New Delhi: Amid the reports of a rapid surge in COVID-19 cases in rural India, the Centre on Sunday issued guidelines for the containment and management of coronavirus spread in peri-urban, rural and Tribal areas to strengthen primary level healthcare infrastructure at all levels.
According to the Ministry of Health and Family Welfare’s (MoHFW) standard operating protocol (SOP), in every village, active surveillance should be done for influenza-like illness/severe acute respiratory infections(ILI/SARI) periodically by ASHA with help of Village Health Sanitation and Nutrition Committee (VHSNC).
“Symptomatic cases can be triaged at village level by teleconsultation with Community Health Officer (CHO), and cases with comorbidity/low oxygen saturation should be sent to higher centres. Every subcentre should run an ILI/SARI OPD for dedicated time slots/days,” it said.
The SOP said that identified suspected COVID cases should link for testing to the health facilities either through COVID-19 rapid antigen testing or by referral of samples to the nearest COVID-19 testing laboratory.
It said CHOs and ANMs should be trained in performing Rapid Antigen Testing, and provision of Rapid Antigen Test (RAT) kits should be made at all public health facilities including Sub-centres (SCs)/ Health and Wellness Centres (HWCs) and Primary Health Centres (PHCs).
COVID-19 patients should also be counselled to isolate themselves till test results are available.
“Those asymptomatic but having history of high-risk exposure to COVID patients (exposure of more than 15 mins without a mask within 6 feet distance) should be advised quarantine and tested as per ICMR protocol.”
Depending upon the intensity of surge and number of cases, as far as feasible, contact tracing should be done as per Integrated Disease Surveillance Programme’s (IDSP’s) guidelines for contact tracing of COVID-19 cases in community settings, it added.
Noting that nearly 80-85 per cent of COVID-19 cases are asymptomatic/mildly symptomatic, as per the SOP, these patients do not require hospitalisation and may be managed at home or in COVID care isolation facilities.
For monitoring of active cases in the home- isolation, the Ministry said it is desirable for each village to have an adequate number of pulse oximeters and thermometers for COVID patients.
“The Village Health, Sanitation and Nutrition Committee (VHSNC) through local PRI and administration should mobilize resources to make provisions for this equipment. A system of providing the pulse oximeters and thermometers on loan to families with a confirmed case of COVID should be developed through ASHA/ Anganwadi workers and village-level volunteers. The pulse oximeters and thermometers should be sanitised after each use with cotton/cloth soaked in alcohol-based sanitiser,” it said.
Follow-ups for patients undergoing isolation/ quarantine could be done through household visits by a frontline worker/ volunteers/ teacher duly following required infection prevention practices including the use of a medical mask and other appropriate precautions.
The ministry said that the home isolation kit shall be provided to all such cases which should include required medicines such as Paracetamol 500 mg, Tab. Ivermectin, cough syrup and multivitamins (as prescribed by the treating doctor). Besides a detailed pamphlet indicating the precautions to be taken, medication details, monitoring proforma for the patient’s condition during the home isolation, contact details in case of any major symptoms or deterioration of health condition and the discharge criteria. The guidelines further said that patient /caregiver will keep monitoring their health, but immediate medical attention should be sought if serious signs or symptoms develop.
According to the Ministry, these could include- difficulty in breathing, dip in oxygen saturation (SpO2 < 94 per cent on room air), persistent pain/pressure in the chest, and mental confusion or inability to arouse.
It said that if SpO2 goes below 94 per cent, the patient should be referred to a facility with an oxygen bed (DCHC or DCH depending on the SpO2 level).
“Patients under home isolation will stand discharged and end isolation after at least 10 days have passed from the onset of symptoms (or from date of sampling for asymptomatic cases) and no fever for 3 days. There is no need for testing after the home isolation period is over,” it added.
The MoHFW said the health infrastructure planned for peri-urban, rural and tribal areas shall be aligned to the already mentioned 3-tier structure – COVID Care Centre (CCC) to manage mild or asymptomatic cases, Dedicated COVID Health Centre (DCHC) to manage moderate cases and Dedicated COVID Hospital (DCH) to manage severe cases, according to the document.
It said peri-urban and rural areas may plan a minimum of 30-bedded COVID Care Centre to offer care for asymptomatic cases with comorbidities or mild cases (Upper Respiratory Tract symptoms, without breathlessness, with oxygen saturation of more than 94 per cent) where home isolation is not feasible.
“CCC should have separate areas for suspected and confirmed cases with preferably separate entry and exit for each,” it said and added that suspect and confirmed cases should not be allowed to mix under any circumstances.
The Ministry said CCCs would be makeshift facilities under the supervision of nearest PHC/CHC and may be set up in schools, community halls, marriage halls, panchayat buildings in close proximity of hospitals or healthcare facilities, or tentage facilities in panchayat land, school ground, etc.
“These CCCs should be mapped to one or more Dedicated COVID Health Centres (DCHC) and at least one Dedicated COVID Hospital (DCH) for referral purposes,” it said.
SOP said that such COVID Care Centres should also have a Basic Life Support Ambulance (BLSA) networked among such CCCs equipped with sufficient oxygen support on a 24×7 basis, for ensuring safe transport of patients to dedicated higher facilities if the symptoms progress from mild to moderate or severe. In addition, the districts may consider providing additional ambulances for networking among nearby CCCs for referral services.
The guidelines further said that Primary Health Centres or Community Health Centres and Sub District Hospitals in these areas shall be the Dedicated COVID Health Centre for management of COVID-19.
“The facility may plan a minimum of 30 bedded DCHC. The district should be prepared to increase DCHC beds as per the case trajectory and expected surge of cases These centres shall offer care for all cases that have been clinically assigned as moderate (Patient breathless; respiratory rate more than 24 per minute; saturation between 90 to <94 per cent on room air),” the guidelines stated.
Moreover, the district hospitals or other identified private hospitals or a block of these hospitals shall be converted as dedicated COVID hospitals.
“DCHC would have beds with assured Oxygen support. Every Dedicated COVID Health Centre should be mapped to one or more Dedicated COVID Hospitals. Care should be taken to locate these DCHCs in a manner that ensures the availability of Oxygen supported beds in relatively close vicinity to the patients,” the ministry said.