared the genetic sequence of the novel
coronavirus for countries to use in developing specific diagnostic kits. Subsequently, laboratory confirmed cases
of 2019-nCoV reported by Thailand, Japan and Korea. On 30th January 2020, 2019-nCoV was declared a global
health emergency by the World Health Organization (WHO).

On 11th February, 2020 WHO officially named the deadly disease caused by Novel Coronavirus as “COVID-
19”. The name represent phrase ‘Coronavirus Disease 19’. Experts created the name without referencing any
animal, place or person.

Objectives of this Document

The new disease with limited available knowledge demands a set of SOPs and guidelines for all levels of care
which are well aligned with national and local context to establish and implement prevention and control measures.
WHO has developed and provided technical documents and interim guidelines to tackle this new infection. The
Ministry of Health Services, Regulations and Coordination (MHSR&C) has also developed guidelines based upon
WHO documents however these documents are mainly focusing upon coordination and response at point of entries
(POEs). There is a need to prepare a comprehensive guiding document covering all aspects including technical
guidance and standard operating procedures and protocols aligned with provincial health system. This document
will amicably address the need and will also

help stakeholders to get all the required information (available so far) about the COVID-19, existing
surveillance mechanism and their respective role and responsibilities; AND
facilitate clinicians and care providers on standard case management.

The document has FOUR main sections:

1. Section- B: Surveillance and Response (S&R)

2. Section- C: Clinical Management Guidelines
3. Section- D: Laboratory Samples Collection and Transportation
4. Section- E: Infection Prevention and Control (IPC)

All important areas related to COVID-19 are covered under these main sections.

01
 section - b
Surveillance and Response

Exposure
to virus

Incubation period can

range from 2 to 14 days

Day 1 Day 14
section- b
Surveillance and Response
Case Definitions
Suspected Case: (Surveillance case definition, may slightly differ from clinical case definitions)

A. Patients with Severe Acute Respiratory Infection (SARI) having fever, cough, shortness of breath (SOB)
and requiring admission to hospital, with no other etiology that fully explains the clinical presentation
AND at least one of the following:

1. History of travel to or residence in the affected areas in the last 14 days prior to onset of symptoms, OR
2. Patient is a health care worker who has been working in an environment where severe acute respiratory
infections of unknown etiology are being cared for.

B. Patients with any Acute Respiratory Illness (ARI) AND at least one of the following:

1. Close contact with a confirmed or probable case of COVID-19 in the 14 days prior to illness onset, OR
2. Visited or worked in affected areas in China during last 14 days prior to the onset of symptoms, OR
3. Worked or attended a health care facility in the 14 days prior to onset of symptoms where patients with
hospital-associated COVID-19 infections have been reported.

C. Any person died of having signs and symptoms of COVID-19 illness in the area with ongoing transmission
of infection OR have definitive epidemiological link with a Probable or Confirmed COVID-19 patient

Probable Case: A suspect case for whom testing for COVID-19 is inconclusive or for whom testing was
positive on a pan-coronavirus assay.

Confirmed Case: A person with laboratory confirmation of COVID-19 infection, (irrespective of clinical signs
and symptoms)

Epidemiology
Infectious Agent

1. A new strain of coronavirus known as “2019-novel Coronavirus” is the causative agent of this pneumonia like
illness named COVID-19.
2. Coronaviruses are a large family of viruses, some causing illness in people and others that circulate among
animals, including camels, cats and fruit bats.
3. Sometimes, zoonotic coronaviruses mutate and infect human and then spread between people such has been
seen with severe acute respiratory syndrome SARS (2002) and middle respiratory syndrome-MERS (2012)
epidemics.

Mode of Transmission: The initial source of COVID-19 still remains unknown however this virus is also
believed of zoonotic origin. Epidemiological information reinforces the evidence that the COVID-19 can be
transmitted from one individual to another. Exact mode of transmission of COVID-19 is still unknown however
based upon the previous knowledge about human to human transmission of other coronaviruses (SARS-CoV &
MERS-CoV), it is suggested that COVID-19 has similar mode of transmission i.e.;
1. Droplet infection
2. Contact transmission
3. Contaminated objects (fomites)
4. Air borne
Incubation Period: Current estimates of the incubation period range from 2-14 days, and these estimates will
be refined as more data become available.

05
Population at Risk: People most at risk of infection from the novel coronavirus are:

1. Those who have recent travel history to the area where human to human transmission of COVID-19 outbreak
is reported
2. Those who are caring people infected with COVID-19 such as family members and healthcare workers, and
3. Those in close contact with animals such are live animal market workers

People of any age and sex may got infected with COVID-19 however reportedly disease course is more severe for
elder patients and patients with any pre-existing chronic disease or co-morbidity.

Seasonality: This is new infection so not much knowledge is available however it is suggested that it may follow
the pattern similar to other coronaviruses.

Clinical Presentation: Limited information is available to characterize the spectrum of clinical illness
associated with COVID-19. The observed clinical signs and symptoms of this illness include:

1. Mild disease with symptoms of common cold and upper respiratory infection (URTI)
2. Fever
3. Cough
4. Difficulty in breathing.
5. Chest radiographs show invasive pneumonic infiltrates in both lungs.

Disease Spread and Morbidity: The first known human infection occurred in early December 2019. An
outbreak of COVID-19 was first detected in Wuhan, China, in mid-December 19. The virus subsequently spread
to all provinces of China and to 28 other countries and territories in Asia, Europe, North America, and Oceania by
6th February 2020. Human-to-human spread of the virus has been confirmed in all of these regions.

Alert/Outbreak Thresholds
Alert Criteria: One suspected case (meeting case definitions of COVID-19) is an alert and to be reported and
investigated immediately.

Outbreak Criteria: One confirmed case of COVID-19 is an outbreak and will trigger epidemic response
protocols.

Surveillance Protocols
 COVID-19 is a category-1 reportable infectious disease and has been declared as Public Health Emergency
of International Concern (PHEIC) under International Health Regulation (IHR) by the WHO.
 Any suspected case of COVID-19 who is meeting the case definition must be reported immediately to
Provincial Disease Surveillance and Response Unit (PDSRU) at office of Director General Health Services
Punjab
 The immediate report must be shared with PDSRU using “COVID-19 Reporting Form” (Annexure 2) duly
filled and signed by focal person.
 The PDSRU should also be informed through phone call, WhatsApp or email. The Event Management Team
at PDSRU will review and evaluate the available information.
 If the case information satisfies the case definition criteria, the respective health facility focal person will be
advised to upload patient information on Disease Surveillance System (DSS) dashboard
 The Rapid Response Team (RRT) will be mobilized by the District Health Authority (DHA).
 However, all suspected patients will be immediately isolated from the other patients and recommended IPC
protocols will be implemented as the patient is reported.
 The specimen collection for laboratory confirmation from the suspected patient will also be ensured (Refer to
Laboratory Guidelines for detailed SOPs)
 The responsibility of case reporting is on:

06
 o Health Authorities operating at POE
o Focal persons at designated health facility
o Medical Superintendents/ In-charges of health facilities
o Laboratory focal person (In-Charge)
o Chief Executive Officer (CEO) of District Health Authority (DHA)
o Administrators of private sector healthcare facilities, parastatal hospitals through respective DHA

 During the current phase of epidemic, it is responsibility of Central Health Establishment (CHE) at POE and
designated health facilities to submit daily status report as well as “Zero Report”

Laboratory Diagnosis
Respiratory virus diagnosis depends on the collection of high-quality specimens, their rapid transport to the
laboratory and appropriate storage before laboratory testing. Designated health facilities must ensure that the
sample collection SOPs and appropriate identified staff are available, staff is trained on PPE donning and doffing,
proper disposal, appropriate collection, specimen storage, packaging and transport under cold chain conditions.

 RT-PCR is the confirmatory test (Test capacity available at NIH Islamabad)

 Collect specimen both from nasopharynx and oropharynx from ambulant patients and transport in one tube
 Collect specimen from lower respiratory tract (expectorated sputum, endotracheal aspirate, broncho-alveolar
lavage) from patients with more severe disease.
 Collect blood cultures for bacteria that cause pneumonia and sepsis, ideally before antimicrobial therapy.
 Serology for diagnostic purposes is not yet available

Contact Tracing and Management

Close Contacts (Higher Risk of Contacting Infection with COVID-19)
Defined as:

 Health care associated exposure in the form of:

o Providing direct care for COVID-19 patients
o Working with health care workers infected with COVID-19
o Visiting patients or staying in the same close environment of a COVID-19 patient.

 A person having had face to face contact or having been in a closed environment with a COVID-19 patient
 Traveling together with COVID-19 patient in any kind of conveyance
 Living in the same household of a COVID-19 patient

Casual Contacts (Relatively low risk but there are chances of contacting infection)
Defined as:

 An identifiable person having a casual contact with an ambulant COVID-19 case

 A person having stayed in an area presumed to have ongoing community transmission

This is the responsibility of RRT to trace and list all the contacts of suspected patients using “Contacts Definitions”
and “Contact Line Listing Format” (Annexure 3)

Managements of Contacts: Close contacts (high-risk exposure)

1. Inform the local health focal person to activate and apply quarantine protocols and active monitoring.
A. If designated quarantine facility is available:
i. Isolate and transfer the contacts to the quarantine area under standard SOPs and IPC protocol
ii. Registration of contact at quarantine facility with all details and contact history
iii. Conduct entry screening (Medical as well as Lab)
iv. Educate, explain and provide psychological counseling

07
 v. Shower, provide new dress and belongings
vi. Shift the contact to allocated room
vii. Daily monitoring for COVID-19 symptoms, including fever of any grade, cough or difficulty
breathing; will be done by the health authorities for 14 days from last contact
viii. Restrict social contact during the quarantine period
ix. Apply IPC measures to daily laundry, leftovers and utensils in use of contact
x. Apply exit protocol once, quarantine period is completed
xi. If contact develops, any kind of symptoms during the observation period, immediately isolate and
move the patient to designated health facility near quarantine site for initial assessment.
xii. Transfer the symptomatic contact to designated health facility if case definition criteria are met.
xiii. Apply all protocols listed in case management section

B. If Designated Quarantine Facility is not available, manage home quarantine and depute one responsible
and trained healthcare staff to maintain liaison with contact to monitor the contact’s health on daily basis.

Low Risk Exposure

1. Inform the local health focal person

2. Instruct the person:
a) To self-monitor for COVID-19 symptoms, including fever of any grade, cough or difficulty
breathing, for 14 days from last exposure
b) Immediately self-isolate and contact health services in the event of any symptom appearing within
14 days.

If no symptoms appear within 14 days of last exposure the contact person is no longer considered to be at
risk of developing COVID-19.

Roles and Responsibilities for PDSRU

The PDSRU will work as overall central unit for:

 Situation monitoring/alert generation

 Coordination for all the teams (HF focal person, CAA, CHE, Rescue1122 and DHA) and units working in
their respective area
 Assist the provincial and DHAs for necessary measures
 Coordinate with national and international partners and stakeholders
 Facilitate the capacity building process and strengthening of DHAs and other stakeholders
 Generate daily situation report for all stakeholders
 Assist the authorities on media briefings and risk communication
 Will operate 24/7
Responsibility Matrix Contact Tracing

Sr. No Contact tracing level Timeframe Responsibility to Responsibility to monitor

identify up to 14 days
1 Point of Entry Immediately after review Airport Health DHA / RRT
passenger health record Authority/ (CHE) PDSRU share report will
and share daily report concerned DHA on daily
with PDSRU basis

2 Community/neighborhood Immediately after receiving DHA through RRT DHA through RRT*
/household alert for suspected case and share daily report
with PDSRU

3 Health Facility Immediately after suspect Health facility nominated Hospital focal person
case reporting focal persons DHA through Rapid
and share daily report response team
with PDSRU

*Cross notification of travel history to concerned DHA

08
 SOPs for DHA – RRTs
1- Coordinate with respective Airport Health Officer (AHO) / POE focal person frequently and prepare daily
report of all screened and suspected travelers of COVID-19 if any in last 24 hours. Daily report must be shared
with provincial focal person at punjab.pdsru@gmail.com and dhscdcpunjab@gmail.com
2- Ensure mandatory data entry of all cases of suspected COVID-19 infection, pneumonia, Influenza Like Illness
(ILI) and Severe Acute Respiratory Infection(SARI) on DSS dashboard by each health facility of the district
3- Maintain a list of private sector hospitals in the district and their focal persons for case notification and
reporting
4- Conduct daily meeting of RRTs to review surveillance data and maintenance of line listing of suspected
COVID-19 cases.
5- Coordinate and facilitate health facility staff in sample collection of suspected patient (s) as per guidelines
6- Ensure appropriate sample handling, recording, and transportation to the designated laboratory and follow up.
7- Ensure availability of sufficient sampling supplies with appropriate sample transportation mechanism in line
with the national guidelines. The sampling protocols have already been shared.
8- Mandatory and immediate notification of suspected cases of COVID-19 infection as per standard case
definition to provincial focal point i.e. DHS CD&EPC and PDSRU Punjab. All suspected COVID-19 cases
must be reported on DSS and through email dhscdcpunjab@gmail.com, punjab.pdsru@gmail.com, Telephone
No. 042-99202970, 042-99200970, SMS or through relevant DDSRU WhatsApp groups.
9- Ensure availability of sufficient stocks of PPE kits including gloves, face masks (surgical & N-95), goggles,
head covers, gowns and shoe covers. Further CEOs must ensure availability of hand washing supplies (soaps,
running water & alcohol based sanitizer) at each health facility.
10- DHA-RRT will coordinate with health facilities and concerned line departments for surveillance of suspected
COVID-19 cases
11- Training/sensitization of healthcare providers on identification of suspected COVID-19 infections by using
standard case definition
12- Training/sensitization of healthcare providers on standard sampling and transportation techniques in line with
the national guidelines
13- A close liaison must be developed by DHA-RRT with private sector hospitals for data entry on DSS and
compliance of SOPs.
14- Case investigation of each suspected case using standard Case Investigation Form (CIF) developed for
COVID-19 infections
15- Ensure sampling of each suspected case and transportation of each sample to reference laboratory
16- Ensure contact tracing through Active Surveillance and Case Finding (ASCF)
17- Sharing of relevant surveillance data (line listing, CIF, laboratory results etc.) with the district focal point and
provincial focal points through proper channel
18- DHA-RRT must act as technical resource team at district level and share updated information regarding
COVID-19 received from the DHS CD&EPC & PDSRU
19- The team must include the following:

a. District Health Officer (PS) Team Lead

b. District Surveillance Coordinator Member
c. Medical Officer/Physician Member
d. District Pathologist Member
e. CDCO Member
f. District Sanitary Inspector Member
g. District DSS focal person Member
h. Any Co-opted (as per need) Member

09
Process flow for contact tracing in health facility and community

10
 section - c
Clinical Management Guidelines
section-c
Clinical Management Guidelines
Scope of This Section
This document is intended for clinicians taking care of hospitalized adult and pediatric patients with clinical
spectrum of acute respiratory illness when a COVID-19 infection is suspected. It is not meant to replace clinical
judgment or specialist consultation but rather to strengthen clinical management of these patients and provide to
up-to-date guidance.

Clinical Case Definition

Suspected Case: Fever or measured temperature ≥38 C° (essential criterion) of less than 14 days,
With ANY one of the following:

 Cough
 Shortness of breath
 Difficulty in breathing
 Flu like illness
 Severe Acute Respiratory Infection (SARI) in a person requiring admission to hospital, with no
other etiology that fully explains the clinical presentation

AND either of the following:

1. A person with history of travel to or reside in to China in the last 14 days.

2. Close contact with a confirmed or probable case of COVID-19 while that patient was ill.

Case Definitions of “Probable Case” and “Confirmed Case” are same as given in Section B of this document.

Case Identification:
(Triage: Early recognition of patients with SARI associated with COVID-19 infection).

 Recognize and sort all patients with symptoms matching case definition and travel history of affected country
or contact with a probable or confirmed case of COVID-19 at any point of contact with health care system.
Consider COVID-19 as a possible cause of severe acute respiratory illness.
 Implement Infection Prevention and Control (IPC) measures and start treatment based on disease severity.

Keeping in view the limited available knowledge of the disease caused by COVID-19 infection and its
transmission patterns, it is strongly advised that all suspected cases should be isolated and monitored in
hospital settings by trained staff. This would ensure both safety and quality of health care (in case patients’
symptoms worsen) and public health security.

Patients NOT meeting the case definition of suspected COVID-19 should be assessed and managed according to
treatment protocols of other respiratory illnesses as diagnosed by the clinician.

14
 Patient Flow Chart
Management of Suspected COVID-19 Patient

Look for other

Respiratory Illness
& Treatment

15
Initial Assessment and Patient Management
 Patients with suspected COVID-19 should be admitted in dedicated isolation unit
 The case management should be initiated immediately by trained and dedicated team of healthcare providers
 Nasopharyngeal and oropharyngeal swabs should be collected as soon as possible at enrollment for laboratory
testing and specimen should be dispatched to the designated laboratory following all recommended SOPs
 Other investigations include

o CBC
o Blood cultures
o Chest X-Ray, if symptomatic
o Other investigations as indicated

 If the patient is clinically stable, provide symptomatic care only

o Antibiotics are NOT indicated

o Advise steam, antihistamines, plenty of fluids.
o Acetaminophen may be used to reduce fever
o Oseltamivir 75mg BD for treatment of influenza and should be de-escalated on the basis of
microbiological/lab results.

 Weight based administration of Oseltamivir to be used for management of pediatric

patients

o If the patient is unstable (e.g., has hypoxemia or is hypotensive), should be admitted in the designated
isolation rooms/HDU and to be managed according to his/her disease severity.

Management of Clinical Syndromes Associated with COVID-19 Infection

 Spectrum of 19-CoV ranges from asymptomatic infection to Severe Acute Respiratory Infection (SARI).
 The disease can take the severe form manifesting as pneumonia to ARDS sepsis and septic shock.
 No specific anti-viral is recommended for treating COVID-19 at present.
 General supportive measures remain the mainstay of treatment.
 Mild diseases require treatment in dedicated isolation units and serious patients will be requiring HDU
management:

Uncomplicated Illness
Patients with uncomplicated upper respiratory tract viral infection may have non-specific symptoms. These
patients do not have any signs of dehydration, sepsis or shortness of breath. The signs and symptoms of
uncomplicated illness include fever, cough, sore throat, nasal congestion, malaise, headache and myalgia.

 The elderly and immunosuppressed may present with atypical symptoms.

Management of Uncomplicated Illness

 Such patient should be managed in isolation unit dedicated for COVID-19 patients
 Only symptomatic management is required including
o Antipyretics
o Antihistamines
o Steam inhalation

16
Mild Pneumonia
In addition to symptoms of uncomplicated illness, patient will have Chest pain and Tiredness.
The diagnosis is purely clinical however chest imaging can exclude complications.

Management of Mild Pneumonia

 Such patients require dedicated inpatient management by trained clinicians who can assess the patient’s
condition and able to pick any signs of disease severity as early as possible
 Management protocols are on same lines i.e. symptomatic management
o Antipyretics
o Antihistamines
o Steam inhalation

Severe Pneumonia
 All patients with severe pneumonia require HDU management with regular monitoring under strict IPC
protocols.
 Signs and symptoms of severe pneumonia include

o In adolescent and adults

 Fever
 Cough
 Shortness of breath
 Respiratory rate >30 breaths/min
 Severe respiratory distress

o In Children
 Cough
 Difficulty in breathing
 Central cyanosis
 Severe respiratory distress (grunting, very severe chest in drawing)
 Inability to breastfeed or drink
 Lethargy or unconsciousness
 Convulsions
 Chest in-drawing
 Fast breathing

Management of Severe Pneumonia

 In patients with SARI and respiratory distress, hypoxemia, or shock, immediately initiate supplemental
Oxygen therapy at 5 liter/min
 Titrate flow rates to reach the targets as below:
 Target:
o SpO2 ≥ 90% in non-pregnant adults
o SpO2 ≥ 92 to 95% in pregnant patients

 Use conservative fluid management in patients with SARI when there is no evidence of shock. (Aggressive
fluid management may worsen oxygen saturation especially in settings where ventilator support is not
available).
 Give empiric antimicrobials to treat likely pathogens causing SARI. Give antimicrobials within one hour of
initial patient assessment for patients with sepsis.
 Empirical antibiotic therapy will be based on clinical diagnosis (community-acquired pneumonia, health care
associated pneumonia or sepsis). Empirical therapy may also include:

17
 o Oseltamivir 75mg BD for treatment of influenza and should be de-escalated on the basis of
microbiological/lab results.

 Do not give systemic corticosteroids routinely for treatment of viral pneumonia or ARDS outside of clinical
trials, unless they are indicated for another reason.
 Closely monitor patients with SARI for signs of clinical deterioration, such as rapidly progressive respiratory
failure and sepsis
 Apply supportive care interventions immediately
 Understand the patient’s co-morbid condition(s) to tailor the management of critical illness and appreciate the
prognosis.
 Communicate early with the patient and the family

Acute Respiratory Distress Syndrome

ARDS is one of the severe form of diseases and requires HDU management with frequent monitoring and
strict IPC measures
 New or worsening respiratory symptoms within one week of clinical presentation.
 The diagnosis of ARDS is mainly through chest imaging using either:

o Radiograph
o CT chest
o Lung ultrasound

Findings include bilateral opacities, not fully explained by effusions; lobar or lung collapse, or nodules
 Echocardiography can be done to exclude hydrostatic cause of oedema.
 Signs and symptoms of severe pneumonia include:

In adults and adolescents:

Non cardiogenic pulmonary oedema
Labored or rapid breathing
Fever
Muscle fatigue
Discolored skin and nails
Rapid pulse rate
Hacking cough

o Classification according to severity:

Mild ARDS 200 mmHg < PaO2/FiO2 ≤ 300 mmHg

Moderate ARDS 100 mmHg < PaO2/FiO2 ≤200 mmHg
Severe ARDS PaO2/FiO2 ≤ 100 mmHg

In children:
Abdominal pain
Cough
Fatigue
Shortness of breath

o Classification according to severity:

Mild ARDS 4 ≤ OI < 8 or 5 ≤ OSI < 7.5

Moderate ARDS 8 ≤ OI < 16 or 7.5 ≤ OSI < 12.3
Severe ARDS OI ≥ 16 or OSI ≥ 12.3
(OI= Oxygenation Index; OSI= Oxygenation Index Using SPO)

18
Management

 Recognize severe hypoxemic respiratory failure when a patient with respiratory distress is failing standard
oxygen therapy of 10-15 liter/min

o High-flow Nasal Oxygen (HFNO) or Non-Invasive Ventilation (NIV) should only be used in selected
patients with hypoxemic respiratory failure.
o The risk of treatment failure is high and patients treated with either HFNO or NIV should be closely
monitored for clinical deterioration.

 Endotracheal intubation should be performed by a trained and experienced provider using airborne
precautions.
 Implement mechanical ventilation using lower tidal volumes (4–8 ml/kg predicted body weight, PBW) and
lower inspiratory pressures (plateau pressure <30 cmH2O).
 In patients with severe ARDS, prone ventilation for > 12 hours per day is recommended
 Use a conservative fluid management strategy for ARDS patients without tissue hypo perfusion
 In patients with moderate or severe ARDS, higher PEEP instead of lower PEEP is suggested
 In patients with moderate-severe ARDS (PaO2/FiO2 <150), neuromuscular blockade by continuous infusion
should not be routinely used.

Sepsis
 Documented or suspected infection, with two or more of the following conditions:

o Temperature > 38 °C (100.4 °F) or < 36 °C (96.8 °F),

o Heart Rate (HR) > 90/min
o Respiratory Rate (RR) > 20/min
o PaCO2 < 32 mm Hg
o White blood cells > 12 000 or < 4000/mm3 or > 10% immature (band) forms

Signs and Symptoms

 Sepsis leads to life threatening organ dysfunction manifested as:

o Altered mental status
o Difficult or fast breathing
o Low oxygen saturation
o Reduced urine output
o Fast heart rate
o Weak pulse
o Cold extremities
o Low blood pressure
o Skin mottling

In children, suspected or proven infection and ≥2 SIRS criteria, of which ONE must be abnormal temperature or
white blood cell count

Septic Shock
 Sepsis-induced hypotension (SBP < 90 mm Hg) despite adequate fluid resuscitation and signs of hypo
perfusion.
 In adults suspected or confirmed for COVID-19 infection, septic shock is labelled when:

o Vasopressors are needed to maintain mean arterial pressure ≥65 mmHg

o Lactate is ≥2 mmol/L
o Absence of hypovolemia

19
 In children
o Hypotension is essential criteria and any TWO of the following
 Altered mental state
 Tachycardia (>150 beats/min in children >160 beats/min in infants)
 Bradycardia <70 beats /min in children and <90 beats/min in infants)
 Prolonged capillary refill time (>2 sec)
 OR
 Warm vasodilation with bounding pulse, tachypnea, mottled skin, petechial or purpuric rash,
increased lactate, oliguria, hyper or hypothermia

Management of Sepsis and Septic Shock

Empirical broad-spectrum antibiotics are the hallmark of management of sepsis and septic shock and adjust
according to culture and sensitivity results
Fluid resuscitation

o Adults: 30 ml/kg of isotonic crystalloid in the first 3 hours.

o Children: 20 ml/kg as a rapid bolus and up to 40-60 ml/kg in the first 1 hr.
o Do not use hypotonic crystalloids, starches, or gelatins for resuscitation.
o Vasopressors when shock persists during or after fluid resuscitation.
o The initial blood pressure target is Mean Arterial Pressure (MAP) ≥65 mmHg in adults’ age-
appropriate targets in children.
o If central venous catheters are not available, vasopressors can be given through a peripheral IV,
but use a large vein and closely monitor for signs of extravasation and local tissue necrosis. If
extravasation occurs, stop infusion.

Vasopressors can also be administered through intraosseous needles.

If signs of poor perfusion and cardiac dysfunction persist despite achieving MAP target with fluids and
vasopressors, consider an inotrope such as dobutamine.

Special Considerations for Pregnant Patients

 Pregnant women with suspected or confirmed COVID-19 infection should be treated with supportive therapies
as described above, taking into account the physiologic adaptations of pregnancy.
 Emergency delivery and pregnancy termination decisions are challenging and based on many factors:
gestational age, maternal condition, and fetal stability.
 Consultations with obstetric, neonatal, and intensive care specialists (depending on the condition of the
mother) are essential.

Note: Certain drugs are being tested in trials for treating COVID-19 patients those may have shown promising
results however name of drug of choice will be updated upon availability scientific evidence

20
 section - d
Laboratory Samples
Collection & Transportation
section-d
Laboratory Samples Collection and Transportation
 Rapid collection and testing of specimens from suspected cases is a priority under laboratory expert.
 Assure SOPs (described below) are available, and the appropriate staff is trained and available for
appropriate collection, specimen storage, packaging and transport.
 There is still limited information on the risk posed by the reported coronavirus found in China and now being
reported in many countries;
 At present samples prepared for molecular testing could be handled as would samples of suspected human
influenza at biosafety level -2.
 In order to culture the novel coronavirus a higher level of biosafety and biosecurity is required.

Samples to be Collected (see Table 1 for details on sample collection and storage)
1. Respiratory material (nasopharyngeal and oropharyngeal swab in ambulatory patients and sputum (if
produced) and/or endotracheal aspirate or broncho-alveolar lavage in patients with more severe respiratory
disease.
2. Serum for serological testing, acute sample and convalescent sample (this is additional to respiratory
materials and can support the identification of the true agent, once serologic assay is available)
3. Repeat sampling may be needed if signs and symptoms appear after first negative test result.

Material and Equipment for Specimen Collection

1. Transport containers and specimen collection bags
and packaging.
2. Coolers and cold packs or dry ice.
3. Sterile blood-drawing equipment (e.g. needles
syringes and tubes)
labels and permanent markers
4. PPE (gloves, N95 mask, Tyvek suit, googles)
5. Supplies for decontamination of surfaces.

Safety Procedures During Sample Collection and Transport

All specimens collected for laboratory investigations should be regarded as potentially infectious, and HCWs
who collect, or transport clinical specimens should adhere rigorously to infection prevention and control (IPC)
guidelines (as mentioned above in table) to minimize the possibility of exposure to pathogens.

Information to be recorded (Please Use Lab Request Form):

1. Patient information – name, date of birth, sex and residential address, unique identification number, other
useful information (e.g. patient hospital number, surveillance identification number, name of hospital,
hospital address, room number, physicians’ name and contact information, name and address for report
recipient),
2. Date and time of sample collection,
3. Anatomical site and location of sample collection,
4. Tests requested,
5. Clinical symptoms and relevant patient history (including vaccination and antimicrobial therapies
received, epidemiological information, risk factors).

24
Infection Prevention Measures
1. Ensure that Health Care workers (HCWs) who collect specimens follow the following guideline and use
the adequate PPE (refer to the table).
2. 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
3. Limit the number of persons present in the room to the minimum required for the patient’s care and
support; and
4. 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
5. Waste management and decontamination procedures: Ensure that all material used is disposed
appropriately as per healthcare facility policies. Disinfection of work areas and decontamination of possible
spills of blood or infectious body fluids should follow validated procedures, usually with chlorine-based
solutions.

Specimens to be Collected from Symptomatic Patients

Specimen type Collection Transport Storage till Comment IPC practices/level

Material to testing
laboratory
Nasopharyngeal Dacron or 4 °C ≤5 days: 4 °C The nasopharyngeal Gloves, N95 mask
and polyester >5 days: -70 °C and oropharyngeal Tyvek suit,
oropharyngeal flocked swabs* swabs should be googles
swab placed in the same tube
to
Increase the viral load.
Broncho- sterile container 4 °C ≤48 hours: 4 °C There may be some Gloves, N95 mask
alveolar * >48 hours: –70 dilution of pathogen, Tyvek suit,
lavage °C but still a worthwhile googles
specimen
(Endo)tracheal sterile container 4 °C ≤48 hours: 4 °C Gloves, N95 mask
aspirate, * >48 hours: –70 Tyvek suit, googles
nasopharyngeal °C
aspirate or nasal
wash
Sputum sterile container 4 °C ≤48 hours: 4 °C Ensure the material Gloves, N95 mask
>48 hours: –70 is from the lower Tyvek suit,
°C respiratory tract googles
Tissue from sterile 4 °C ≤24 hours: 4 °C Gloves, N95 mask
biopsy or autopsy container with >24 hours: –70 Tyvek suit, googles
including from saline °C
lung
Serum (2 samples Serum 4 °C ≤5 days: 4 °C Collect paired samples: Gloves, N95 mask
acute and separator tubes >5 days: –70 °C • acute – first week of Tyvek suit, googles
convalescent (adults: collect illness
possibly 2-4 weeks 3-5 ml • convalescent – 2 to 3
after acute phase) whole blood) weeks later
Whole blood collection tube 4 °C ≤5 days: 4 °C For antigen detection Gloves, N95 mask
>5 days: –70 °C particularly in the first Tyvek suit,
week of illness googles
Urine urine 4 °C ≤5 days: 4 °C Gloves, N95 mask
collection >5 days: –70 Tyvek suit, googles
container °C
*For transport of samples for viral detection, use VTM (viral transport medium) containing antifungal and antibiotic supplements.

25
Specifics for Transport of Samples to Laboratory
1. Ensure that personnel who transport specimens are trained in safe handling practices and spill
decontamination procedures.
2. Specimen should be transport in triple packaging in refrigerated temperature.
3. Deliver all specimens by hand whenever possible.
4. State the full name, date of birth of the suspected case clearly on the accompanying request form.

Notify the laboratory as soon as possible that the specimen is being transported.

Sample Collection and Transportation Protocols

Activity When Who
1 Provision of viral transport medium /cold chain Available with the DHA-RRT NIH through DHA-RRT
boxes (to be handed over to HF focal
person in advance)
2 Sample collection Immediately on reporting to Microbiologist/skilled hospital
the HDU/HF based lab staff
3 Sample sealing in NIH provided VTM/cold Immediately after sample Microbiologist/skilled hospital
chain box and filling of Lab request form collection based lab staff
4 Request for transportation of sample to DSC Immediately after sample Notified hospital focal person
collection
5 Sample transportation to NIH or designated Immediately DSC of DHA through designated
provincial Lab courier service

Picture Credits Getty Images

https://www.who.int/news-room/detail/06-02-2020-who-to-accelerate-research-and-innovation-for-new-coronavirus

26
 section - e
Infection Prevention
and Control
section-e
Infection Prevention and Control
 Infection prevention and control remains the mainstay in effective management of any communicable disease
control.
 Procedures should be developed to ensure proper implementation of administrative controls, environmental
controls, and use of personal protective equipment (PPE).
 Administrative policies that address adequate staffing and supplies, training of staff, education of patients and
visitors, and a strategy for risk communication are particularly needed.
 There are two tiers of precautions to prevent transmission of infectious agents:
o Standard Precautions
o Transmission-Based Precautions.
Standard Precautions
 Standard precautions are intended to be applied to the care of all patients in all healthcare settings, regardless
of the suspected or confirmed presence of an infectious agent.
 Implementation of standard precautions constitutes the primary strategy for the prevention of healthcare-
associated transmission of infectious agents among patients and healthcare personnel.
 Standard precautions include: hand hygiene; use of gloves, gown, mask, eye protection, and face shield,
depending on the anticipated exposure;
 The application of standard precautions during patient care is determined by the nature of the HCW-patient
interaction and the extent of anticipated blood, body fluid, or pathogen exposure.
 Some new elements of standard precautions that are evolved during the course of recent epidemic responses
are:
o Respiratory/ cough etiquettes
o Use of masks for insertion of catheters or injection of material into spinal or epidural spaces via lumbar
puncture procedures
o Safe injection practices
Transmission Based Precautions
 Transmission-based precautions are used when the route(s) of transmission is (are) not completely interrupted
using standard precautions alone.
 For some diseases that have multiple routes of transmission (e.g., SARS), more than one transmission-based
precautions category may be used.
 Transmission based precautions include:
o Contact precautions
 Intended to prevent transmission of infectious agents which are spread by direct or indirect
contact with the patient or the patient’s environment
 A single-patient room is preferred for patients who require contact precautions.
 In multi-patient rooms, ≥3 feet spatial separation between beds is advised to reduce the
opportunities for inadvertent sharing of items between the infected/colonized patient and
other patients.
 Healthcare personnel caring for patients on contact precautions wear a gown and gloves for
all interactions that may involve contact with the patient or potentially contaminated areas in
the patient’s environment.
 Donning PPE upon room entry and discarding before exiting the patient room is done to
contain pathogens
o Droplet precautions
 Droplet precautions are intended to prevent transmission of pathogens spread through close
respiratory or mucous membrane contact with respiratory secretions
 A single patient room is preferred for patients who require droplet precautions.
 Spatial separation of ≥3 feet and drawing the curtain between patient beds is especially
important for patients in multi-bed rooms with infections transmitted by the droplet route.
 Healthcare personnel wear a mask for close contact with infectious patient.

30
 o Airborne precautions

 Airborne precautions prevent transmission of infectious agents that remain infectious over
long distances when suspended in the air
 The preferred placement for patients who require airborne precautions is in an airborne
infection isolation room with negative air pressure
 A respiratory protection program that includes education about use of respirators, fit-testing,
and user seal checks is required in any facility designated to manage such patients.
 In settings where airborne precautions cannot be implemented due to limited engineering
resources, masking the patient, placing the patient in a dedicated isolation with the strict
barrier nursing, and providing N95 or higher level respirators reduce likelihood of airborne
transmission
 Healthcare personnel caring for patients on airborne precautions wear N-95 mask or respirator
along with full PPE
 Airborne precautions are required especially when healthcare provider is performing any
aerosol generating procedure upon suspected patient like intubation, tracheal lavage etc.

 When used either singly or in combination, they are always used in addition to standard precautions.
 Application of different levels of precautions is given in the table below.

Healthcare/Patient Interaction Level Recommended PPE Protection

Staff dealing with travelers at POE
Outpatient Level
Inpatient Care in Isolation Room
Inpatient Care in HDU
Specimen Collection from a suspected patient
Specimen Handling and Transportation
Specimen Testing in Lab
Transfer of Patient/Suspected case
Handling of Deceased body
At Community/Household level
Standard Precautions that may be enhanced to contact or
droplet precaution if any suspected with respiratory symptoms
is received.
Standard Precautions
Standard Precautions+ Contact Precaution+ Droplet
Precaution
Standard Precautions+ Contact Precaution+ Droplet
Precautions+ Airborne Precautions
Standard Precautions+ Contact Precaution+ Droplet
Precautions+ Airborne Precautions
Standard Precautions+ Contact Precaution
Standard Precautions+ Contact Precaution+ Droplet
Precautions+ Airborne Precautions
Standard Precautions+ Contact Precaution+ Droplet
Precautions
Standard Precautions+ Contact Precaution+ Droplet
Precautions
Standard Precautions that may be escalated to Contact
Precaution+ Droplet Precautions if any suspected case is
around

Visitors Protocol for Infection Prevention and Control Precautions

 Screening visitors for symptoms of acute respiratory illness before entering the healthcare facility.
 Facilities should evaluate risk to the health of the visitor (e.g., visitor might have underlying illness putting
them at higher risk for COVID-19) and ability to comply with precautions.
 Facilities should provide instruction, before visitors enter patients’ rooms, on hand hygiene, limiting surfaces
touched, and use of PPE according to current facility policy while in the patient’s room.
 Facilities should maintain a record (e.g., log book) of all visitors who enter patient rooms.
 Visitors should not be present during aerosol-generating procedures.
 Exposed visitors (e.g., contact with COVID-19 patient prior to admission) should be advised to report any
signs and symptoms of acute illness to their health care provider for a period of at least 14 days after the last
known exposure to the sick patient.
 Establish procedures for monitoring, managing and training visitors regarding hand hygiene, respiratory
hygiene, cough etiquette, use of PPE and limited movement within the facility

31
SOPs for Suspected Patient Transfer
1. The suspected traveler or patient identified by screening at POE will be assessed by POE Health Authorities
following POE guidelines issued by the Ministry.
2. The PDSRU and District RRT will be informed
3. The RRT will make arrangements to receive suspected patient/ traveler from POE authorities as per SOPs
4. The designated vehicle (not necessarily fully equipped ambulance) with trained ambulance team (Paramedic,
Driver and Medical Officer In-Charge) will be deputed at airport/POE to receive and transfer to designated
facility
5. The ambulance team will follow IPC guidelines as per situation

a. If a patient with symptoms is to be transferred to health facility, the team must use complete PPE with
N95 mask
b. If a traveler (close contact) is to be transferred to designated quarantine site, the team may use basic
PPE and follow all respiratory IPC etiquettes

6. The decontamination of transfer vehicle will be done immediately after each transfer
7. The staff involved in transfers will also practice decontamination SOPs after each transfer
8. PPEs used during transfers will be immediately disposed as per SOPs.

Managing Bodies of Deceased COVID-19 Patients

 There is no knowledge about postmortem transmission of COVID-19 so far hence utmost precautions are
required to be practiced while handling a deceased COVID-19 (Ebola burial guideline).
 The deceased bodies potentially may pose a risk when handled by untrained personnel.
 Body washing of COVID-19 cases should preferably be done at hospitals by the trained professionals.
 The relatives of the deceased may be educated and given briefing and if needed, one of the attendants may
join the body preparation as observer under complete IPC protocols and with PPEs.
 The deceased body in coffin must be handed over to the relatives properly treated and prepared.
 All relevant infection control precautions including appropriate use and disposal of PPEs must be ensured.
 The vehicles used for transfer of dead body must be decontaminated following recommended IPC guidelines
immediately after the use.
 The staff involved in transfer and handling must also be trained on IPC protocols.

Recommendations for Public

 Wash your hands frequently with soap and water for at least 20 seconds
 If soap and water are not available, use an alcohol-based hand rub with at least 60% alcohol
 Cover mouth and nose with flexed elbow or tissue paper while coughing and sneezing
 Discard tissue immediately into a closed bin and clean your hands with alcohol-based hand rub or soap and
water.
 Avoid touching any part of your face especially eyes, nose and mouth
 Avoid close contact with sick person or if you are caregiver, practice all precautions advised by the medical
staff
 While sick, limit contact with other people and stay at home
 If you have fever, cough and difficulty breathing, seek immediate medical care early
 As a general precaution, practice general hygiene measures when visiting live animal markets, wet markets or
animal product markets
 Avoid consumption of raw or undercooked animal products
 Handle raw meat, milk or animal organs with care, to avoid cross-contamination with uncooked foods, as per
good food safety practices.
 Slaughterhouse workers, veterinarians in charge of animal and food inspection in markets, market workers,
and those handling live animals and animal products should practice good personal hygiene, wear protective
gowns, gloves and masks.
 Equipment and working stations should be disinfected frequently, at least once a day.

32
 section - f
Annexures

Annex 1: COVID-19 Process Flow Chart

Annex 2: Patient Reporting Form
Annex 3: Contact Tracing and Line listing Template
Annex 4: Lab Request Form
Annex 5: Hand Hygiene
Annex 6: Burial Protocol of Deceased died due to COVID-19 Infection
Annex 7: Contact Details of COVID-19 Focal Points in Punjab
Anexx 1: COVID-19 Process Flow Chart

35
 Annex 2: Patient Reporting Form

WHO Case ID (International) ______________________________________

Interim case reporting form for COVID-19 Contact Listing Form

of confirmed and probable cases
WHO Minimum Data Set Report Form

Date of reporting to national health authority: [_D_][_D_]/[_M_][_M_]/[_Y_][_Y_][_Y_][_Y_]

Reporting institution: _________________________________________________
Reporting country:_______________________________
Case classification: □ Confirmed □ Probable
Detected at point of entry □ No □ Yes □ Unknown If yes, date [_D_][_D_]/[_M_][_M_]/[_Y_][_Y_][_Y_][_Y_]
Section 1: Patient information
Unique case identifier (used in country): _____________________________
Date of birth: [_D_][_D_]/[_M_][_M_]/[_Y_][_Y_][_Y_][_Y_] or estimated age: [___][___][___] in years
if < 1 year, [___][___] in months or if < 1 month, [___][___] in days
Sex at birth: □ Male □ Female
Place where the case was diagnosed: Country: ______________________________
Admin Level 1 (province): _______________________________ Admin Level 2 (district): _________________________
Patient usual place of residency: Country: ______________________________
Admin Level 1 (province): _______________________________ Admin Level 2 (district): ____________________________

Section 2: Clinical information

Patient clinical course
Date of onset of symptoms: [_D_][_D_]/[_M_][_M_]/[_Y_][_Y_][_Y_][_Y_] □ Asymptomatic □ Unknown
Admission to hospital: □ No □ Yes □ Unknown
First date of admission to hospital: [_D_][_D_]/[_M_][_M_]/[_Y_][_Y_][_Y_][_Y_]
Name of hospital: ___________________________________
Date of isolation: [_D_][_D_]/[_M_][_M_]/[_Y_][_Y_][_Y_][_Y_]
Was the patient ventilated: □ No □ Yes □ Unknown
Health status (circle) at time of reporting: Recovered / Not recovered / Died / Unknown
Date of death, if applicable: [_D_][_D_]/[_M_][_M_]/[_Y_][_Y_][_Y_][_Y_]
Patient symptoms (check all reported symptoms):
□ History of fever / chills □ Shortness of breath □ Pain (check all that apply)
□ General weakness □ Diarrhoea ( ) Muscular ( ) Chest
□ Cough □ Nausea/vomiting ( ) Abdominal ( ) Joint
□ Sore throat □ Headache
□ Runny nose □ Irritability/Confusion
□ Other, specify ____________________________________________________________________________________________________
Patient signs :
Temperature: [___][___][___] □°C / □ F
Check all observed signs:
□ Pharyngea exudate □ Coma □ Abnormal lung x-ray findings
□ Conjunctival injection □ Dyspnea / tachypnea
□ Seizure □ Abnormal lung auscultation

36
 Section 4: Laboratory Information
Name of laboratory that conducted the test : ____________________________________________________________________________
Please specify which assay was used: ________________________
Was sequencing done? □ Yes □ No □ Unknown
Date of laboratory confirmation: [_D_][_D_]/[_M_][_M_]/[_Y_][_Y_][_Y_][_Y_]

37
Annex 3: Contact Tracing and Line listing Template
COVID-19

38
Line Listing

39
3

40
Annex 4: Lab Request Form COVID-19

41
 Annex 5: Hand Hygiene
Wash hands often with soap and water for at least 20 seconds. Disposable paper towels to dry
hands are desirable. If not available, use dedicated cloth towels and replace them when they
become wet.
If hands are not visibly soiled and soap and water not available, 60% alcohol-based hand rub
can be used. Cover all surfaces of hands and rubbing them together until they feel dry.

Five moments for Hand hygiene

42
Annex 6: Burial Protocol of Deceased died due to COVID-19 Infection
Burial Protocols for Deceased body died due to COVID-19 Infected Infection
Before starting any procedure, the family must be fully informed about the burial process. Formal
agreement and consent from the family should be taken.

1. Prior to departure

Team should be comprised of:

a. 4 members, wearing full PPE for field situation
b. 1 sprayer, wearing full PPE for field situation
c. 1 technical supervisor, not wearing PPE
Disinfectant preparation

Disinfectant solutions must be prepared for the same day:

a. 0.05% chlorine solution for hand hygiene, disinfection of object and surfaces
Assemble necessary equipment
b. Impermeable, vinyl, minimum thickness 400 microns with 4 handle and able to hold 100-125
kilos (200-250 lbs) body bag should be available
c. For hand hygiene alcohol-based hand rub solution with supply of clean running water, soap and
towels Or chlorine solution 0.05% should be available
d. Personal Protective Equipment (PPE) including one pair of disposable gloves, one pair of heavy-
duty gloves, disposable coverall suit (e.g. Tyvek suit) + impermeable plastic apron, goggles and
mask for face protection and rubber boots or shoes with puncture-resistant soles and disposable
overshoes should be available
e. For disinfection, one hand sprayer, one back sprayer, Leak-proof and puncture resistant sharps
container, two leak-proof infectious waste bags: one for disposable material (destruction) and
one for reusable materials (disinfection) should be available
f. Prior to departure the team leader must brief the burial team about how to conduct a burial
according to particular religious and social beliefs.

2.Arrival:

a. Greet the family and offer your condolences. The staff should not be wearing PPE upon arrival.
b. Identify the family members who will be participating in the burial rituals.
c. Verify that the grave is dug. If not then send selected people to dig the grave at the cemetery or
at the area identified by the family
d. A dry ablution can be performed by a Muslim member of the burial team on the deceased patient
before or after being placed in the body bag. This process takes about 1-2 minutes.
Dry ablution

The hand of the Muslim Burial team member carrying out the dry ablution (in PPE), softly strikes th eir
hands-on clean sand or stone and then gently passes over the hands and then the face of the deceased.
This symbolically represents the ablution.
a. The deceased patient is shrouded by wrapping in a plain white cotton sheet before being placed
in the body bag. The shroud should be knotted at both ends.
b. If there are female members of the Burial team, they should shroud deceased female patient
prior to placing in a body bag

3. Put on all Personal Protective Equipment (PPE)

a. Locate the room for the body of the deceased patient; open the windows and doors for optimal
light and ventilation
b. Identify with the family, the rooms and annexes (bathroom, toilet) that were used by the
deceased patient as they need to be cleaned and disinfected
c. Put on all personal protective equipment (PPE) by burial management team in the presence of
the family
4. Placement of the body in the body bag

a. Enter into the house with at least 2 persons of the burial team.
b. Laboratory-Epidemiology team collects a post-mortem sample for confirmation

43
 c. Place the body bag along the body and open it; at least two persons should take the body by
arms and legs and place it in body bag and close it
d. Disinfect the outer side of the body bag by spraying over the surface of the body bag with a
suitable disinfectant (e.g., 0.5% chlorine solution)
5. Sanitize family’s environment
a. Clean with clean water and detergent and then disinfect with a suitable disinfectant (e.g., 0.5%
chlorine solution) all rooms of the house that were possibly infected by the deceased patient.
Special focus should be given to areas soiled by blood, nasal secretions, sputum, urine, stool
and vomit.
b. Clean with water and detergent all objects possibly infected by the deceased patient; then
disinfect with a chlorine solution 0.5%.
c. Collect any sharps that might have been used on the patient and dispose them in a leak -proof
and puncture resistant container.
6. Remove PPE, manage waste and perform hand hygiene
a. Disinfect boots without removing them
b. Remove apron: Untie the apron, remove it and discard into infectious waste bag for disinfection.
Wash outer gloves
c. Remove outer gloves, Wash inner gloves
d. Remove coverall: Take Hood off , Pull zip down ,Wash inner gloves ,Remove coverall suit, from
inside, peeling it off , Dispose the coverall suit in the infectious waste bag for destruction , Wash
inner gloves
e. Remove goggles from behind; Place it in a waste bag for disinfection. Wash inner gloves
f. Remove mask from behind Place it in waste bag for destruction Wash inner gloves
g. Remove inner gloves: Grasp the outer edge of the 1st glove and peel it off. Hold the 1st glove
in the gloved hand and drag a bare finger under the 2nd glove. Remove 2nd glove from the
inside, creating a "bag” for both gloves and throw it in waste bag for disposal. Wash hands
h. Recover the single-use PPE in an appropriate waste bag, prepared by the supervisor. The bag
will be closed and disinfected and there after brought for incarnation at hospital.
7. Transport the body bag from the house to the cemetery
a. Distribute disposable gloves to the family members who will carry the coffin
b. The Body Bag is placed in rear of car usually the head towards the front.
c. No family member should sit in the car cabin; only the burial management team, without PPE
can sit in the car cabin
d. The other participants of the funeral will follow on foot.

8. Placement of body bag into the grave

a. Manually carry body bag to the grave by the carriers wearing disposable gloves.
b. Place strings/ropes for lowering the body bag into the grave. The body bag is placed on the
ropes. Slowly lower the body bag into the grave, either with ropes or with individuals wearing
gloves who stepped into the graves
c. Place the body bag into the grave
9. Burial at the cemetery: engaging community for prayers
a. Family members and their assistants should be allowed to close the grave
b. Special attention should be given to the first shovel of earth; in general, this is done carefully
around the head area Family members should be allowed to close the grave
c. Place identification on the grave i.e name of the deceased and the date
d. Place disposable gloves in an infectious waste bag. The car used for the funerals needs to be
cleaned and disinfected (especially the rear)
e. Burial team to attend funeral and offer condolences
f. All members involved in the funeral process should wash hands with disinfectant after the burial
(using chlorine solution 0.05% or alcohol-based hand-rub).
10. Return to the Hospital
a. Organize the incineration of the single-use equipment at the hospital.
b. The reusable equipment is again disinfected and dried
c. The post-mortem samples are sent to the laboratory team
d. At the end of the working day, before going back home, each team member should take off
rubber boots and disinfect them with 0.5% chlorine solution.
e. Rubber boots should be kept at the hospital.
f. Any problems detected should be reported

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 Annex 7: Contact Details of COVID-19 Focal Points in Punjab

PDSRU O/o DGHS Punjab Focal Persons for COVID-19:

Sr. No. Name Designation Contact No.
1 Dr Sarmad Wahaj Manager ICT CD&EPC DGHS 0333-4463226
Office Lahore
2 Dr Mohsin Wattoo Technical Support Officer FELTP 0300-4222617
NIH Islamabad
3 Dr Ahmed Shafique Director Programs Punjab 03459440010
IHSS-SD USAID, DGHS Office
Punjab
Email: punjab.pdsru@gmail.com. Help Line: 0800-99000
Focal Persons from Teaching Hospitals, Point of Entries and District Health Authorities for COVID-19 Lahore
District Teaching Hospital with High Point of Entry DHAs
Dependency Unit
Lahore Services Hospital Lahore Allama Iqbal International Airport CEO DHA Lahore
Dr. Ahmad Nadeem Lahore Dr Shoaib Ur Rehman
Dr Amina Saqib Gormani
0333-4262959 Incharge Airport Health
Establishment Lahore 0300-7302270
0322-8456756
Wahga Border
Dr. Humera Ajmal
Incharge Health Check Post Wahga
Border Lahore
0321-6710860
Multan Nishtar Hospital Multan Multan International Airport CEO DHA Multan
Prof. Dr Anjum Naveed Jamal Dr. Zahid Akhtar Dr Munawwar Abbas
HOD Pulmonology Department Incharge Airport Health 0312-9255555
Establishment Multan
Dr. M. Irfan Arshad 0301-2020918
AMS Establishment & Focal 0310-0770076
Person Infectious Diseases
0333-6119093
Sialkot Allama Iqbal Teaching Hospital Sialkot International Airport CEO DHA Sialkot
Dr. Raffad Dr Khurram Shahzad Dr Ashgar Ali
Head of Department Medicine Medical Officer Civil Aviation 0333-8108024
Professor of Medicine Authority, Sialkot
0333-4200547 0312-9205968
Rawalpindi Benazir Bhutto Hospital Islamabad International Airport CEO DHA Rawalpindi
Rawalpindi Dr Sara Saeed Dr Sohail Ahmad
Prof. Dr. Fazlurrehman Incharge Airport Health 0334-5172000
Professor of Medicine Establishment Islamabad
0300-5226950 0312-9645413

Faisalabad Allied Hospital Faisalabad International Airport CEO DHA

Dr Jamshaid Mumtaz Dr. Syed Soofan Shah Faisalabad
Senior Registrar Medical Unit 3 Incharge Airport Health Dr. Muhstaq Ahmad
& Focal Person Infectious Establishment Islmabad Sipra
Diseases 0300-3754226 0300-9697290
0333-6728968

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