WORK OF COVID TEAM AND MANAGEMENT OF COVID PATIENTS

Rapid response team

How does the government system deal with Coronavirus spread within a Ward?

The CoronaVirus has not just affected our health as a population but has also managed to alter the behaviour of our whole community. It is important to learn how the community has evolved to deal with the CoronaVirus. While public gatherings are restricted, travelling is also discouraged.

It is the Ward level Team which at the face of this calamity is acting as the Rapid Response Team(RRT) that is given the responsibility to enforce this quarantine. The RRT is expected to maintain a line list (a list of all such persons with their necessary information and relevant dates).Because the RRT is part of the community there, they are expected to know the individuals or families living there. The team has to have surveillance over the 400 odd families in that community. If this job is done with care and precision, half the battle against Corona is won.

The RRT is expected to take daily updates from the people staying in home isolation and make sure that they are healthy and also that they have all facilities required for a comfortable stay.

If the person has any health issues, the ASHA worker must take action, report the same to higher authorities and get the person health support.

Because the people who form RRT are from the local area, they can call the persons in quarantine and have candid conversations about his well being.If there is any problem faced by a mother and child in quarantine, the Anganwadi worker is the person to tend to it.

If a person does not follow the rules laid out by the government, the RRT may report the same to the Panchayat. The panchayat has the support of the police and is empowered to enforce the quarantine.

Management of COVID patients

Around 70 % of the patients are asymptomatic. They may be managed with the help of the following systems. These will be dealt with in detail in the coming chapters

 

1.TeleHealth Helpline: The Medical Officer of the Panchayat shall facilitate setting up of TeleHealth Helplines. This will be the states first line of defence against Corona. The patients who are in isolation in their own homes may call into this TeleHealth Helpline for any health-related assistance like a consultation with a doctor for any symptoms, COVID related or not, or to order delivery of medicines to their doorsteps. There is also a Central TeleHealth Helpline at the district level for the healthcare workers to call for referrals. The doctors and nurses at the panchayat level may utilize the TeleHealth Helpline to clear any doubts that they have.

2.First-Line Treatment Centres: These are for individuals who do not have facilities to self isolate themselves in their homes.

3.Field Response home care teams: The Medical Officer of each panchayat may constitute a Field Response Home Care Team to give medical care to people in home isolation in their own homes.

 

Treatment of covid 19 patients

There are two key principles that have to be made the foundation stone in this war.

First Principle:“Separating COVID and Non COVID by creating a parallel COVID Healthcare System & utilizing existing Healthcare system for Non COVID patients”.

A clear demarcation between a non-COVID Patient and a COVID Patient has to be made.

When the existing healthcare systems are overburdened as the COVID-19 cases rise, we need to create an alternative parallel healthcare system exclusively for COVID-19 patients.

This way, other patients, like cardiac patients, antenatal cases, orthopedic patients etc. can easily avail the mainstream healthcare systems.

Second Principle:”Decentralization of the existing system to the panchayat and ward level”

We cannot build hospitals overnight and thus have to protect the existing healthcare system from crashing due to an overload of patients.

This is done by decentralizing the treatment through a three-tier system under the direct supervision of the district administration.

Categorisation of covid patients:

Based on the severity of symptoms of COVID-19, patients are categorized into symptomatic (with symptoms) or asymptomatic (no symptoms).

Symptomatic patients are sub classified into Mild, Moderate and Severe.

Mild category

Mild category consists of patients with mild symptoms of fever/sore throat/dry cough/rhinitis or diarrhoea. Patients belonging to this category generally can be managed in home quarantine with symptomatic treatment with the help of Tele-Health Helpline Unit.

The tele-health helpline unit is situated in the district control room. The members are doctors, nurses, pharmacists, information technology and management experts. They will receive calls for help from the patients and RRT members. The helpline will give expert advice to patients and help in transferring the patients to hospitals or treatment facilities.

Those who are unable to maintain home quarantine due to any constraints can be managed at the First Line Treatment Centres (FLTC).These patients can be shifted from home to FLTC using double chambered auto-rickshaw.

Moderate Category

Moderate Category is formed by patients whose symptoms have worsened despite symptomatic management or those with comorbidities like uncontrolled diabetes mellitus, hypertension, chronic kidney disease, coronary artery disease, malignancies, etc. along with moderate symptoms.

Pregnant women and immunocompromised individuals with moderate symptoms are also included in this category. These group of patients can be managed at Secondary Level Treatment Centres (SLTC).

Such patients are shifted to an SLTC using a double chambered ambulance.

Severe Category

Severe Category is the third group of patients who exhibit severe symptoms or symptoms of Acute Respiratory Distress Syndrome. These are the patients who require the highest level of care.

Common features noted are breathlessness, drowsiness, drop in pressure, blood stained sputum while coughing or bluish discoloration of skin which are important red flag signs that have to be kept in mind during the management of these patients.

In the pediatric age group, influenza-like illness is an alarming sign to be kept in mind.

Worsening of underlying comorbidities/diseases is also a common feature seen in these patients. Hence it is ideal to manage them at the highest level centres or the Apex Centre.Shifting of severe category patients will require ICU ambulances to ensure proper monitoring and supportive care is given during the shift to an Apex Centre.

 

3 –Tier healthcare system:

Various initiates were implemented by different state governments during this COVID pandemic, one of the effective initiative by Government of Kerala was introducing a 3-tier system for pandemic treatment.

First Line Treatment Centre

The First Line Treatment Centre (FLTC) cater to patients who are below the age of 60 years and have mild symptoms with no significant comorbidities. Generally, this population will be advised to maintain home isolation with symptomatic treatment but will be admitted at this facility if they are unable to maintain home isolation due to any reasons.

SECOND LINE TREATMENT CENTRES (SLTC)

Second Line Treatment Centres (SLTC) will be formed by the Government Taluk Hospitals and designated private hospitals. SLTC will be catering to patients with moderate symptoms and those above 60 years / having any comorbidities with moderate symptoms.

These facilities will be equipped with adequate infrastructure and equipment to monitor all the mandatory baseline investigations and provide any emergency interventions.

SLTC will conduct all laboratory investigations and chest X-ray to attain a clearer status of the patient's health.

APEX CENTRES

Apex Centres will be set up in the hospitals with advanced facilities like the medical colleges and private hospitals of each district. These facilities will be equipped to cater to all severe cases of COVID-19. Apex facilities will have ICU beds, ventilators, dialysis machines and well trained human resources to cater to all complicated cases of COVID-19.

More hospitals may be notified by the district administration as Apex Centres for COVID-19 as and when the need arises.

District Administration at Ernakulam has successfully conducted two Mockdrills to test the feasibility of this 3-Tier Healthcare system and the efficient working of other systems like the Ambulance system, Teleconsultation system etc in sync with this 3-Tier healthcare system.

ACTIVATION OF THESE TREATMENT CENTRES:

There are 3 Phases to the way COVID-19 is treated.

Phase 1 is when a panchayat only has 3 or less than 3 cases in a population of 10,000. During this phase, all the COVID-19 patients are treated in the Apex Centres.

Phase 2 is when any panchayat starts to have more than 3 cases in a population of 10,000. Then, the SLTCs are activated. All the mild and moderate cases will be treated in the SLTCs while only the critically ill will be sent to the Apex Centres.

Phase 3 is when a Panchayat starts to have more than 10 cases in a population of 10,000. Then, FLTCs are activated to treat the asymptomatic and mildly symptomatic patients. The SLTCs continue to treat the moderately symptomatic patients and Apex Centres only treat the most severely ill.

When number of cases still goes up, the panchayat boundaries of such Hotspots are sealed to contain the virus.

Vaccines:A vaccine is a biological preparation that provides active acquired immunity to a particular infectious disease. A vaccine typically contains an agent that resembles a disease-causing microorganism and is often made from weakened or killed forms of the microbe, its toxins, or one of its surface proteins. The agent stimulates the body's immune system to recognize the agent as a threat, destroy it, and to further recognize and destroy any of the microorganisms associated with that agent that it may encounter in the future.

Widespread immunity due to vaccination is largely responsible for the worldwide eradication of smallpox and the restriction of diseases such as polio, measles, and tetanus from much of the world.

Production of vaccines

On average, it takes between 12-36 months to manufacture a vaccine before it is ready for distribution. Successful manufacturing of high-quality vaccines requires international standardization of starting materials, production and quality control testing, and the setting of high expectations for regulatory oversight of the entire manufacturing process from start to finish, all while recognizing that this field is in constant change.

Any licensed vaccine is rigorously tested across multiple phases of trials before it is approved for use, and regularly reassessed once it is introduced. Scientists are also constantly monitoring information from several sources for any sign that a vaccine may cause health risks.

Post Vaccination in India

Right after getting vaccinated, you are monitored for 30 minutes for any possible Adverse Event Following Immunisation(AEFI) before leaving.

AEFI is classified into :

·         Minor AEFI : Common and self-limiting reactions.

Eg: pain, swelling at site of injection,fever, irritability,tiredness,dizziness and nausea

·         Severe AEFI: Disabling or rarely life-threatening, no long term problems.

Eg: High fever, allergic reactions

·         Serious AEFI: require inpatient hospitalisation, may cause significant disability

If you develop symptoms at the site,

All vaccinators and supervisors at the site will be trained to provide primary treatment.

If needed, cases are referred to the nearest hospital/health facility and are reported to the appropriate authorities.

COVID-19: Origin and how it became a Pandemic

   COVID-19 is an infection caused by the family of viruses known as Coronaviruses. Coronaviruses are known to cause infections in both humans and animals.

Coronavirus infections range from common cold to severe respiratory or lung infection. COVID-19 is caused by infection with the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus strain. SARS-CoV2 was unknown before the outbreak that started in Wuhan, China in December 2019.

On 11/03/2020, the WHO declared COVID-19 a Pandemic. A pandemic is defined as “an epidemic occurring worldwide, or over a very wide area, crossing international boundaries and usually affecting a large number of people”.

COVID-19 Infection

COVID-19 infection is most commonly associated with symptoms like fever, dry cough and lethargy/ tiredness.

Other symptoms include ache/pain, sore throat, nasal congestion, conjunctivitis, loss of taste or smell, headache , breathing difficulties and diarrhoea in some patients.

Anyone can be infected with COVID-19 irrespective of age or sex or religion or nationality.The elderly and people with underlying health conditions such as diabetes, lung/heart problems, high blood pressure or cancer are at higher risk of developing more symptoms and worsening. These are called co-morbid conditions, the presence of these will make an individual more susceptible to get infected by the virus.

But that does not rule out the possibility of the younger population getting infected. Anyone who develops breathing difficulty/chest pain or loss of speech or movement should be considered as a severe case of infection.

How does COVID-19 infection spread?

The infection usually spreads from an infected person to normal individuals. Droplets or aerosols from the nose and mouth of infected persons generated while coughing, sneezing or speaking are the primary route of spread. These heavy droplets generally tend to sink to the ground quickly but when in close proximity of 1 metre or less, a person can breathe in these droplets and acquire infection.

Similarly touching droplets resting on surfaces of doorknobs, tables, handrails followed by touching or rubbing eyes, nose or mouth can result in acquiring the infection

Testing of COVID-19

It is recommended that people with symptoms undergo testing. We have an antigen and RT PCR test currently available in our medical field of expertise. The RT PCR test is a global standard system, it is costly(varies from Rs.500-1500 in various states) and the result is accurate ,but time-consuming (approx. 24 hours). It tests for viral RNA presence and Virus genetic material may be detected.

The Antigen tests (cost varies from Rs.150 to Rs.300) check the presence of protein, the accuracy is lesser as compared to RT PCR. It is an easily accessible test. The virus particle is detected. For checking antibodies present, a blood sample is taken and if the virus enters a person's body, it will take around 7 – 8 days to get this antibody test back positive.

Our Immediate future with COVID-19.

In the current scenario, COVID-19 cases are increasing which has raised red flags across general public and government officials. It is also essential for us to understand the possibility of the disease persisting for a longer duration than expected.

Moreover, the COVID infection has long-term health effects which needs to be studied and managed.

Therefore public has to come forward and partner with the local government bodies to create an efficient system to fight this disease.

Information is the best weapon we have to fight the virus. It is very important that everyone in the public is aware of the best practices to curb the transmission of the virus. Also data relating to the capacity of the healthcare facilities also play a crucial role.Communicating such real-time accurate data of the healthcare capacity within each district/state will

Enable the administration to make effective decisions and policies based on real data.

The awareness that such data creates among the general public will motivate them to comply more strictly with the social distancing norms advocated by the administration.

The million dollar question is 'When will this pandemic end?' but it still remains a question unanswered by all major world bodies or governments across the world, even when multiple vaccines are available and all governments across the globe are engaged in aggressive public vaccination drives.

Keeping this uncertainty in mind, the general public has to make the conscious effort to start living their normal life while fighting this pandemic as just another added task that we face in our daily life.

The first step forward is to create a good public awareness regarding COVID-19, safety precautions to be followed, existing facilities that can be utilized and the proposed plan of action for the future.

A community based approach is essential to fight the impacts of this pandemic as its tentacles have gripped various segments of our daily life including healthcare, economy, education, secure employment, supply of essential requirements,etc.

Every individual will have a role in rebuilding or reinventing methods to revive various sectors/segments of the community. It is time that the citizen, especially the youth step up and partake more in this fight against the virus.

Major challenges during a pandemic:

One of the most significant problems that we still face one year into dealing with the pandemic is the limitation faced by the mainstream healthcare facilities of any state or nation due to the uncertainty in the number of patients.

For example, the overall healthcare infrastructure of Kerala has ~100,000 beds for 330 lakh people in Kerala which is very comfortable during regular times but will fall short during pandemics. This ratio for Kerala is among the best in comparison to other states in the country.

Even with Kerala's sincere efforts from the early stages of the pandemic, we are experiencing an unprecedented surge in the number of Covid positive cases.

To summarise, the three key challenges that we should be prepared for during a pandemic are:

1.Uncontrolled spread of the infection: The uncontrolled spread of infection in the community due to lack of adequate precautions and awareness in the general population.

2.Large volume of patients: Even the most advanced nations across the world fail due to the sheer volume of patients that a pandemic creates in a short period of time. Therefore it is essential to tackle this by preventing an uncontrolled spread.

3.Augmenting our Healthcare Infrastructure to meet the load: Our existing healthcare infrastructure may be inadequate to cater to those who are affected by the pandemic and for regular patients. The healthcare system of any state should be able to absorb the load created by the increased number of sick people so that the system doesn't collapse due to overload.

For example, augmenting the healthcare system for the Coronavirus in Kerala is done by creating Corona First-Line Treatment Centers where community halls/auditoriums etc. are temporarily converted to clinics. This model is explained in detail in subsequent chapters.Ensuring Correct and Prompt Treatment for regular patients. It is important that the healthcare facilities should also be available to other people who might need medical attention for regular diseases like cardiac, kidney, diabetic problems or antenatal care, etc.

Even with the introduction of vaccines, the virus persists to spread rapidly in many parts of the world. Our lack of understanding of the nuances of the virus even after 1 years time, and the rapid rate at which the virus is mutating are all great causes of concern.

 

The highest level of care must be taken in preventing the spread of the infection from one individual to the other.

General Advice

·         Always wear a mask in public places.

·         Limit your movement. The lesser people you interact closely with, the less likely you and the people around you are to being sick.

·         Encourage repeated hand washing. Carry a hand sanitizer and use it wherever soap and water are not available. Wash your hands as soon as you get home. Wash your hands or sanitize before you touch your eye, nose or mouth.

·         Maintain social distancing. Limit contact even while running errands. For example, at the grocery store, do not touch the items unnecessarily. Maintain 1-meter distance from anyone and avoided touching common surfaces like cash counter etc.

·         Respiratory hygiene and cough etiquettes must be observed by all.

·         Cover your mouth and nose with a tissue or your sleeve (not your hands) when you cough or sneeze.

·         Establish a system to ensure proper disposal of masks/tissue papers.

Proper usage and disposal of masks:

During the initial phase, WHO warned us that the common populace using masks could potentially lead to danger. But when the virus started to spread, it has become a norm for the society to be trained on how to use a mask. Now, wearing a mask is a necessity. It helps in decreasing the spread of the disease. While we sneeze, we need to cover our mouth and nose. If someone who is a carrier of the virus sneezes, it could act as a vector and go unnoticed as he or she is asymptomatic. We need to wear a mask to prevent the spread of the virus occurring due to our daily activities and it must be worn properly. The major problem we see nowadays is that people tend to forget the importance of wearing masks and pull their masks away from the nose and mouth. Careless touching of the outer side of the mask should also be avoided.

Proper disposal of used masks and PPE kits:

If it is a cloth mask, boiled water can be used to clean the mask. Surgical masks or N95 masks are not recommended because they are to be used by medical personnel, wherein burning the mask is one way of disposing it. N95 is recommended for aerosols or people who are in contact with those tested positive for COVID-19.

We can only ensure proper waste management if everyone does their part. If we touch an area that people frequently use, we need to wash our hands properly since the probability of getting the disease by touching our eyes and mouth increases. If we are wearing gloves, need to be extremely careful since we need to dispose of it after each use. So the best practice is the use of hand sanitizer.

Hand Hygiene:

One must be extremely careful while washing their hands or while using a hand rub.

The following steps must be followed:-

Home Quarantine:Asymptomatic patients are advised to stay at home.

Clinical eligibility for home quarantine

·         The patient is covid postive by any of the confirmatory tests.

·         The patient is asymptomatic.

·         The patient does not have any other health conditions.

·         Psychologically fit and willing for room isolation.

·         If patient is less than 12 years of age, a guardian may accompany the child.

Social eligibility criteria for home quarantine

·         The house has adequate road access and communication facility.

·         Facility for room isolation with attached bathroom and adequate ventilation.

·         The Covid positive patient should not come in contact with another vulnerable individual.

·         An adult healthy individual should be willing to act as a caretaker .

·         The family should have adequate community and social support.

Self care

·         A balanced diet.

·         Take warm water and fluids.

·         Adequate rest and sleep for 7-8 hours.

·         Self monitor for symptoms and red flag signs.

·         Maintain a diary of daily symptoms.

·         Promptly respond to any communication from health authorities.

·         The caretaker and the patient should wear a 3 layer mask while interacting for food or other necessities.

·         The patient should not use any other part of the house for any purpose.

·         The patient should not share common household objects.

·         Wash clothes in the bathroom and disinfect all objects in the room daily. Wash hands frequently.

·         Burn general waste. Biodegradable waste should be buried under the soil.

·         If any symptoms start developing , the patient must be moved from the house according to severity.

 

How does our government respond during times of disaster?

In the event of any disaster, the decision making authority must be as decentralised as possible, in order to ensure quick communication and better understanding of the field conditions. This ensures that the decisions made by the authority are quickly implemented on the field.

One of the key decision-making authorities during the time of any disaster is the District Collector.

Every district has rural and urban areas.

Urban areas are divided into Corporations/Municipalities/Panchayats and further divided into divisions.

The rural areas are divided into Blocks, Panchayats and Wards.

Every ward has a Ward Level Team. The official members of this team are:

Ward Member who is an elected representative from the public.

ASHA Worker (Accredited Social Health Activist) is a community health worker who is trained by the Health Department and nominated by the Local Self Government Department (LSGD).

Asha Workers report to the Subcenter (a grassroot level office of the health department for approximately 5000 population) where there is a Junior Health Inspector (JHI) and Junior Public Health Nurse (JPHN). Higher on the hierarchy is the Primary Health Centre (PHC), at Panchayat level, it's called Family Health Centre or Community Health Centre (CHC). These centres have a doctor, a pharmacist and a lab with basic support systems. At Least 10-20 people work here.These centres take care of the public health needs. Above this is the Taluk hospital, and further above is the Jilla or General Hospital. At this level there is usually a separate centre for Women and Children.

The medical colleges that we commonly hear about are part of a separate Medical Education system under the Director of Medical Education (DME). Nursing colleges may be under either the medical education system or under the general hospitals.

We shall read about the structure of the health system in the coming chapters.

Anganwadi Worker is appointed by the Social Justice Department to work for the welfare of Mothers and Children. They are in the payroll of the State Government.Anganwadi workers are monitored by ICDS (Integrated Child Development Services) Supervisor and Child Development Project Officer (CDPO). They have officers at block and the district levels.

 

The Department of Social Welfare has a special wing in the collectorate. Social Security Mission is a program/wing similarly supported by the Social Welfare Department under the State Government Program. They supervise and support the ICDS and CDP. It is ultimately under the control of the Health Minister.

Kudumbashree ADS Chairperson ( Applicable to the state of Kerala )

The objective of Kudumbashree is Poverty Alleviation through Women Empowerment. Women in the community can form their own Self-Help groups(Ayalkootam). An ayalkootam has 10-20 women members. An average ward may have 10-15 such Self-Help Groups (Ayalkootam).

Each Self-Help Group (Ayalkootam) nominates 1 person to form an Area Development Society (ADS) within every ward. The ADS has a Secretary and a Chairperson. The ADS Chairperson will have direct control over all the Self-Help Groups (Ayalkootam) within the ward. This ADS chairperson is also part of the Ward Level Team.

Kudumbashree is an independent society that has its own election mechanism till the Panchayat Level. Above the Ward Level there is CDS (Community Development Society). From each Self Help Group, one nominated person forms the ADS (Area Development Society) at the Ward level and one person from each ADS is nominated to form the CDS.

Although only women from the community form these groups, the benefits reach the whole family. Therefore, out of 400 families in a ward, on an average, at least 100-150 families will be part of this society. Thus, the benefit reaches to at least 30% of the community.

Ward Level Team also includes other stakeholders like:Non Governmental Organisation (NGOs), Community Based Organisations (CBOs) Eg: Rotary club, Lions Club, may even be political organisations, Residents Associations, representatives of churches, temples etc.

These are individuals or groups who are actively involved in various sectors and activities in the community.

The different members of the team may have their own agendas or designated roles but in the time of crisis, they all come together and work with unity.

This team is self-sufficient to a large extent in dealing with any problem within the community without much external support.This team is the most effective body at the field level.They are the ones who ultimately work with the community. Many times, we underestimate the power and effectiveness of the ward level team. Our goal is to empower this team to be more efficient and work alongside them to overcome various challenges.

These four official members of the ward level team belong to different arms or departments of the state and community. The hierarchy of the system must be understood from bottom to top. This will be explained in detail in the coming chapters.