Coronavirus

Operational Considerations for Community Isolation Centers for COVID-19 in Low-Resource Settings

The coronavirus disease 2019 (COVID-19) pandemic has presented numerous challenges to health systems, including large numbers of patients with COVID-19 that can overwhelm health facilities and staff. The World Health Organization (WHO) estimates that about 80% of people with COVID-19 have mild or moderate symptoms1 [1]. Treatment for mildly to moderately ill patients may not…

The coronavirus disease 2019 (COVID-19) pandemic has presented numerous challenges to health systems, including large numbers of patients with COVID-19 that can overwhelm health facilities and staff. The World Health Organization (WHO) estimates that about 80% of people with COVID-19 have mild or moderate symptoms1 [1]. Treatment for mildly to moderately ill patients may not require hospitalization, but some people may not be able to isolate safely at home, putting household contacts and, in turn, community members at risk of COVID-19 [2, 3]. Isolation shelters, or community isolation centers (CICs), can provide people with mild to moderate symptoms, who are not at increased risk for severe disease, with a safe space to voluntarily2 isolate until they are no longer considered infectious according to Ministry of Health guidelines [1, 2]. Such centers can reduce household transmission and reserve health facility resources for more seriously ill patients.

People with increased risk for severe disease or severe symptoms should seek care at a health facility or hospital where advanced care and treatment can be provided, if beds are available. If no hospital beds are available, it is preferable for these people to be isolated in a CIC rather than staying at home. People with mild or moderate illness who have been tested and are awaiting a diagnosis should isolate at home until they know their status to avoid becoming infected from other patients at a CIC. However, in cases where safely isolating at home is not possible, people who are awaiting a diagnosis may isolate in a CIC. CICs should ensure that people with suspected COVID-19 (either awaiting test results or unable to be tested due to lack of tests) and those with confirmed cases are placed in separate areas.

This document provides operational considerations for CDC Country Offices, Ministries of Health, and partners about establishing and operating CICs for people with suspected or confirmed COVID-19 who are remaining in the CIC voluntarily, and ensuring that people in CICs are safe and have access to adequate healthcare, food, water, sanitation, and hygiene products and services. It is intended for non-US settings. While this document is most relevant for low-resource settings, it may also be applicable to other settings.

Guiding principles:

  • Each community is unique, and CDC Country Offices, Ministries of Health, and partners may wish to consider local context, local health system capacity, and other factors which may preclude people being able to isolate safely at home.
  • CICs may be implemented at any time, regardless of the level of community transmission, based on guidance from public health officials, and may be scaled up or down as needed.
  • While specific considerations may vary by country and location within a country, locating CICs close to the community they are intended to serve may facilitate support from patients’ families and encourage use of these centers.

Footnotes

  1. Mild illness may include: uncomplicated upper respiratory tract viral infection symptoms such as fever, fatigue, cough (with or without sputum production), anorexia, malaise, muscle pain, sore throat, dyspnea, nasal congestion, or headache. Rarely, patients may also present with diarrhea, nausea, and vomiting.
  2. Considerations regarding involuntary quarantine can be found hereexternal icon: World Health Organization, Considerations for quarantine of individuals in the context of containment for coronavirus disease (COVID-19), Interim Guidance, March 19, 2020

Community Engagement

Establishing connections at the community level in the early stages of planning may facilitate adequate resources, community buy-in, and support, which may help ensure that operations are sustainable. Arrangements and organization of CICs may vary according to the local context, so local adaptations should be considered.

CDC Country Offices, Ministries of Health, and partners may wish to consider setting up a community advisory board focused on COVID-19 planning and response early in the planning process. This group may include:

  • Local, state, provincial, or regional health departments
  • Local government and community leaders
  • Healthcare workers
  • Religious leaders
  • Traditional healers
  • Emergency management
  • Law enforcement
  • Nonprofit organizations

Collaboration with the community advisory board may help to identify sites (e.g., schools, hotels, gymnasiums, convention centers, other large covered structures) that can be converted to CICs to safely isolate and manage people with mild or moderate COVID-19. A community advisory board can help draft plans to ensure that the CICs will be safe and secure, appropriately staffed, and stocked with the necessary supplies. These advisory boards can continue to meet to address any challenges or issues in the implementation and use of CICs, make operational decisions, and provide advice as needed.

Depending on the specific setting, the community advisory board may prefer to set up fewer, larger CICs, as this will likely be easier to manage than many smaller CICs and require fewer staff members to run. Rural areas may require a larger number of smaller CICs to ensure that facilities are close to the communities they serve, so that patients’ families can help provide support. Densely populated settlements and displaced persons camps may require multiple, smaller CICs, as no suitable, larger spaces may exist. Security may be of particular concern in these areas, and facilities should consider employing a full-time guard to ensure safety of patients and staff.

Establishing a Community

The physical set-up of a CIC takes time, planning, and specific resources to meet the needs of both patients and staff. A variety of settings can be adapted to support a CIC, including a hotel, school, church, or other area able to host groups of people; the size of space needed will depend on the size of the community the CIC is meant to support and the number of active COVID-19 cases in the community [3]. If no suitable buildings exist, it may be necessary to use a tent, construct one, or convert shipping containers to be used as a CIC.

Communities should consider locating the CIC next to a COVID-19 designated health facility to facilitate transfer in case a patient develops more severe symptoms or complications. If this is not possible, the community should consider the availability of mobile telephone service to enable the use of telemedicine [1]. Other considerations include: ensuring good access and guaranteed security for those at the CIC, avoiding flood areas or areas with a danger of landslides, and choosing locations with the option to connect to basic services such as water and electricity [2].

In the process of preparing a CIC, some adaptations to the space are needed to reduce the risk of spread of SARS-CoV-2 (the virus that causes COVID-19) among staff, patients, and visitors. These include

  • Designating areas for the following purposes:
    • Intake and patient assessment.
    • Area for staff to don and doff personal protective equipment (PPE; equipment, such as masks, gloves, goggles, gowns designed to protect the wearer from exposure to or contact with infectious agents).
    • Staff respite area separate from the patient care area with a bathroom for staff use only; an area where staff can store personal belongings, take breaks, and eat. PPE should not be worn in this area, but masks should be worn whenever possible. If more than one staff member is using the area, there should be at least 2 meter distance between staff.
    • Patient care area or rooms with access to patient bathrooms/shower areas.
    • If the facility has shared rooms, consider a private changing area for patients next to the bathrooms, or ensure that the bathrooms are big enough to allow patients to change.
    • Designated area in the patient care area where staff monitor patients and document key vital signs; depending on the size of the CIC, it may be reasonable to use the same area for intake and routine monitoring.
    • Clean supply storage area.
    • Dirty utility area.
  • Using physical barriers to protect staff who will interact with patients. For example, placing an additional table between staff and patients at reception or marking the ground with tape may help maintain a distance of at least 2 meters between them. Clear plastic sheeting can be used to separate areas for staff and patients, allowing staff to provide oversight but preserving PPE.
  • Patient housing areas
    • Women and men should have separate rooms, while children/families should either be housed in private rooms (one per family) or a third room that is only for mixed gender families, with at least 2 meters of space between family units.
    • In shared spaces, keep mats/beds of people who are not part of a family unit at least 2 meters apart [2].
    • Patients can be housed in individual rooms, if that is an If individual rooms are not available, multiple patients can be housed in a large, well-ventilated room [4].
    • If limited individual rooms are available, specific considerations should be given to placing patients with suspected COVID-19 (i.e., never tested or waiting on test results) or families in individual rooms.
    • If patients with suspected COVID-19 (i.e., never tested or waiting on test results) are admitted to the facility, they should be housed in areas that are physically separated from confirmed cases (and ideally in individual rooms), and keep 2 meters distance between themselves and other patients.
  • Ensuring adequate potable water (25 liters/patient per day).
  • Ensuring adequate toilet facilities.
    • One per 20 patients, with at least one for females and one for males, in addition to a designated staff toilet.
    • Toilets have convenient handwashing facilities close by.
    • Toilets are easily accessible (i.e., no more than 30 meters from all users).
    • There is a cleaning and maintenance routine in operation that ensures that clean and functioning toilets are available at all times [5].

community isolation layout plan as described in text

Possible layout for Community Isolation Shelter. If confirmed female or male cases come through patient entrance, go directly to triage. If suspected female or male cases come through staff entrance, go to directly to triage, then PPE donning/doffing.

Developing a Staffing Plan

As these facilities are not intended to provide care for severely ill patients, the staff are there primarily to ensure the orderly functioning of the center and triage patients. A staffing plan for a CIC may include patient care and, where applicable, administrative, cleaning staff, and food preparation staff; the number of staff will depend on resources and the size of the facility/ intended number of patients. Having patient care staff with at least some medical training (e.g., nurses, nursing assistants, or community health workers) onsite to perform patient assessments may be beneficial. If these are not available, consider training community volunteers in the correct, and appropriate use of PPE, and assessment of patients.

Additional considerations include:

  • Include at least one person with infection prevention and control (IPC) training who is regularly available to address questions and concerns, and provide training for staff.
  • Develop a plan to monitor for infectious diseases (e.g., infectious diarrhea) and to provide regular cleaning and disinfection of the facility (see table).
  • While the number of staff required at any given time may depend on the capacity of the CIC, consider having at least one staff member available at the CIC 24 hours per day to perform intake of patients, monitor patients, and ensure patient safety.
  • While one staff member may be enough to manage the CIC, having two staff present at all times may be beneficial.
  • The staffing plan may need to take into account that staff members may need to take sick days or emergency leave for other reasons. In addition to at least one staff to provide oversight and assessment of patients, depending on the setting, it may be prudent to have a guard to ensure that the patients and staff are safe.

Isolation center, 3 health workers, 1 with fever not allowed

Image of a community isolation center and 3 workers; one worker has a fever and should not report to the center for work.

Flexible and non-punitive sick leave policies for staff/employees will ensure that people do not present to work with illness, helping to maintain the health of the overall workforce. Developing a written protocol/ log for identifying, monitoring, and reporting COVID-19 among staff may be useful. The following reporting protocol may be considered.

  • All staff must self-assess for fever and/or a defined set of COVID-19 symptoms [6]. If fever or respiratory symptoms are present, staff should:
    • Remotely report this information to their supervisor.
    • Be provided with immediate medical assessment and follow-up actions.
    • Determine with the supervisor whether they should report to work, depending on whether they are in contact with only confirmed cases, how ill they are, and whether they feel comfortable coming to work (ensuring that they are not penalized for deciding NOT to come to work).

Develop a procedure and inform staff who to contact if they have a work-place exposure or become ill, and ensure that there is a process in place for reporting staff exposure and infections to the authority responsible for operating the CIC and the Ministry of Health.

Supplies

The following supplies should be considered when setting up a community care center:

  • Bedding: Cots, mats, etc., depending upon what is most available and acceptable in the local context. Ideally, cots, mats, or mattresses will be covered in plastic sheeting or covering to enable easy cleaning and disinfecting or laundering between patients [7].
  • Bed linens: depending on the local context, these may be supplied by the CIC, or patients may be asked to bring their own sheets/blankets.
    • If supplied by the CIC, consider a plan for laundering these properly between patients. Upon discharge or if linens become soiled, patients may be asked to place linens in a clean laundry bag. Linens should be washed with regular laundry soap and water or machine-washed at 60–90 °C (140–194 °F) with common household detergent, and dried thoroughly [3].
    • If staff wash patient bed linens, they should do so wearing gloves and protective clothing (e.g., plastic aprons) [3].
  • Medicine: CICs should not be caring for patients with severe disease or multiple comorbidities, thus should not be expected to supply a full range of medications. However, CICs should consider having a supply of anti-pyretics (paracetamol/acetaminophen, ibuprofen) and oral rehydration solution. Patients requiring more advanced medical management should be referred to a healthcare facility.
  • Food: The CIC should ensure that patients have enough food; this may entail having food prepared at the CIC, having food delivered from outside, or having patients’ families bring food to the Food should be dropped off outside the facility and picked up by staff to limit visitors entering the facility. Use disposable food service items, including utensils and dishes, if possible. If disposable items are not feasible or desirable, ensure that all non-disposable food service items are handled with gloves and washed with dish soap and hot water or in a dishwasher, or having each patient keep their own dedicated plate and utensil, which they could wash for themselves.
    • Consider having pre-packaged boxes or bags for each patient and avoiding any self-serve food or drink options.
  • Water: Provision of potable drinking water (25 liters/patient per day) at the facility for cooking, cleaning, bathing, and drinking must be assured; this may require procuring water jugs and purifying tablets.
  • Pulse oximetry: Consider having at least one pulse oximetry machine available in each facility.
  • Oxygen: All facilities should consider having oxygen cylinders and single-use nasal cannula tubing on site; this is especially important in facilities which are not located near a health facility. The amount of equipment should reflect the needs in the population seeking care at the facility, which may vary based on sociodemographic factors; as a starting point, CICs could consider ensuring sufficient equipment to allow for 5%-10% of patients to be using oxygen at any given time. However, oxygen use in the facility should be monitored and scaled up as needed. Ensure there is a strategy for maintaining and refilling the oxygen cylinders. Patients receiving oxygen therapy should be monitored every 4-6 hours and oxygen saturation and respiratory rate documented. Patients should be instructed in the safe use of oxygen.
    • Facilities which have oxygen should not allow smoking or lighting matches/fire in patient care areas.
  • Automatic blood pressure monitors: Where possible, consider having 1-2 automatic blood pressure monitors.
  • Personal protective equipment (PPE)pdf iconexternal icon: Ensure medical masks, face shields/goggles, gloves, and gowns/aprons are available for staff and volunteers. If feasible, medical masks should be available for patients.
  • Masks: If it’s not feasible to supply enough masks for patient use, consider providing at least two masks meeting WHO standards [8] for each patient on entry to the facility; masks are not PPE but can be used for source control.
  • IPC/cleaning/sanitation supplies: An adequate supply of alcohol-based hand sanitizer, soap and paper towels, tissues, no-touch trash cans, personal hygiene supplies, disinfectantsexternal icon, mops, buckets and other cleaning supplies (e.g., detergent, cloths, spray bottles, gloves) should be planned.
  • Personal hygiene products: While patients should be expected to bring the personal supplies they need for a presumed 14-day stay, a small supply of personal hygiene products should be available at the CIC to provide to people who do not arrive with such supplies, including toothbrushes, soap, and sanitary napkins.

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