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POSITION STATEMENT ON DE-ISOLATION OR DISCHARGE FROM COVID 19 PATHWAY, JUNE 2020, GHANA

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Ghana’s current position on discharge of confirmed COVID-19 cases was based on the Interim WHO guideline published in March 20201, which placed premium on the test- based strategy for discontinuing transmission-based precautions thus a patient was discharged after obtaining 2 negative PCR tests at least 24 hours apart.  

This strategy initially was adequate, however with the increase in the number of cases, currently more than 10,000 cases itbrought to the fore some challenges namely:

Rising cost in testing, based on the current strategy before any patient is discharged, the individual on the average must undergo 3 different PCR tests.
Increasing workload with associated delay in transmission of results has led to the clogging of isolation and treatment centers with patients who are healthy and only waiting for lab results. This has resulted in rising maintenance costs with respect to feeding.
The increasing numbers of healthy patients being kept in these centers have led to these patients agitating to be discharged from the centers, leading to many unpleasant scenes across the country.

Judging from the above there is a need to re- think our strategy since the status quo is untenable.

COVID 19 disease characteristics has been evolving rapidly. New data from other studies have led to new insights to the management of this disease. New evidence on viral shedding and clinical presentations have led to the revision of many guidelines from several countries.

The WHO on the 27th of My 2020, released a new Clinical management  guide2 modifying the discharge criteria. The revised WHO discharge criteria combines both the time based and symptom based strategies. Specifically, for cases exhibiting symptoms discharge after a period of time of being symptom free and for those not showing any symptoms, a period of time after initial test was done.

The new recommendation from WHO:

Discontinue transmission-based precautions (DE-ISOLATE) andrelease from the COVID-19 care pathway as follows:

For symptomatic patients: 10 days after symptom onset, plus at least 3 days without symptoms (without fever and respiratory symptoms).

• For asymptomatic patients: 10 days after initial positive test

NEW EVIDENCE:

Most patients with mild COVID-19 infection continue to shed SARS-CoV-2 from their upper airways for approximately 7-12 days3,4.The duration of shedding is longer in severe cases,though in both mild and severe cases, significant variation is seen3,5.

Viral shedding does not necessarily equate to infectiousness,however. Viral shedding may decline to a level below the infectious threshold before it ceases completely, and/or non-viable virus may be shed. In a small cohort of mild COVID-19 cases from Germany (n=9), viral loads and viral cultures were performed on a variety of specimens simultaneously6.

The virus was readily culturable from specimens taken during the first week of symptoms, but no positive cultures were obtained from samples taken after day 8. Importantly, this was despite ongoing high viral loads being detected at the time. The authors estimated that there would be a <5% chance ofsuccessful culture by day 10.

This work aligns with epidemiological modelling which suggests that infectiousness likely peaks near to the onset of symptoms, and falls rapidly over the course of a week thereafter7,8.

While the duration of viral shedding1 by PCR may extend to a month and sometimes longer for a small group of patients, it is important to note that viral RNA detection by PCR does not equate to infectiousness or viable virus.

Unpublished data from the first 146 recovered COVID 19 patients in two centers in Accra found that the average time to viral clearance for most of the patients was 14 days.

At a special meeting in Kumasi, of all 16 Regional Directors of Health Service, members of the National Case Management team, Head of the National Public Health Reference and with inputs from other experts, we deliberation to arrive at a proposal on De-isolation or Discharge in the context of Ghana.

PROPOSAL:

Based on the above, in Ghana

THE FOLLOWING SHALL APPLY FOR DE-ISOLATION FOR ALL LABORATORY CONFIRMED COVID 19 PATIENTS

A. ASYMPTOMATIC

DE-ISOLATE14 days after initial positive test. (datesample was taken).

B. SYMPTOMATIC

DE-ISOLATE14 days after symptom onset, plus at least 3 days without symptoms.

Point to Note:

A repeat PCR test is no longer necessary for de-isolation.

Patients after de-isolation are to be reviewed at LEAST TWICE before finally discharged from care.

Full recovery may take several weeks even after de-isolation

References

1. WHO. interim clinical management of suspected SARI  March 2020.

2. Clinical management of suspected or confirmed COVID-19 disease Version 4 (18 th May 2020).

3. Young BE, Ong SWX, Kalimuddin S, Low JG, Tan SY, Loh J, et al. Epidemiologic Features and Clinical Course of Patients Infected with SARS-CoV-2 in Singapore. JAMA – J Am Med Assoc. 2020 Apr 21;323(15):1488–94.

4. Liu Y, Yan LM, Wan L, Xiang TX, Le A, Liu JM, et al. Viral dynamics in mild and severe cases of COVID-19. Vol. 20, The Lancet Infectious Diseases. Lancet Publishing Group; 2020. p. 656–7.

5. Zhou F, Yu T, Du R, Fan G, Liu Y, Liu Z, et al. Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study. Lancet. 2020 Mar 28;395(10229):1054–62.

6. Wölfel R, Corman VM, Guggemos W, Seilmaier M, Zange S, Müller MA, et al. Virological assessment of hospitalized patients with COVID-2019. Nature. 2020 May 28;581(7809):465–9.

7. He X, Lau EHY, Wu P, Deng X, Wang J, Hao X, et al. Temporal dynamics in viral shedding and transmissibility of COVID-19. Nat Med. 2020 May 1;26(5):672–5.

8. Yen MY, Schwartz J, King CC, Lee CM, Hsueh PR. Recommendations for protecting against and mitigating the COVID-19 pandemic in long-term care facilities. Vol. 53, Journal of Microbiology, Immunology and Infection. Elsevier Ltd; 2020. p. 447–53.

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