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PRACTICE STORY
Year : 2020  |  Volume : 18  |  Issue : 3  |  Page : 199-202

Coronavirus disease of 2019: The premise for framing strategies towards infection prevention control management


1 Department of Medicine, SMS Medical College Hospital, Jaipur, Rajasthan, India
2 Department of Pharmacology, SMS Medical College Hospital, Jaipur, Rajasthan, India
3 Department of Physiology, SMS Medical College Hospital, Jaipur, Rajasthan, India

Date of Submission25-May-2020
Date of Decision01-Jun-2020
Date of Acceptance11-Jun-2020
Date of Web Publication10-Jul-2020

Correspondence Address:
Dr. Shivankan Kakkar
Department of Pharmacology, SMS Medical College Hospital, Jaipur, Rajasthan
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/cmi.cmi_82_20

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  Abstract 


The ever-growing menace of Coronavirus Disease of 2019 (COVID-19) has ravaged mankind the world over. There has been a lot of exploratory work going on to unravel the pathophysiology of the disease and to come up with a rationale and realistic management protocol. Here is one such attempt to present the Government, Societal and Medical measures framed by Tertiary Care Medical College Teaching Hospital of State of Rajasthan, namely, S. M. S. Medical College and Attached Hospitals, Jaipur. These measures were undertaken for the entire state so as to curtail the rise of COVID-19 pandemic to some extent. The combative approach was multi-focal and multi-axial with the aim to address issues from all conceivable angles inclusive of preparative ground-work, fluidic containment, slowing of transmission, and appropriate logistics to ensure steady-state supplies.

Keywords: COVID-19, fluidic containment, readiness, strategies


How to cite this article:
Bhandari S, Singh A, Sharma R, Mehta S, Kakkar S, Gupta J, Gupta K, Tak A, Dube A. Coronavirus disease of 2019: The premise for framing strategies towards infection prevention control management. Curr Med Issues 2020;18:199-202

How to cite this URL:
Bhandari S, Singh A, Sharma R, Mehta S, Kakkar S, Gupta J, Gupta K, Tak A, Dube A. Coronavirus disease of 2019: The premise for framing strategies towards infection prevention control management. Curr Med Issues [serial online] 2020 [cited 2020 Aug 5];18:199-202. Available from: http://www.cmijournal.org/text.asp?2020/18/3/199/289427




  Introduction Top


The Coronavirus Disease of 2019 (COVID-19), caused by a novel coronavirus (CoV) severe acute respiratory syndrome CoV 2 (SARS-CoV-2) belonging to a large family of viruses of coronaviruses afflicting primarily the airways giving rise to varied symptom complex (ranging from the common cold to severe respiratory illness of acute respiratory distress syndrome), made its presence felt in December 2019 when China alerted World Health Organization (WHO) about a cluster of pneumonia cases that we now know of as COVID-19.[1] The ever-growing menace of COVID-19 has ravaged humankind the world-over and relentless ongoing exploratory work is underway to unravel the pathophysiology of the disease process and come up with a rationale and realistic management protocol.

In the absence of a definitive management protocol for COVID-19, the only combative strategy available is that of Infection Prevention Control Management for a global outbreak of SARS-CoV-2 causing COVID-19, and its effective execution is a herculean task being faced by countries world-over. In this context, it would be worthwhile to underscore the strategies planned and framed by a premier Tertiary Care Medical College Teaching Hospital and subsequently adopted by the State of Rajasthan, Jaipur (in North India) in tackling the pandemic of COVID-19 with encouraging results and could give invaluable insight in framing policies to other countries and help in the global fight against the dread of COVID-19.


  Overview of the Strategic Responses Top


The combative approach was multi-focal and multi-axial with the aim to address issues from all conceivable angles inclusive of preparative ground-work, fluidic containment, slowing of transmission, and appropriate logistics to ensure steady-state supplies. Such perspectives included measures undertaken, difficulties faced in promptly identifying and treating suspects and confirmed cases, and subsequent alternates conducive for containment. The safety and protection of medical personnel and patients were of utmost concern, and steps taken in this direction gave the desired dividends, with the basic premise of being sensitive to changing demands. It is essential that health facilities are kept in optimal functional status.

The strategic responses need to be aggressive, agile, and continuously adapting to changing requirements. These are discussed as under:

First, in the absence of known cases, the focus needs to be on readiness and aptness. The information and lessons learnt from other parts of the world need to put in motion appropriate and adequate surveillance systems with rapid identification of suspect cases, their isolation, and testing to ensure that the entire system is responsive and agile.[2] COVID-19 dedicated work-force needs to be evolved, and consequently, specialized training needs to be imparted to respective medical personnel inclusive of undergraduate medical students (primarily students undergoing compulsory rotating internship). Requisite steps need to be initiated to purchase and set up equipment, ventilators, Personal Protective Equipment (PPE) kits, masks, and other related inventory well in advance to ensure adequate preparedness. To optimize the use of the limited number of PPEs measures such as autoclaving can be adopted. A core treatment group needs to be evolved with inputs from respective Departments of a Medical School with optimal utilization of available resources and conversion of Tertiary Care Medical College Teaching Hospital into COVID-19 Hospital. Appropriate surveillance with rapid identification of suspect cases (those with history of travel to affected countries/tourists with symptoms), isolation, and testing to ensure the entire system is ready to respond need to be key ingredients of any reverberant and effective system. A control room that is operational 24 × 7 needs to be created.

Second, the principles of Fluidic Containment need to be made operational in the eventuality of the detection of a few or clusters of cases. Such a measure needs to be executed through limiting spread in community by meticulous contact tracing, self-isolation, and respective social distancing (now rightly called as physical distancing) measures, as well as ensuring suspect cases to be rapidly identified, isolated, and tested.[3],[4] Patient awareness regarding social distancing and the use of PPEs like mask usage can be done by providing them a list of DOs and DONTs as soon as they get their hospital appointment confirmed. This can be provided in the form of a written document in varied regional languages or even in the form of a video message in a choice of language as preferred by the patient. A proactive and diligent initiative by States/Nations need to be undertaken to limit movement by prohibiting mass gatherings, closing down gyms, cinema halls, coaching centers, schools, and colleges.[5] The rationale for such an initiative is to rend and split the transmission chain based on the incubation period. The Teaching Medical Schools Hospitals have the requisite paraphernalia and expertise in such introspective measures, and necessary inputs need to be taken from such Institutes.

As for the cases, appropriate clinical care (based on the available evidence-based medicine), particularly of vulnerable patients to reduce severity and mortality needs to be ascertained. Provisions should be made in place to ensure that the patients seeking medical care have compulsory masks. In the state of events, if a patient does not have access to masks, there should be facilities at the major entry ports of the hospital concerned to provide patients with the same either free or chargeable. The whole hospital should be designated as COVID-19 Treating Hospital. All medical personnel needs to be included as a part of the COVID-19 Working Group and the protection of the entire staff is a priority concern of the state. All PPEs and Safety Protocols need to be ensured as per laid down norms of regulatory bodies. Separate designated areas for treatment to minimize the risk of transmission to others need to be planned. Cohorting patients together enhance the risk and chances of transmission of disease among patients where some are, and some are not, infected. Subsequently, segregated wards need to be created for confirmed and suspected cases and flow, transfer, and localization of patients planned accordingly.

Here it is imperative to underscore the importance of unlimited support from Government Organizations and Nongovernment Organizations and Philanthropist Organizations for up-gradation of intensive care unit, wards, diagnostic, and all other facilities. Active participation of the society is the need of the hour and has to be sought unconditionally.

A very well-planned duty rosters for faculty, staff, and residents need to be prepared and charted out well in advance for effective management of COVID-19 services. Protocols regarding the use of disinfectants in health-care workplace should be from credible sources such as WHO and the Indian Council of Medical Research. Those posted in designated COVID-19 wards need to be given separate accommodation in nearby hotels and motels during and after their duty period to ensure that they are isolated from family and public. Food, transport, and logistics need to be made available. The efforts of the administration and State Government in ensuring smooth functioning with the provision of required resources and inventory remain essential for any effective policy to be implemented. All medical and paramedical personnel assigned duties in designated COVID-19 wards/hospitals need to be screened for SARS-CoV-2 in a separate building both before and after the completion of their duties. To ensure that the health care workers are up to date with the recent national and international advances in terms of guidelines and management protocols of COVID-19, webinars with heads from various research and medical institutes can be made to keep the medical community at the foot with the best treatment plans for the patients.

The other step to be incorporated in an effective Infection Prevention Control Management is that of slowing of transmission when containment is no longer possible with the extensive person-to-person transmission in the community, and the focus needs to be shifted to the consequent flattening of the epidemiological curve. A Nationwide strict lockdown has to be implemented to circumvent rapid increases in cases that would put pressure on the health-care system. Within the cities, the pandemic is at different stages at different times across different areas. Subsequently, microbiology testing laboratories are needed to provide testing capacity with the focus being to optimize the testing capacity of reverse transcriptase-polymerase chain reaction.

It needs to be ensured that appropriate logistics to ensure steady-state supplies are operational with no delay, and the Government needs to maintain both medical and nonmedical supplies. The crucial measures and demands need to be categorized and outlined, and strategies implemented with alacrity. Decentralization in terms of treatment and testing is the essence in combating a pandemic that has no definitive management protocol. COVID-19 treating facilities need to be evolved across cities to cater to the rising demands, and separate testing facilities (where ever possible) need to be created as part of an integral part of the response. Another area that needs due attention is having a trusted source of information for the general public. Daily reports need to be published online and be easily accessible to all.


  Keeping the Infection under Bay Top


The measures inclusive of Government, Societal and Medical, so outlined were designed, framed by Tertiary Care Medical College Teaching Hospital of State of Rajasthan namely, S. M. S. Medical College and Attached Hospitals, Jaipur for the entire state and the rise of COVID-19 pandemic could be curtailed to some extent. The same is exemplified in [Figure 1]. The bottom line is that efforts are on to address knowledge gaps and accelerate the development of new therapeutics that may help prevent disease spread and improve treatment outcomes.
Figure 1: Boxplot (blue) forecasting the cumulative cases of coronavirus disease of 2019 in Rajasthan based on previous datasets and a line graph (red) outline the real observed cases.

Click here to view



  Conclusions Top


To conclude, the principles to tackle such a situation are the same across the world. However, implementing measures varies considerably. It depends on the capacity, context, and, importantly, the dynamics of the pandemic within a given setting. The resources in terms of workforce, logistics, and stratagem need to be pooled in from across different sections of society on a common platform roping in the passion across all cadre to combat COVID-19.

Acknowledgments

We would like to acknowledge our heartfelt gratitude for outstanding and exemplary support of Shri Rohit Kumar Singh (Additional Chief Secretary, Government of Rajasthan) and Shri Vaibhav Galriya (Secretary, Medical Education, Government of Rajasthan) for COVID-19 containment programme. Their immense and unlimited support has been a pillar of strength for us. We also acknowledge the support of Dr. K. K. Sharma (Director), Dr. Ravi Sharma (Additional Director), Dr Ruchi Singh (State Microbiologist) and team Department of Medical and Health, Government of Rajasthan.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
The Novel Coronavirus Pneumonia Emergency Response Epidemiology Team. The epidemiological characteristics of an outbreak of 2019 novel coronavirus disease (COVID-19) – China, 2020. China CDC Wkly 2020;2:1-10.  Back to cited text no. 1
    
2.
Hellewell J, Abbott S, Gimma A, Bosse NI, Jarvis CI, Russell TW, et al. Feasibility of controlling COVID-19 outbreaks by isolation of cases and contacts. Lancet Glob Health 2020;8:e488-96.  Back to cited text no. 2
    
3.
Fong MW, Gao H, Wong JY, Shiu EY, Xiao J, Fong MW, et al. Nonpharmaceutical measures for pandemic influenza in nonhealthcare settings – Social distancing measures. Emerg Infect Dis 2020;26:961-6.  Back to cited text no. 3
    
4.
Keeling MJ, Hollingsworth TD, Read JM. The Efficacy of Contact Tracing for the Containment of the 2019 Novel Coronavirus (COVID-19). MedRxiv; 2020.  Back to cited text no. 4
    
5.
Hens N, Ayele GM, Goeyvaerts N, Aerts M, Mossong J, Edmunds JW, et al. Estimating the impact of school closure on social mixing behaviour and the transmission of close contact infections in eight European countries. BMC Infect Dis 2009;9:187.  Back to cited text no. 5
    


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