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The Centre is focusing on coronavirus disease (Covid-19) containment and management in non-urban areas, as “a gradual ingress is now being seen in peri-urban, rural and tribal areas as well”, said new detailed guidelines that the Union health ministry released on Sunday, adding that the disease is still predominantly an urban phenomenon.
The focus will be on locally managed care centres and scaling up rapid testing where RT-PCR facilities are not accessible.
“With larger spread of Covid-19 cases in peri-urban, rural and tribal areas, it is important to ensure that community-based services and primary level health infrastructure in these areas are equipped and oriented to manage Covid-19 cases,” the health ministry said in the guidelines.
Gram panchayats have been assigned the prime responsibility of coordinating community action and awareness creation at village level and the block development officer (BDO) at the taluka level. The efforts on the medical care side will be coordinated by the village health, nutrition and sanitation committee (VHSNC) along with the primary health centre and sub-centre.
Surveillance, screening, isolation and referral
The centre has directed states to periodically conduct surveillance for influenza-like illness or severe acute respiratory infections (ILI/SARI) using accredited social health activists (ASHA) , with the help of VHSNCs. Symptomatic cases can be triaged at village level by teleconsultation with the Community Health Officer (CHO), and cases with comorbidity or low oxygen saturation will be sent to higher centres. All subcentres will run an ILI/SARI out patient department for dedicated time slots every week.
Suspected Covid-19 patients will be linked for testing to the health facilities either through rapid antigen testing or by referral of samples to the nearest Covid-19 testing laboratory.
Provision of Rapid Antigen Test (RAT) kits will be made at all public health facilities including sub-centres, health and wellness centres, and primary health centres, and community health officers as well as auxiliary nurse midwives will be trained in performing these tests. The suspected cases will need to be counselled to isolate themselves till test results are available.
“It is important to test symptomatic cases so that positive individuals can be isolated early, and stopped from spreading the infection within the community. ILI and SARI cases need to get tested to rule out Covid-19 as symptoms can be similar,” said Dr GC Khilnani, senior pulmonologist and former head of the pulmonology department, AIIMS, Delhi.
Those asymptomatic but having history of high-risk exposure to Covid-19 patients (exposure of more than 15 minutes without a mask within six-feet distance) need to be quarantined and tested as per the Indian Council of Medical Research (ICMR) protocol.
“Depending upon the intensity of the surge and number of cases, as far as feasible, contact tracing should be done as per the integrated disease surveillance programme’s guidelines.”
Home and community-based isolation
About 80-85% of the Covid-19 positive cases are mild and do not require hospitalisation; these can largely be managed at home. However, there are still conditions laid down for home isolation by the health ministry such as having a separate room and washroom for those isolating, a caretaker available 24×7, among other things that need to be strictly adhered to.
“Of all the positive cases that need hospitalisation, about 5% will develop serious illness needing intensive care. The rest can be managed with oxygen therapy,” said Dr Khilnani.
Each village needs to have an adequate number of pulse oximeters and thermometers, as monitoring of oxygen saturation is important for Covid-19 patients.
“A system of providing 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 an alcohol-based sanitiser,” the guidelines say.
A home Isolation kit will be provided to all such cases which should include required medicines such as paracetamol 500mg for fever, anti-parasitic ivermectin, cough syrup, multivitamins (as prescribed by the treating doctor).
The government has directed peri-urban and rural areas to plan a minimum 30-bed Covid care centre that will offer care for asymptomatic cases with comorbidities or mild cases where home isolation is not feasible. Family members of a positive case also need to quarantine, and be watchful of symptoms.
The community health officer, auxiliary nurse midwife, or multipurpose health worker will be the nodal person for the Covid care centres from the health sector, and accredited social health activist or anganwadi worker will support them. Qualified Ayush doctors, or final year Ayush students, or final-year BSc nurses can run the care centre, according to the prescribed guidelines.
Tribal Covid care
Tribal areas pose additional challenges and hence require additional focus. “Tribal communities are geographically and socioeconomically relatively segregated and may have poor access to health care. Strengthening community-based management through Gram Sabhas should be taken and they should be involved at every stage of planning and executing Covid-care activities,” said the guidelines, adding that there needs to be integration of Covid care with mobile medical units under the national health mission in tribal areas.