This is Version 3.1 Live Guideline

COVID-19 (new Coronavirus) Outbreak in Sri Lanka Interim Guidelines for Sri Lankan Primary Care Physicians

1. INTRODUCTION

Coronaviruses (CoV) are a large family of enveloped viruses that cause illness ranging from the common cold to more severe diseases such as Middle East Respiratory Syndrome (MERS-CoV) and Severe Acute Respiratory Syndrome (SARS-CoV). Coronavirus disease (COVID-19) is a new strain that was discovered in 2019 and has not been previously identified in humans. The World Health Organization (WHO) recently declared COVID-19 as a global pandemic.

Incubation period of the virus is 2-14 days (1).  The median incubation period is estimated to be 5.1 days and 97.5% of those who develop symptoms will do so within 11.5 days (2). During the incubation period, the virus may not be identified with the currently available Reverse Transcriptase Polymerase Chain Reaction (RT -PCR) test with a single sampling. However, people are contagious when they are most symptomatic.

The virus spreads by droplets. Direct spread occurs when a person facing a patient who talks, coughs or sneezes. The droplets can spread to a distance of 1-2 meters and directly get into another person’s airways. More importantly it can spread when the virus lands on a surface and when a person touches the contaminated surface and then the face. Its survival on that surface will be determined by the temperature, humidity and the type of the surface. The third method of spread identified is by inhalation of the aerosolized virus which can exist in the air for up to three hours.

Primary Care Physicians (PCPs) are in the frontline of patient care in any healthcare crisis as the closest healthcare professionals to the family. They have a major responsibility in looking after high-risk groups, identifying suspected cases, preventing spread and opportunistic patient education during the current pandemic of COVID-19.

This guideline is for Primary Care Physicians in (a) Private Family Practice/General Practice Clinics (b) Primary Medical Care Units (PMCU), and (c) the Divisional Hospitals (d) Doctors working in Outpatient Departments (OPDs) of secondary & tertiary care institutions and private hospitals delivering primary curative care (3).

2 . CASE DEFINITION

UPDATED INTERIM CASE DEFINITIONS ON COVID-19 AND ADVICE ON

INITIAL MANAGEMENT OF PATIENTS (version dated 04.04.2020)

 

The present recommendation is to isolate and test all clinically/epidemiologically suspected cases of COVID-19 infected patients.

All patients with medical/surgical, obstetrics/gynecological or paediatric conditions

should receive the usual standards of care in keeping with clinical status, in a designated area. Management of these patients should NOT be delayed under any circumstances pending COVID-19 test result.

All confirmed cases once stable should be transferred to a designated COVID-19 Treatment Centre.

Clinically Suspected Case:

  1. A person with ACUTE RESPIRATORY ILLNESS (with cough, shortness of breath , sore throat; one or more of these) with a history of FEVER (at any point of time during this illness), returning to Sri Lanka from ANY COUNTRY within the last 14 days.

OR

  1. B. A person with ACUTE RESPIRATORY ILLNESS (with cough, shortness of breath, sore throat; one or more of these) AND having been in close-contact* with a confirmed or suspected COVID-19 case during the last 14 days prior to onset of symptoms;
    *Close-contact: A person staying in an enclosed environment for >15 minutes (e.g. same household/workplace/social gatherings/travelling in same vehicle). OR who had direct physicalcontact.

OR

  1. C. A person with ACUTE RESPIRATORY ILLNESS (with cough, shortness of breath, sore throat; one or more of these) with a history of fever (at any point of time during this illness) with a history of travel to or residence in a location designated as an area of high transmission of COVID-19 disease as defined by the Epidemiology Unit, MoH, during the 14 days prior to symptom onset.

OR

  1. D. A patient with acute pneumonia (not explainable by any other aetiology) regardless of travel or contact history as decided by the treating Consultant.
  • Management of such patients should NOT be delayed under any circumstances.
  • Patients should receive the standards of care in keeping with the known underlying cause in a designated area (ETU/isolation unit/designated respiratory unit/designated ward-HDU/ICU).
  • A sample for the PCR test obtained and sent (not the patient) to a designated
  • Once the result is available, if positive, the patient (once stable) can be transferred to a designated COVID-19 treatment center.

OR

 

  1. A patient with fever and in respiratory distress as evident by RR>30 per minute, Sp02 <90% on room air, regardless of travel or contact history and without a definable cause, as decided by the treating Consultant.
  • Management of such patients should NOT be delayed under any circumstances.
  • Patients should receive the standards of care in keeping with the clinical condition in a designated area (ETU/isolation unit/designated respiratory unit/designated ward-HDU/ICU).
  • A sample for the PCR test obtained and sent (not the patient) to a designated laboratory.
  • Once the result is available, if positive, the patient (once stable) can be transferred to a designated COVID-19 treatment center.
  1. Any person irrespective of the presence of symptoms, with an epidemiological link to a confirmed COVID-19 case who needs testing, as decided by the Regional Epidemiologist or the Central Epidemiology Unit.

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

Disposition of cases:

Disposition of suspected cases

  • All patients fitting to the above suspected case definitions (A, B, C) should be admitted and transferred by ambulance to the closest designated hospital (refer updates on the list of designated hospitals) for confirmatory testing and management. This should be done only after stabilizing the patient and in prior consultation with the respective designated hospital, adhering to necessary infection prevention and control (IPC) precautions.
  • In case of D and E, patient should be managed in the same hospital in a designated area (ETU/isolation unit/designated respiratory unit/designated ICU). A sample for the PCR test obtained and sent (not the patient) to the designated laboratories. Once the result is available, if positive, the patient (once stable) can be transferred to a designated COVID-19 treatment center. In case of F, all COVID-19 positive individuals will be admitted to a designated treatment facility.

Disposition of confirmed cases
All confirmed cases should be transferred to a COVID-19 Treatment Centre.

The above case definition was adopted from Updated interim case definitions on COVID-19 and advice on initial management of patients (Version dated 04.04.2020)

3. PRIMARY CARE CONSULTATION

It is advisable to discourage patients with respiratory symptoms with or without fever visiting your practice for treatment. This recommendation is valid also for any chronic disease consultation.

It is strongly recommended to establish a remote consultation service (hotline / video conferencing) with your patients which will enable you to advise them and clarify queries related to respiratory symptoms and fever regardless of your availability in your practice due to the situation in the country (4).

3.1 REMOTE CONSULTATION

During the COVID-19 pandemic it is recommended to initiate all first contact care consultations as remote consultations over the phone. This will enable you to triage COVID-19 suspected patients appropriately with minimum exposure to healthcare staff and other patients. At the same time, it enables non-COVID patients to be managed appropriately.

Patients with respiratory symptoms should be discouraged from visiting primary care settings without a prior telephone consultation.

Modes of communication for remote consultations

  • With audio only –Telephone calls etc.
  • With audio and video – WhatsApp, Viber, Video conferencing with Zoom, Google hangouts, Skype etc.

Of the two methods, telephone consultations are familiar to the majority and they would be adequate in most instances such as for delivery of general information, consultation of uncomplicated patients with mild symptoms and provision on routine/periodic care (4).

However, video consultations can provide additional visual diagnostic clues and therapeutic presence. Thus, video conferencing could be suitable for patients who are more ill or more anxious.

Preparation

A notice could be displayed outside your clinic indicating the above facts. (Sample notice in Annex 1)

Documentation of remote consultations

Use the ‘Doctor – Patient telephone consultation record’ (Annex 2) or the usual medical record to document the remote consultation. If documented in existing medical records use it as a guide. Record keeping is even more important in this crisis situation as consultations without active follow-up is of less value.

Tips for a successful remote consultation

  • Be proactive – doctor-initiated consultations for high risk patients
  • Introduce yourself
  • Confirm the identity of the patient
  • Open ended questions and closed ended questions for triage purpose.
  • Listen with a third ear – pick not only the literal meaning but also the emotions and context
  • Check for understanding
  • Give opportunity to clarify
  • Use simple culturally appropriate non-medical language

When to avoid remote consultation

    • To assess patients with serious or potentially high risk conditions requiring a physical examination (5)
    • When a physical examination is required to support the clinical decision making
    • When a patient’s ability to communicate via telephone or video is compromised and there is no one to assist during the consultation
    • When the doctor has any doubt about the clinical appropriateness of a remote consultation

 

Figure 1 (Algorithm on Remote Consultation) and the Figure 2 (Quick Fact Sheet) will provide you guidance on carrying out a successful Remote Consultation.

 

 

  • Please refer page 21 and 22 for safety precautions for Primary Care Physicians (6) (7) (8).

4.HISTORY

The majority of the patients with COVID-19 identified up to now have a clear contact history. This makes a detailed history extremely important in a primary care setup.

Important points to elicit in the history; (9)

 

  • Elderly patients can present with atypical symptoms (confusion, drowsiness) (10)
  • Anosmia and ageusia can be early symptoms of COVID-19 (11).
  • Travel and social history is extremely important.
    • Recent visit to any foreign country (within 1 month)
    • Coming into contact with a suspected or a confirmed COVID-19 patient within last 14 days
    • Coming into contact with a person that arrived from abroad within last 14 days
    • Residing in or recent visit to an area of high transmission of COVID-19/lock down area
    • Elderly patients can present with atypical symptoms (confusion, drowsiness) (10)
    • Anosmia and ageusia can be early symptoms of COVID-19 (11).
    • Travel and social history is extremely important.
      • Recent visit to any foreign country (within 1 month)
      • Coming into contact with a suspected or a confirmed COVID-19 patient within last 14 days
      • Coming into contact with a person that arrived from abroad within last 14 days
      • Residing in or recent visit to an area of high transmission of COVID-19/lock down area
      • Contacts of the current high-risk healthcare workers
      • Employees in aviation, tourism and hotel industry
      • Recently released from a quarantine centre / self-quarantine
      • Staff or armed forces who have worked in quarantine facilities
      • Family members, relations or associates of any of the above groups

 

Patients at risk of developing complications from COVID-19

Patients with non-communicable diseases (NCDs) and multiple comorbidities are at a higher risk of developing complications. This makes it a high priority for primary care doctors to pay extra attention to this group of patients. Minimizing exposure by social isolation should be the top preventative strategy and the patients should be discouraged from visiting clinics. The caregivers should be requested to come instead and get the prescription refills if needed. Alternatively, such patients should be offered remote consultations and e-prescriptions could be issued. (as above)

Patients should be permitted to contact you at any time of the day and get your advice. It would help them to not feel alone and helpless.

 

Following categories of patients are at higher risk.

 

        • Older adults (above 50 years of age) are at higher risk and the elderly patients above 70 years of age are the most susceptible to develop severe disease from the COVID-19 infection (12).
        • PCPs are advised to specially focus on the following groups of patients (13).
          1. Patients with chronic medical conditions – heart disease, lung disease (cystic fibrosis, asthma and COPD), diabetes, hypertension, liver disease, kidney disease
          2. Smokers, alcohol consumers and patients with substance abuse (14).
          3. People with Body Mass Index of (BMI) 40 kg/m2 or above
          4. Patients with psychiatric disorders
          5. Immunocompromised patients – patients on steroids, immunosuppressive therapy, undergone organ transplantation, cancer, HIV/AIDS
          6. Patients living alone
          7. Patients living in elderly homes
        • Pregnant women – all newly registered and high risk expectant mothers whose period of amenorrhea (POA) of more than32 should be followed up at routine antenatal clinics. For more details, please refer to the specific guideline issued by the Ministry of Health (15). (Interim Guidelines for field maternal and child care services during the outbreak of COVID -19)

 

5.EXAMINATION

Key equipment: Infrared / digital thermometer, fingertip pulse oximeter and stethoscope.

It is advisable not to use a mercury thermometer and to avoid taking oral/anal temperature.

  • Limited examination is recommended. Auscultation is not essential if overall clinical judgment is clear about respiratory illness status. It is advisable to all doctors not to examine the throat of patients.
  • Assessing blood pressure increases contact time significantly, thus should be considered only in essential decision making unless you have a digital blood pressure meter (16).
  • For cleaning of equipment please refer to the environmental cleaning guideline by the Ministry of Health (7). (Annex 7)

Initial presentation: No specific signs would be found in the early staged of COVID-19.

Late presentation: Change in vital signs, lung signs (reduced air entry and added sounds), tachypnoea (respiratory rate>30) and low oxygen saturation (SpO2 <90%) may be found.

 

Look for atypical signs in elderly patients. (Confusion, drowsiness)

 

6.INVESTIGATIONS

  • There is no specific clinical or laboratory investigation to screen for COVID-19 at the moment.
  • We do not recommend FBC, CRP to arrive at a diagnosis of a probable COVID 19.
  • Reverse transcription polymerase chain reaction (RT-PCR) test is available for ‘suspected cases’ of COVID-19 as a confirmatory test at government hospitals and some approved private hospitals after admission.
  • Patients should be informed that the PCR is not a screening test. In addition, it is important to explain that even if the PCR is negative, the patient may harbour the virus during the incubation period (17).
  • Although detection of IgM/IgG to diagnose COVID-19 has been suggested, it cannot replace RT-PCR in acute diagnosis and management of patients due to late antibody response. It would miss the patients in early stages of the disease (18).

7. TREATMENT

  • Do not use any medications specific to COVID-19 in primary care, specifically chloroquine, hydroxychloroquine, azithromycin or any other antiviral drug for treatment or for prophylaxis (19).
  • Treatment with ACE inhibitors and ARBs Currently there is no evidence for discontinuation of ACE inhibitors and ARB in those with confirmed COVID-19 (20).

 

8. MANAGEMENT AND DISPOSITION OF THE PATIENTS AND NOTIFICATION

RE: Regional epidemiologist, MOH: medical officer of health, PHI: public health inspector 

 

The above table summarizes the circular ‘Interim guideline for  risk assessment referral system to rationally manage COVID-19 case load in isolation centers by DDG-MS-1/23/2020 dated 6/4/2020’ (21).

Patient information leaflet on home quarantine is available at epidemiology website.

  • If you suspect a patient to have COVID-19 infection according to the above ‘suspected case’ definitions (Category 3 and 5/A to F), unless you have used appropriate PPE, immediately leave the consultation room to avoid further exposure.Follow the precautionary methods (22) and relevant environmental cleaning procedures provided by MoH.
  • Stabilize the patient and preferably contact the relevant hospital before transferring.
  • Call and get down an ambulance (Suwasariya – 1990) and transfer the patient to the closest designated hospital (see Annex 3) (23) adhering to necessary infection prevention and control (IPC) precautions without exposing the general public.
  • If any patient refuses to admit / home isolation, seek police/legal support in accordance with the Quarantine Law.

9. PROCEDURE FOLLOWING A CLOSE CONTACT

A Primary Care Physician and the staff with high or medium risk exposure to a patient suspected of having COVID-19 infection (until excluded) should refrain from working for 14 days after the last exposure with self-quarantine measures (24). They should be actively monitored by the local public health authority by establishing regular communications to assess the development of any clinical features such as fever or respiratory symptoms. In low risk exposure, self-monitoring by taking their temperature twice a day and remaining alert for respiratory symptoms would be adequate. If they develop fever or respiratory symptoms further medical evaluation is needed.

The risk exposure categories are given in the Annex 4. (25)

10. MANAGING ASYMPTOMATIC PATIENTS WITH POSSIBLE EXPOSURE

  • Close contacts of a patient with confirmed or suspected COVID-19: Advice on strict home quarantine after discussing with the regional epidemiologist. Inform the medical officer of health (MOH), public health inspector (PHI) and police.
  • Low risk exposure to a patient with confirmed COVID-19: Reassure and advise to be vigilant about symptoms.

11. MANAGING OTHER PATIENTS WITH URTI SYMPTOMS

A face-to-face consultation is not required for symptoms of common cold and upper respiratory tract symptoms within the first 2-3 days of the illness. There is no clinical examination that can differentiate COVID-19 from other common viral upper respiratory tract infections (URTIs).

Even though community spread is not visible at the moment, the risk cannot be excluded. It is best to advise all your patients with respiratory symptoms (with or without fever) to rest at home without exposing themselves to the community as much as possible. Although it is advisable to wear a facemask when going out of the house, they should be encouraged to strictly practice social distancing, respiratory hygiene and hand washing frequently (26).

Medical certificates could be issued for a few days depending on the severity of illness.

Obtain patient’s contact details and maintain a register for patients with fever and respiratory symptoms.

(Refer above Quick Fact Sheet and the Algorithms)

12. FOLLOW-UP OF COVID-19 PATIENTS AFTER DISCHARGE

Patients are discharged when they are clinically well, fever free for more than 72 hours with two (2) negative PCR tests more than 24 hours apart (12).

 

Patients should be advised to follow strict home isolation for a minimum period of three weeks as viral shedding may be prolonged. Medical certificates for that period should be issued by the government institution treating the patient.

 

The patient should be advised to stick to remote/telephone consultations as much as possible. The immediate follow-up could be done together with the MOH office.

13. COVID-19 AND MENTAL HEALTH

 

13.1 For the people who are suspected to have COVID-19 or in quarantine centres / under home quarantine stress the following.

  • Trust medical professionals who are treating you
  • It is not your fault that you contracted COVID-19
  • It is alright to be scared and anxious but don’t be overwhelmed – request a referral to a mental health professional if you need help

13.2 Ask these two questions from the people to access their psychological status

Over the last 2 weeks,

Interest or pleasure in doing things

Feeling down, depressed, or hopeless

 13.3 People in self-quarantine / quarantine facilities

  • You are doing the right thing – however, distressing and uncomfortable it may be
  • Stay connected and maintain your social networks
  • Even when isolated, try as much as possible to keep your personal daily routines or create new routines
  • During times of stress, pay attention to your own needs and feelings
  • Engage in healthy activities that you enjoy and find relaxing
  • Exercise regularly, keep regular sleep routines and eat healthy food
  • Seek information updates and practical guidance from credible sources

Any queries contact consultant psychiatrist hotline 0712 578578 (8.00 am to 8.00 pm)        (27) (28).

 

14. HOME VISITS

It is best to avoid visiting patients with respiratory tract infections considering your safety.

Home visits may be arranged according to your clinical judgement in situations involving patients with a disability or other specific circumstances. PPE should be worn on such a visit.

History should be obtained over the phone before visiting the patient to screen the risk factors for COVID-19  (29).

15. HANDLING DEATHS AT PRIMARY CARE SETTINGS

In case a Primary Care Physician is required to handle a death of a patient in any of the following settings, the doctor and the supporting staff should wear appropriate personal protective equipment (PPE).

  1. A death of a patient treated in a Divisional Hospital (DH)/PMCU
  2. A dead body is brought to a DH / PMCU
  3. A GP is called to confirm a death that has taken place at home
  4. A dead body is brought in to the general practice

The PCP should go through the history and find out whether the diseased person fits in to the COVID-19 case definition. If the diseased person fits into either suspected or high risk COVID-19 case definitions, the PCP should not give a cause of death, but should take steps to inform the police, MOH/PHI and the RE. Handling of the body and the quarantining the family members of the diseased should be done according to the instructions received from the RE.

If the diseased person does not fall into the case definition of COVID-19, the PCP may give the cause of death according to the usual practice (12).

General advice that could be given to patients by PCPs are found in Annex 6

References

  1. Coronavirus [Internet]. [cited 2020 Mar 24]. Available from: https://www.who.int/health-topics/coronavirus
  2. Lauer SA, Grantz KH, Bi Q, Jones FK, Zheng Q, Meredith HR, et al. The Incubation Period of Coronavirus Disease 2019 (COVID-19) From Publicly Reported Confirmed Cases: Estimation and Application. Ann Intern Med [Internet]. 2020 Mar 10 [cited 2020 Apr 13]; Available from: https://annals.org/aim/fullarticle/2762808/incubation-period-coronavirus-disease-2019-covid-19-from-publicly-reported
  3. Reorganising Primary Health Care in Sri Lanka.pdf.
  4. Greenhalgh T, Koh GCH, Car J. Covid-19: a remote assessment in primary care. BMJ. 2020 Mar 25;m1182.
  5. Guide-to-providing-telephone-and-video-consultations.pdf [Internet]. [cited 2020 Apr 12]. Available from: https://www.racgp.org.au/FSDEDEV/media/documents/Clinical%20Resources/Guidelines/Guide-to-providing-telephone-and-video-consultations.pdf
  6. COVID-19 Office Prep Checklist.pdf [Internet]. [cited 2020 Apr 15]. Available from: https://www.aafp.org/dam/AAFP/documents/patient_care/public_health/COVID-19%20Office%20Prep%20Checklist.pdf
  7. Environment cleaning.pdf [Internet]. [cited 2020 Mar 24]. Available from: http://www.epid.gov.lk/web/images/pdf/Circulars/Corona_virus/environment%20cleaning.pdf
  8. WHO-2019-nCoV-IPC-2020.3-eng.pdf.
  9. COVID-19 Signs and Symptoms Tracker [Internet]. CEBM. [cited 2020 Apr 4]. Available from: https://www.cebm.net/covid-19/covid-19-signs-and-symptoms-tracker/
  10. Saxena and Lawley – 2009 – Delirium in the elderly a clinical review.pdf.
  11. Mao L, Wang M, Chen S, He Q, Chang J, Hong C, et al. Neurological Manifestations of Hospitalized Patients with COVID-19 in Wuhan, China: a retrospective case series study [Internet]. Infectious Diseases (except HIV/AIDS); 2020 Feb [cited 2020 Apr 16]. Available from: http://medrxiv.org/lookup/doi/10.1101/2020.02.22.20026500
  12. COVID-19 CPG _ version 4.pdf [Internet]. [cited 2020 Apr 2]. Available from: http://www.epid.gov.lk/web/images/pdf/Circulars/Corona_virus/covid-19%20cpg%20_%20version%204.pdf
  13. CDC. Coronavirus Disease 2019 (COVID-19) [Internet]. Centers for Disease Control and Prevention. 2020 [cited 2020 Apr 7]. Available from: https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/people-at-higher-risk.html
  14. Vardavas and Nikitara – 2020 – COVID-19 and smoking A systematic review of the e.pdf.
  15. Interim guidelines for field maternal and child care services during the outbreak of covid-19 infection .pdf [Internet]. [cited 2020 Mar 24]. Available from: http://www.epid.gov.lk/web/images/pdf/Circulars/Corona_virus/interim%20guidelines%20for%20field%20maternal%20and%20child%20care%20services%20during%20the%20outbreak%20of%20covid-19%20infection%20.pdf
  16. Rapid diagnosis of community-acquired pneumonia for clinicians [Internet]. CEBM. [cited 2020 Apr 10]. Available from: https://www.cebm.net/covid-19/rapid-diagnosis-of-community-acquired-pneumonia-for-clinicians/
  17. Gorbalenya et al. – 2020 – iSevere acute respiratory syndrome-related coron.pdf.
  18. Patel R, Babady E, Theel ES, Storch GA, Pinsky BA, St. George K, et al. Report from the American Society for Microbiology COVID-19 International Summit, 23 March 2020: Value of Diagnostic Testing for SARS–CoV-2/COVID-19. mBio. 2020 Apr 28;11(2):mBio.00722-20, e00722-20.
  19. COVID19_Specific Treatment Guidance_Version 1 (22_03_2020) – PDF584596308145516105.
  20. Angiotensin converting enzyme (ACE) inhibitors and angiotensin receptor blockers in COVID-19 [Internet]. CEBM. [cited 2020 Apr 4]. Available from: https://www.cebm.net/covid-19/angiotensin-converting-enzyme-ace-inhibitors-and-angiotensin-receptor-blockers-in-covid-19/

21.DDG_(MS)1_23_2020_6_04_2020_Interim_guideline_for_risk_assesment_referral_system_to_rationally_manage_COVID_19_case_load_in_isolation_centers.pdf.

  1. Coronavirus disease 2019 (covid-19): a guide for UK GPs | The BMJ [Internet]. [cited 2020 Mar 24]. Available from: https://www.bmj.com/content/368/bmj.m800
  2. Sri Lanka Pharmacy Locater – Online Pharmacy Database [Internet]. Sri Lanka Pharmacy Locater – Online Pharmacy Database. [cited 2020 Apr 5]. Available from: http://pharmacy.health.gov.lk/pharmacylocator/index.php

24.Screening_and_management_of_healthcareworkers_following_exposure_to_a_confirmed_suspected_case_of_COVID_19_(V2_dated_01042020).pdf.

  1. CDC. Coronavirus Disease 2019 (COVID-19) [Internet]. Centers for Disease Control and Prevention. 2020 [cited 2020 Mar 24]. Available from: https://www.cdc.gov/coronavirus/2019-ncov/hcp/guidance-risk-assesment-hcp.html
  2. Guidance-on-the-rational-use-of-personal-protective-equipment.pdf [Internet]. [cited 2020 Mar 24]. Available from: http://www.epid.gov.lk/web/images/pdf/Circulars/Corona_virus/guidance-on-the-rational-use-of-personal-protective-equipment.pdf
  3. Snapshot [Internet]. [cited 2020 Apr 16]. Available from: http://slcpsych.lk/about-mental-illness/about-covid-19-2/
  4. Mental-health-considerations.pdf [Internet]. [cited 2020 Apr 16]. Available from: https://www.who.int/docs/default-source/coronaviruse/mental-health-considerations.pdf?sfvrsn=6d3578af_2

29.COVID_19_Guidance_for_infection_prevention_and_control_in_healthcare_settings_Version_1..pdf.

 

Annex 1

Notice

 

Please contact the doctor first over the phone and get advices before coming here if you have cough, cold or fever.

That is for your own safety.

Please call ……………..

 

Annex 2

Annex 3

The Ministry of Health has named the following 32 hospitals with isolation facilities to admit and treat suspected patients.

National Hospital of Sri Lanka (NHSL)

National Hospital Kandy

Colombo South Teaching Hospital (CSTH)

Castle Street Hospital for women (CSHW)

Lady Ridgeway Hospital for children (LRH)

North Colombo Teaching Hospital, Ragama

Teaching Hospital Karapitiya

Teaching Hospital Jaffna

Teaching Hospital Anuradhapura

Teaching Hospital Batticaloa

Provincial General Hospital Badulla

Provincial General Hospital Kurunegala

Provincial General Hospital Ratnapura

District General Hospital Negombo

District General Hospital Gampaha

District General Hospital Vavuniya

District General Hospital Polonnaruwa

District General Hospital Chilaw

District General Hospital Monaragala

District General Hospital Hambantota

District General Hospital Matara

District General Hospital Hambantota

Base hospital Minuwangoda

Base Hospital Kattankudi

Base Hospital Homagama

Nevil Fernando (Teaching) Hospital (For maternal care)

Colombo East Base Hospital Mulleriyawa

Base Hospital Beruwala

District General Hospital Kalutara

COVID-19 Treatment Centres

·         Iranawila special COVID Hospital

·         National Institute of Infectious Diseases (IDH) – Colombo East Hospital

·         Base Hospital Welikanda

·         Kotelawala Defence University Hospital ICU

Annex 4

Risk exposure for Healthcare Professionals

Close contact for healthcare exposures is defined as follows: a) being within approximately 6 feet (2 meters), of a person with COVID-19 for a prolonged period of time (such as caring for or visiting the patient; or sitting within 6 feet of the patient in a healthcare waiting area or room); or b) having unprotected direct contact with infectious secretions or excretions of the patient (e.g., being coughed on, touching used tissues with a bare hand).

High-risk exposures

High-risk exposures refer to healthcare professionals (HCP) who have had prolonged close contact with patients with COVID-19 who were not wearing a facemask while HCP nose and mouth were exposed to material potentially infectious with the virus causing COVID-19.  Being present in the room for procedures that generate aerosols or during which respiratory secretions are likely to be poorly controlled (e.g., cardiopulmonary resuscitation, nebulizer therapy) on patients with COVID-19 when the healthcare providers’ eyes, nose, or mouth were not protected, is also considered high-risk.

Medium-risk exposures

Medium-risk exposures generally include HCP who had prolonged close contact with patients with COVID-19 who were wearing a facemask while HCP nose and mouth were exposed to material potentially infectious with the virus causing COVID-19.  Some low-risk exposures are considered medium-risk depending on the type of care activity performed.  For example, HCP who were wearing a gown, gloves, eye protection and a facemask (instead of a respirator) during an aerosol-generating procedure would be considered to have a medium-risk exposure.  If an aerosol-generating procedure had not been performed, they would have been considered low-risk. 

Low-risk exposures

Low-risk exposures generally refer to brief interactions with patients with COVID-19 or prolonged close contact with patients who were wearing a facemask for source control while HCP were wearing a face mask or respirator. Use of eye protection, in addition to a face mask or respirator would further lower the risk of exposure.

Reference: Interim U.S. Guidance for Risk Assessment and Public Health Management of Healthcare Personnel with Potential Exposure in a Healthcare Setting to Patients with Coronavirus Disease (COVID-19)

Annex 5

 

Annex 6

 

General advices that can be given to the public by primary care physicians
  • Promote using face masks among people who are under quarantine, immunocompromised patients, care givers of the immunocompromised patients, all the patients with respiratory symptoms and fever.
  • Frequent hand washing with soap and water following correct hand washing techniques. When soap and water is not accessible, use 70% alcohol hand rub.
  • Maintain social distancing by keeping at least 1 metre distance between two people specially with anyone who is coughing or sneezing.
  • Advice patients who are at high risk categories (immunosuppressed, hypertension, diabetes, CKD) against leaving home.
  • Avoid touching face, eyes, nose and mouth
  • Maintaining coughing etiquette to protect respiratory hygiene.
  • Avoid crowded places and public transport as much as possible. If unavoidable, choose transport with minimal congestion.
  • Avoid social gatherings.
  • Drink adequate water and liquids to maintain good hydration.
  • Consume foods containing vitamin C and zinc to ensure good immunity.

Annex 7

Annex 8

 

Interim Guidelines for Sri Lankan Primary Care Physicians V 3.1 Live Guideline

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