Faqs About COVID-19 Prevention and Treatment

FOREWORD

The year of 2020 began with an unexpected crisis, ex- posing humankind to a common enemy – the novel coronavirus (SARS-CoV-2). Taking this opportunity, we would like to pay our tribute to all the healthcare workers around the globe who have devoted themselves to saving the patients despite all odds.

As a designated hospital for treating patients with COV- ID-19, The Fourth Affiliated Hospital, Zhejiang University School of Medicine(ZJU4H) is also part of the effort in lending strengths to people in need, especially in sharing our knowledge and experience with the healthcare workers who are confronting this new virus for the first time as we did.

Based on our experience in preventing and containing the epidemic, ZJU4H brought alive the COVID-19 Consulting Platform at our International Telemedicine Center on March 13th. As of now, we have hosted 11 video conferences with the healthcare staff from UAE, India, Egypt, Iran, Bosnia and Herzegovina, Jordan, Iraq, Columbia, Chile, and Argentina. More than 300 questions raised by our international colleagues have been answered during the video conferences. This handbook is a collection of those FAQs to share with the readers our experience because we believe that the most pow- erful weapon to overcome this pandemic is cooperation rather than isolation. MESSAGE FROM THE PRESIDENT

The virus knows no borders and the epidemic knows no races. Only through solidarity and cooperation can the international community overcome the epidemic and safeguard the common homeland of mankind.

At present, the epidemic is still spreading all over the world, with increasing uncertainties and complexities intertwined with other traditional and non-traditional security issues. The only certain fact is that the nations of the world share a common destiny. The only correct approach is to build a community of common health Dr. XU Jian for mankind as a concrete practice of global health cooperation to implement the vision of building a President of ZJU4H community with a shared future for mankind.

Since the outbreak of the epidemic, ZJU4H has been one part of the efforts in offering sincere help to people in need, especially in sharing knowledge and experience with the healthcare workers from all over the world who are also confronted with this new virus. We have been working to keep the world posted on the latest information about the disease.

In this joint fight against the epidemic, cooperation is the practical weapon. We hope that this handbook can be useful, and we thank our medical fellows who have contributed to this handbook.

We also welcome valuable feedback and advice from health professionals worldwide. Keep up the fight and we will win. CONTENT

Part One Patient Management / 2

Part Two Staff Management / 9

Part Three Diagnosis / 12

Part Four Treatment Protocol / 16

Part Five Imaging Examination / 21

Part Six Nucleic Acid Test / 22

Part Seven Hospital Infection Control / 25 3.As the human-to-human transmission human-to-human the 3.As transmission should nasal of the virus is confirmed, with on all patients be taken swabs and lower symptoms upper respiratory tract infection?respiratory historyA: Epidemiological CT and chest particularly are scan important. If a patient or findings epidemiological positive has his/her chest CT suggestive scan is highly should be performed. RT-PCR of COVID-19, more are tests RT-PCR such patients, For than nasal sputum samples to sensitive swabs. when a patient auscultate do we 4. How suit? the Hazmat wearing A: It be particularly could to challenging So, in those scenarios. use a stethoscope perform seldom we on those auscultation If necessary it was certainpatients. for cas- stethoscope. use a wireless would we es, -

2. How to isolate suspected cases right suspected cases right isolate to 2. How entry of point the they that so from area waiting the same not share would with other patients? for screened be should patients All A: history, epidemiological temperature, the at of COVID-19 and clinical features - and res with fever Patients area. screening triaged to be should piratory symptoms should be located which Clinic, the Fever waiting The building. main the from away Clinic should be divided in the Fever area with patients separating areas, two into the findings from epidemiological positive others. care staff screen all patients at the points at the points all patients staff screen care of entry? the at be screened should patients A: All patients All entry of points nurses. by TOCC for should be screened and visitors and cluster, occupation, history, (travel Individuals contact) and temperature. positive or with fever who presented findings should be then triaged to TOCC Samples should be taken Clinic. the Fever RT-PCR the suspected for patients from reaction) chain tests polymerase (real-time area in the designated on the coronavirus to It better be Clinic. would Fever the in experience clinical with professionals have all the patients screen such as nurses to of entry. the points at and visitors 1. How should we triage the patients the patients triage should we 1. How sus- identify to the hospital to coming health have pected we Should cases?

Patient Management Patient PartOne

FAQs about COVID-19 2 5. Individuals who have traveled back 8. How do you manage the patients who from other places are suggested to fol- have recovered? low self-quarantine at home, but they would go out once their swab results A: We would follow up on their conditions have come out negative before the in the first, the second, and the fourth quarantine period is due. Do we have to week after they have been discharged admit all suspected cases? Is home quar- from the hospital. Specific tests that we antine safe for such cases? would run include complete blood cell counts and biochemistry tests, and RT-PCR A: The swab tests may produce false-neg- tests on respiratory tract specimens. Be- ative results. Therefore, with only one neg- sides, a chest CT scan might be reviewed ative result, we would still advise them to according to the patients’ conditions. stay at home until the 14-days quarantine is due. 9. Do we have to assume that all patients are potentially infected, even if they 6. When should further assessment be show up in the ER with a broken leg or performed on the individuals under traumatic brain injury (TBI)? home quarantine? A: We don’t think so. However, strict A: If they started to show fever or respira- screening is necessary. We screen all ER tory symptoms, they should be further as- patients for TOCC (travel history/occupa- sessed. But for close contact, he/she must tion/contact/cluster). It is a rigid policy. A monitor himself/herself closely at home. patient is identified as a suspected case if he/she shows positive epidemiological history or has a chest CT scan highly sug- 7. In our setup, an individual is identified gestive of COVID-19. as a suspected case if he/she has either positive travel history in the past 14 days or contact exposure to a COVID-19 patient. For such cases, we would send samples for RT-PCR tests and quarantine them at home. Can they resume their work and other social activities if the test results come back negative? Or do they remain under quarantine for 2 weeks?

A: A negative RT-PCR result is not the exclusion criterion for COVID-19. All suspected cases should be quarantined for 2 weeks despite their RT-PCR results. PAGE

3 - - vent physical contact with other family contact with other family physical vent they develop Once 14 days. members for or if or respiratory tract symptoms, fever of the features their chest images show RT-PCR they should receive COVID-19, re all suspected cases are Currently, tests. tests. RT-PCR have to quired not are we that things the are What 13. think necessary? but you doing, is no medication There is new. A: COVID-19 - avail vaccine validated or effective proven isolation and Quarantine now. right able slow to measures effective most the are would Ouradvice its transmission. down confirmed/suspected the identify to be them cases as early as possible and isolate the Meanwhile, the communities. from historyepidemiological of the residents health their and be investigated, should should be managed on the conditions transportation Public community level. crowds cause may that and gatherings Last but not least, should be suspended. home and at stay people to encourage health conditions. their own monitor 12. Concerning the individuals who are individuals who are the 12. Concerning don’t we be quarantined, to required capacityconductthe RT-PCR to have Is it moment. this on all of them at tests RT- an without home them send to safe PCR test? prevent to way is the best A: Isolation Intransmission. China, such individuals sites designated the to quarantined are being before quarantine centralized for available no bed were If there home. sent send would we sites, quarantine in those pre to required are But they them home. - - A: We suggest individuals with positive positive suggest individuals with We A: historyepidemiological (travel/residence history- with con in the communities to contactexposure close or firmedcases home, at be quarantined cases) confirmed suspectedand that cases be quarantined epi Individuals positive with hospitals. in 11. Who else should be quarantined else should be quarantined Who 11. apart travelers? from essary. - and/or respira fever history, demiological tory and chest images tract symptoms, suggesting COVID-19. A: We would admit such cases if there are are cases if there admit such would We A: Otherwise, send still open beds. would we be strictly to But they have them home. closely by and monitored quarantined they started Once develop to themselves. be nec would hospitalization symptoms, 10. If a confirmed COVID-19 with patient 10. If confirmed a hospital, your came to mild symptoms send him/her back home or ad- do you hospital? your mit him/her to

FAQs about COVID-19 4 14. What is your interpretation of the sudden flattening of the curve in China?

A: In China, most of the confirmed cases were in Wuhan. After Wuhan was locked down, the government initiated the action to identify as many confirmed and suspected cases as possible on the community level. At the peak of the outbreak, the case number went beyond the capacity of all hospitals combined in Wuhan. In response to that, the local government built 16 makeshift hospitals to manage mild and moderate cases. In this way, they were able to isolate the confirmed cases from the local communities and treat them according to the established guidelines. Thanks to the thorough prevention and strict control efforts, the epidemic was soon brought under control in China.

15. When should we perform the RT-PCR tests on suspected cases?

A: As early as possible because we would like to identify and isolate the infected individuals in the earliest stage. If possible, we would suggest two RT-PCR tests. Any individual with a negative result for the first test should receive a second test after 24 hours. If an individual has two negative RT-PCR results and shows no clinical features, then he/she can be ruled out and discharged from the hospital. Those cases that cannot be ruled out because of their clinical manifestations should receive further RT-PCR tests until they can be excluded or confirmed.

16. When we send patients home, for how many days should they stay at home?

A: At least 14 days. And they should prevent physical contact with other family members. PAGE

5 - - - - - In our hospital, we set up the exclusive one-way access at the entrance of the Outpa- the entrance at one-way access up the exclusive set In we our hospital, ： tient Department. The nurses would screen the outpatient visitors for temperature, epide temperature, for visitors the outpatient screen nurses would The Department.tient suspected and makeshift or facilities, hospitals in isolated are cases In A: confirmed China, for the Clinical Guidance staff follows healthcare The in hospitals. quarantined cases are Close contacts and and treatment. diagnosis in China for published Treatment COVID-19 quar are in the past 14 days areas affected history the severely to individuals with a travel 18. How should we manage the outpatients with respiratory symptoms during the coro symptoms with respiratory manage the outpatients should we 18. How A adopt? we should protocols kind of quarantine What 19. ing relevant features. ing relevant pandemic? navirus with respirato Patients area. the screening at and clinical manifestations history, miological the Fever to history epidemiological transferred should be ry and fever/positive symptoms - epidemiologi positive or fever a not have did Ifsymptoms respiratory with a patient Clinic. room. consultation him/her in a regular receive would physician the respiratory cal history, the monitor workers Healthcare service or community healthcare in hotels antined centers. individual Any 14 days. is of quarantine duration The of those individuals. health conditions period should be transferred during the quarantine symptoms fever/respiratory who shows Clinic. Fever the to A: If possible, individuals under quarantine should take RT-PCR tests, especially those who those who especially tests, take RT-PCR should quarantine individuals under A: If possible, chest images indicat or symptoms, fever/respiratory history, epidemiological positive have 17. Should the individuals under quarantine take RT-PCR tests? RT-PCR take quarantine the individuals under 17. Should

FAQs about COVID-19 6 21. In case of massive transmission among children, do we test all febrile children?

A: If possible, you can test all febrile children. For febrile children with positive epidemiological history or other clinical manifestations, the test is necessary. For febrile children with negative epidemio- 20. For mothers with suspected symp- logical history and no other clinical symptoms or a confirmed COVID-19 diagnosis, tom, you may not test them as a routine should the newborn babies be isolated? practice due to the scarcity of resources. If yes, for how long? Should the mothers suspend breastfeeding? If yes, for how long? 22. What is the incubation period in the A: Currently, the US CDC’s advice is to tem- pediatric population? porarily separate newborn infants from mothers who are persons under investi- A: It ranges from 2 to 14 days. In most of gation (PUI) for SARS-CoV-2 or who have the cases, it’s 3-7 days. confirmed COVID-19 diagnosis because of the concern for transmission of SARS- CoV-2 to the infant via respiratory drop- 23. As the pandemic persists, do we need lets. Whether and how to start or continue to test (RT-PCR on throat swabs) all the breastfeeding should be made by the patients having respiratory (upper and mother in coordination with her family lower) symptoms? and health care practitioners.

The US CDC has developed interim guid- A: It is not necessary. If the patients with ance on breastfeeding, recommending respiratory symptoms have a fever or pos- that women who intend to breastfeed and itive epidemiological history, the test can who are temporarily separated from their be considered depending on the availabil- infants express their breastmilk, ideally ity of the resources. However, for patients from a dedicated pump, practice good with respiratory symptoms who do not hand hygiene before and after pumping, have a fever or positive epidemiological and consider having a healthy person feed history and cannot be with respiratory the infant. symptoms who do not have a fever or positive epidemiological history and can- The US CDC advises that women with not be ruled out for COVID-19 due to their COVID-19 who choose to room-in with clinical manifestations (especially imaging their infants and feed them at the breast findings), the test should be done. should practice good hand hygiene and wear a facemask to prevent transmission of the virus to the infant via respiratory droplets during breastfeeding. SARS- CoV-2 has not been isolated from breast milk. PAGE

7 27. Can you explain why the mortality mortality the why explain you Can 27. in China? is low rate mortality The patients of COVID-19 rate A: China. in regions different across varies mortality the our experience, to According with adequate in the regions is lower rate In the early of the stage resources. medical was Wuhan the mortalityepidemic, in rate disproportionately high because of the shortagehigh case number and of med- the mortality Meanwhile, ical resources. low is in other Chinese provinces rate for resources medical of sufficient because cases. fewer people provide do to should we 28.What support?with psychological on education public, the general A: For and control disease prevention infectious patients, hospitalized For is necessary. - and psychologi duringcare compassion Information essential. cal interventions are to way transparency is also an effective panic. and prevent clarify confusion measur- temperature a up set to 29.How ing point? should measuring points Temperature A: hospital the of entrance the at up set be it entrances, several are If there building. keep the main access to is recommended should There viable and close the others. measuring points temperature be several Clinic, Fever such as the areas in different and the inpatient building, the outpatient measuring Every temperature building. access two than more have should point crowds. avoid to routes - - - 25. Is it possible for the incubation peri incubation the for possible it Is 25. started clini- patients develop to A: A few weeks than two after more cal symptoms Up until the virus. to their exposure since period longest incubation the re now, immunity has de think herd 26. Do you than any cases more had many Wuhan A: be more may There other Chinese city. in SARS-CoV-2 immune to people who are whether herd not sure are But we Wuhan. to yet It’s or not. immunity has developed be determined. A: Since the serological markers are just just markers are the serological A: Since it is un- clinical use recently, for proved last. known could antibodies long the how the recovered some cases where had We RT-PCR a positive came back with patients The after they had been discharged. result be understood. to yet specific causes are be the false-neg could One major reason - during Re-in hospitalization. results ative - the be not may virus same the by fection reason. be longer than 2 weeks? od to ported 24 days. was veloped in Wuhan? 24. Can a corona infection provide infection provide a corona 24. Can long-lasting immunity other viral as in re-infection infections? Is immediate possible after the recovery?

FAQs about COVID-19 8 Part Two Staff Management

1. How do healthcare staff protect them- Protection measures for staff’s families can selves and their families? include:

A: Protection measures for healthcare staff 1) one room for one person, if possible; can include: 2) wearing masks when talking to other 1) formulating personal protection guide- family members; lines for healthcare staff according to different regions and different risk levels; 3) washing hands frequently;

2) providing staff training followed by 4) avoiding face-to-face dining with other tests to ensure that they understand how family members; to use personal protective equipment 5) ventilating and cleaning the space fre- (PPE); quently;

3) ensuring that the rules of infection con- 6) avoiding visits, gatherings or dining trol are provided to all staff in the hospital; with other people to minimize the contact checking on the actual implementation by with other people (applicable to both the the managerial staff; healthcare staff and their family mem- 4) monitoring and recording the health bers); conditions of all staff working in the hos- 7) maintaining everyday routine and en- pital, including body temperature, respira- suring adequate nutrition, sufficient sleep, tory symptoms, and travel history; and proper exercise to improve immunity. 5) arranging designated isolation accommodation for the frontline staff working in the isolation wards, and restricting unap- proved activities outside the accommodation facility;

6) performing RT-PCR tests on the staff returning from the affected places before sending them back to work; PAGE

9 Required PPEs Required Disposable surgical cap Disposable surgical mask Disposable surgical uniform Work cap Disposable surgical (N95) respirator Medical protective uniform Work or disposable pr gown Disposable protective medical gown tective gloves Disposable latex shield Goggles or face Shoe covers cap Disposable surgical (N95) respirator Medical protective uniform Work gown Disposable medical protective gloves Double disposable latex shield Goggles or face Shoe cover Level I Level Level II Level Level III Level protection Level of Protection Level Region Fever Clinic Fever Screening & Screening Isolation Ward Isolation

Observation Ward & Observation Ward Shared clinical areas Shared

must undergo strict the staff must undergo ward, or the isolation Clinic working in the Fever A: Before The don and doff PPE. they know to that how ensure to examinations) by (followed training accommodation isolation in the designated should stay areas staff in the isolation frontline of all staff working health conditions The and should not go outside without permission. health mon- staff, the frontline For and documented. in the hospital should be monitored Exposed staff should symptoms. and respiratory on body temperature is required itoring they such as fever, symptoms relevant If any the staff developed home. at be quarantined staff the frontline When tests. RT-PCR by and screened immediately should be isolated at themselves quarantine they should members finish their service areas, in the isolated Clinic in the Fever work other specialists to hospital leadership should coordinate The home. and the observation areas. 3. What is the policy for mass exposure of hospital staff to an extent where quarantine quarantine extent where to an of hospital staff is the policy mass exposure What for 3. the capacity workforce? of the decrease may A: All staff should wear proper personal protective equipment according to the level of risks. of risks. level the to according equipment protective personal proper wear should staff All A: of the full gear. mask instead to a face the PPEs reduce they can rest area, In the staff 2. How can healthcare workers protect themselves while working in the hospital? Do in the hospital? Do while working protect themselves workers can healthcare 2. How don full PPEs? should they When time? full PPEs all the wear to they have

FAQs about COVID-19 10 4. Is any prophylaxis (chloroquine) need- 6. Is daily self-monitoring on health con- ed for doctors after exposure to conditions necessary for the staff? firmed patients? A: Yes. If the staff member develops sus- A: We do not advocate using any medica- pected symptoms of COVID-19 (such as tion as prophylaxis, including chloroquine. fever, cough, sore throat, chest distress, Even if the doctors were exposed to the dyspnea, fatigue, nausea and vomiting, high-risk environment without adequate diarrhea, conjunctivitis, and myalgias), he/ protection, they should monitor their she should go to the nearest hospital or body temperature and clinical symptoms clinic for treatment immediately instead of by themselves for 14 days and receive RT- going to work. PCR tests if possible. 7. What should the staff do before entering the workplace? 5. What should healthcare workers do before returning to work? A: The staff should have their temperature checked and put on a medical mask. Those A: Before returning to work, healthcare whose temperature exceeds 37.5℃ must workers should make sure that they do not enter the workplace and should seek not show suspected symptoms such as medical treatment in a timely manner. fever and cough. The following healthcare workers should be temporarily suspended from work: those who have a recent 8. What should the staff do when taking residential or traveling history in severely an elevator? affected areas of the epidemic, those who have contacted with the COVID-19 pa- A: According to our experience, staff work- tients, and those who have a fever or feel ing on lower floors are encouraged to sick. take the stairs. Those who work on higher floors and have to take the elevators should avoid touching the buttons with bare hands and keep a proper distance from each other. Do not stay in the elevator longer than necessary. Tissue container can be set up next to the elevator so that the users can use tissue to cover their hands when pressing the buttons. Used tissue should be discarded into the gar- bage bin.

9. How can we keep a safe distance?

A: At least one meter should be kept from each other. Staff should avoid visiting other colleagues or talking to each other during working hours. PAGE

11 - - - features are identified as positive; or when as positive; identified are features identified are of the clinical features three risk is when epidemiological as positive not clear. 3. A suspectedcon- as a case is classified of the following firmed case when any criteria is met: or serological etiological detection of the nucleic acid 3.1 Positive assay RT-PCR real-time by of SARS-Cov-2 specimen including expectorat (on any oro ed sputum, nasopharyngeal swab, and blood); urine, stool, pharyngeal swab, evidence genome sequencing Viral 3.2 supporting with SARS- high homology CoV-2; col specimens consideration, safety (For suspectedlected cases or confirmed from virus culture.) for should not be sent detection of serological 3.3 Positive - anti IgG and antibody IgM viral-specific body; of viral-specific increase titration during folds least four at by IgG antibody the baseline period from the convalescent should phase (the results in the acute level caution because with great be interpreted of the possibility false-positive of results). - - - - -

1. What are the tests and investigations and investigations the tests are What 1. COVID-19? can help diagnose that on is based of COVID-19 diagnosis The A: history, epidemiological the individual’s or and etiological clinical manifestations, cri diagnostic The evidence. serological as Chinese hospitals are by adopted teria follows. history1. Epidemiological and its Wuhan in or residence to Travel 1.1 or other communities neighboring areas with reported case(s) within the COVID-19 illness onset; prior to 14 days COVID-19-infect to exposure Contact 1.2 re RT-PCR ed individual(s) (with positive the illness prior to sult) within the 14 days onset; - cases identi onset (2 or more 1.3 Cluster symp and/or respiratory fied with fever in a small-scale area within 2 weeks toms and school class). office, such as home, 2. Clinical features symptoms; and/or respiratory 2.1 Fever of COVID-19 2.2 Radiographic evidence pneumonia; count, cell white 2.3 Normal or reduced lymphocyte count and normalor reduced during early onset. A person is classified as a suspected case epidemio one of the listed when any of the clinical two risks and any logical

Diagnosis Part Three

FAQs about COVID-19 12 2. Can we use a scoring system to diagnose COVID-19 cases?

A: So far, there is no scoring system that has been proposed. COVID-19 can be diagnosed through tests detecting the viral nucleic acid (RT-PCR assay with a positivity rate of 72-95% on lower respiratory tract specimens) and viral-specific antibodies. Thus, the scoring sys- tems may be more useful in areas with a limited capability of testing.

3. What should we do if a patient’s CT scan is highly suggestive of COVID-19, but the RT- PCR result is negative?

A: If COVID-19 was highly suspected according to the patient’s epidemiological history, clinical manifestations, and imaging findings, extra RT-PCR tests are recommended, and lower respiratory tract specimens are preferred for such tests. Nucleic acid tests on stool, urine, or blood samples can also be done. A patient can be diagnosed with COVID-19 once any one of the above tests come back positive. Besides, if the viral-specific IgM and IgG antibodies were tested positive, or the titration of the viral-specific IgG antibody increased by 4 times during the convalescent period from the baseline level, the case can be confirmed as COV- ID-19. (This should be interpreted with great caution because of the possibility of false-positive results.)

4. Are blood work like CBC and CRP useful for screening potential patients for SARS- CoV-2 testing?

A: In the early stage of the disease, the peripheral blood leukocyte count could be normal or decreased, while the lymphocyte count often decreases. In most cases, CRP would show an increase. For patients with normal or decreased WBC and/or lymphocyte count and normal or slightly increased CRP, tests for SARS-CoV-2 and other viral infections such as flu are recommended. Progressive decline in the peripheral blood lymphocyte count and/or progressive increase of CRP are considered to be the warning signs for severe and critically severe COVID-19 cases. A rapid and significantly elevated C-reactive protein level can indicate a potential secondary infection. PAGE

13 - ID-19 with mild to moderate symptoms symptoms ID-19moderate to mild with and signs? had patients COVID-19 InA: cases, most blood cell white normal or decreased and an CRP, normal or increased count, But none of them were ferritin. increased of diagnosis the in predictors specific ad- upon Huang, to According COVID-19. had leucopenia, mission, 25% of patients 30% had leukocytosis, and 45% remained in the normal range. 6. What is the negative predictive values values predictive is the negative What 6. Ferritin and CRP, WBC, serial of (NPVs) COV in excluding respectively, tests, - -

5. Should all patients with flu-like symp with flu-like 5. Should all patients A: The possibility of COVID-19 should should possibility COVID-19 of The A: with primarily in patients be considered and/or respiratory fever newly developed and dyspnea). cough tract (e.g. symptoms in patients It be considered should also tract respiratory illness lower severe with Other consistent cause. clear any without diarrhea, and include myalgias, symptoms with patients All aberrancies. smell or taste to recommended are flu-like symptoms if sufficient on SARS-Cov-2 the test receive available. are medical resources pa- If the capacity is limited, of testing with a higher likelihood of COVID-19 tients in propriety:should be tested in or traveled resided who have Patients a location to within the prior 14 days community transmission was there where of SARS-CoV-2; had close contact who have Patients suspectedor confirmed with a case of including prior days, the 14 in COVID-19 settings. in health care work through Close contact is defined as being within meters) (about two six feet approximately period time of a prolonged for of a patient personal protective while not wearing direct contact (PPE) or having equipment wear not while secretions infectious with toms and negative chest auscultation chest auscultation and negative toms SARS-CoV-2? for findings be tested the line? draw do you Where ing PPE.

FAQs about COVID-19 14 7. To which extend is it possible for a 9. What are the typical symptoms of COVID-19 patient to be asymptomatic? COVID-19?

A: According to the data published by the A: Fever, dry cough, and fatigue are the Chinese Center for Disease Control and main clinical manifestations. Other symp- Prevention, up to 81% of the COVID-19 toms can include nasal obstruction, runny cases were mild cases, who had no sig- nose, sore throat, myalgia, and diarrhea. nificant respiratory symptoms or physical In severe cases, patients could develop signs. dyspnea and/or hypoxemia within one week after onset. Some of them deterio- rated rapidly to acute respiratory distress 8. Is it noticed that COVID-19 cases usu- syndrome (ARDS), septic shock, refractory ally present with florid physical signs metabolic acidosis, coagulation dysfunc- (high-grade fever, diffuse crepitations, tion, and multiple organ failure. It has also and bronchial breaths) despite minimal been noted that some severe patients symptoms? only presented mild-to-moderate-grade fever in the entire course of the disease, A: WHO recommends the use of a dis- and that some even did not develop a fe- posable surgical cap, disposable surgical ver at all. It is fraudulent that some critical mask, work uniform, disposable latex patients were well tolerated to hypoxemia. gloves, or/and disposable isolation clothing, when dealing with patients with COV- Some children and newborns presented ID-19. Chest auscultation was not avail- atypical symptoms, such as vomiting, di- able in this condition, so it was not clear arrhea, and other gastrointestinal discom- whether diffuse crepitations or bronchial forts, or only exhibited drowsiness and breaths could be heard in patients with shortness of breath. minimal symptoms. But it was common in most mild cases (about 81% of all COV- In mild cases, patients only presented low- ID-19 cases) that patients with fever had grade fever and slight fatigue, without no significant respiratory symptoms. evident pneumonia. PAGE

15 - - - 4.What is the latest treatment protocol? treatment is the latest 4.What the manage a case is confirmed, A: Once drug treatment, includes isolation, ment are There and follow-up. monitoring, and mild for of treatment: levels several the majority cases, manage moderate good sleep, is closely monitoring, ment Nevertheless, antiviral diet. and a healthy as probiotics as well antibiotics therapy, if necessary. suggested are asymptomatic treating they are 5. How with medicine? patients They too. put under isolation are They A: intake, energy and rest sufficient obtain Med- every themselves day. and monitor hydroxy chloroquine/ icines of arbidol, Chinese (traditional TCM or chloroquine, recommended. medicine) are - - -

A: Hydroxychloroquine has been suggest A: Hydroxychloroquine - close con for especially ed as prophylaxis, adequate tactswithout staff medical and The equipment). PPEs (personal protective and one must pay yet efficacy is proven of the drug. the side effects to attention 3.Can we use hydroxychloroquine as as hydroxychloroquine use we 3.Can prophylaxis? A: There is no proven prophylaxis, but we but we prophylaxis, proven is no There A: Chi- (traditional TCM try and thymalfasin nese medicine) in our practice. A: Patients have a sufficient rest and en- rest a sufficient have A: Patients Oxygen rooms. supply in isolated ergy as soon as they be given should therapy inter as such therapies antiviral and need, drug is the possible prophylactic 2.What COVID-19? for ment and treatment of COVID-19? and treatment ment ribavirin, lopinavir/ritonavir, arbidol, feron, can be hydroxychloroquine chloroquine/ (traditional TCM also use We prescribed. of meager Chinese medicine) in the face If they all these regimens. for evidence additional care or critically ill, severe are support life and other therapies involves such as glucocorticoids. 1.What are the modalities of manage the modalities are 1.What

Treatment Protocol Treatment Part Four

FAQs about COVID-19 16 6. How do you address new-onset fibro- 8.What experience do you have with cy- sis developed after COVID-19? tokine storm management?

A: Anti-fibrotic and anti-oxidative drugs A: Cytokine storm is linked with MODF can be used per pulmonologist’s recom- (Multiple Organ Dysfunction Failure) mendation, but efficacy remains elusive. and complicated regardless of the cause. Respiratory rehabilitation may be more Though many scientists have made efforts, helpful. there is no specific therapy that could bring the cytokine storm under control. Experts found that cytokines have been linked with the severity of disease, and IL-6 7. There are the indications for intubat- is one of the representations of cytokine ing a patient? storm. High level of IL-6 is an important indication for the use of immunotherapy A: Tracheal intubation is based on disease and glucocorticoids. In addition to drugs, progression, systemic status, and compli- blood purification therapy can also be cation for stable patients with a low oxy- considered to eliminate inflammatory me- genation index (<100 mmHg). For patients diators. Nevertheless, due to inadequate with an oxygenation index less than 150 availability of advanced healthcare tech- mmHg, worsening symptoms of respirato- nology in Yiwu, Zhejiang Province, blood ry distress or multiple organ dysfunction purification therapy remains a knowledge within 1-2 hours after high-flow (60 L/min) but not an experience for us. and high-concentration (> 60%) HFNC oxygen therapy, tracheal intubation should be administered as early as possible. 9.How to oxygenate a hypoxemic patient with limited respiratory reserve when high-flow oxygen positive pressure oxygenation is not available?

A: For patients with significant respiratory distress, they are either severe or critically ill. Oxygen therapy should be provided as soon as possible to maintain oxygen saturation at 93-96% for patients without chronic pulmonary disease and at 88%- 92% for those with chronic type II respiratory failure. HFNC is the first choice. When it is not available, oxygen delivered via a mask, a Venturi or oxygen mask, could be attempted while the patient’s clinical status and blood gas are constantly monitored. Be ready for intubation at any time, and when this is needed, no time should be wasted. PAGE

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A: Most critically ill patients with COVID-19 respond well to prone ventilation, with a rapid rapid a with ventilation, prone to well respond COVID-19 with Most patients A: ill critically as a is recommended ventilation Prone and lung mechanics. oxygenation of improvement man- marked < 150 mmHg or with imaging with a PaO2/FiO2 patients for strategy routine lasts for ventilation prone recommended, As unless otherwiseifestations contraindicated. above maintained is PaO2/FiO2 once weaned is patient The hours each time. than 16 more be attempted may proning Awake 4 hours in the supine position. than more 150 mmHg for oxy impaired with but distressed significantly or intubated been not have who patients for 10.What experience do you have in prone ventilation without ventilatory support? without ventilatory ventilation in prone have do you experience 10.What he/she is ICU, to is admitted a patient plan. Once a step-wise management adopted We A: for with that consistent are principles of treatment The or critically ill. as severe regarded or supportive of the underlying disease, management treatment, critically ill patient: any 11. Management plan, including ICU protocol. 11. Management genation or consolidation in gravity-dependent lung zones on lung images. Each procedure Each procedure on lung images. lung zones in gravity-dependent or consolidation genation on the ef- depending times a day, it several can have and patients least 4 hours, at lasts for fects and tolerance. nutrition support, out enteral gan function and watching support, prevention, complication secondary managed based on the established protocols. for infection. ARDS and shock are and balanced properly benefits and risks are help when the potential may therapy Antiviral activation of inflammatoryresponse the excessive Take duration. a reasonable is used for the Monitor immunotherapy. for be an indication may and cytokine (IL-6) account, level into inflammatory biochemistry, blood factors, urine analysis, blood count, complete for patient towards is the basic step control infection should keep in mind that Everyone and chest CT. and conduct do, to going are you what to PPE according proper namely wearing success, ing hand hygiene.

FAQs about COVID-19 18 12. Does the combination of fever + res- 16.Supplemental therapy? Vitamin C, se- piratory symptoms + radiological signs lenium, zinc? of pneumonia justify antibiotic treatment? A: We do not use vitamin C, selenium, or zinc as supplemental therapy. However, A: We use antibiotics only when the pa- we believe it is necessary to maintain nor- tient is complicated with confirmed or mal serum levels of vitamin C, selenium, suspected bacterial infections, regardless and zinc. of the presence of bacterial infection evidence. 17. Your experience with the use of corticosteroids in the treatment of COVID-19 infection? 13. Azithromycin, yes or no? What is the dose and how long does it last? A: We have used corticosteroids in several patients to inhibit cytokine cascade and A: Without evidence of MP (Mycoplasma to prevent disease progression as early Pneumoniae) or bacterial infection, we do as possible. As shown below, we should not use azithromycin. It is given at 10mg/ avoid using them at a high dose and for kg/d for 3-5days for children. There are a prolonged duration due to concerns also reports of good outcome with com- of adverse reactions and complications. bined azithromycin and chloroquine ther- Methylprednisolone at a dose of 0.75~1.5 apy, but it is not recommended in Chinese mg/kg intravenously once a day (nearly guidelines. 40 mg once or twice a day) is recommended for initial management. However, methylprednisolone at a dose of 40 mg q12h can be considered for patients with 14. Are there any differences in the treat- falling body temperature or significantly ment of COVID-19 children with chronic increased cytokines despite routine doses diseases (eg. asthma and bronchitis)? of steroids. Even methylprednisolone at a Parenteral corticosteroids, yes or no? dose of 40-80 mg q12h is acceptable for critical cases. Patients on corticosteroids A: The treatment principles for chronic are monitored for body temperature, diseases amid COVID-19 are consistent blood oxygen saturation, complete blood with the original treatment principles, and count, C-reactive protein, cytokines, bio- there is no obvious difference. Inhaled chemical profile, and chest CT every 2 to 3 corticosteroids can be used. days as necessary. Methylprednisolone is tapered by half every 3 to 5 days if patients are clinically improved with normal body temperature or lung lesions on CT are 15. Mucolytic drugs? Efficiency? significantly absorbed. Oral methylprednisolone (Medrol) once a day is recommend- A: Patients with sputum can receive mu- ed when the intravenous dose is reduced colytics via intravenous infusion. Though to 20 mg per day. As there is no defined with controversy in the international com- upper limit of duration, some experts have munity, it works according to our experi- suggested stopping corticosteroids when ence. patients are nearly recovered. PAGE

19 - - - 20. What is the dose of chloroquine and and chloroquine of dose the is What 20. the confirmed for hydroxychloroquine infection? coronavirus on adults can be used A: Chloroquine 500 mg bid old (at 18-65 years between ≥ 50 kg those weighted for days seven for days, the first two 500 mg bid for while at for days five the following 500 mg qd for ≤ 50 kg). Hdroxychloro those weighted about 400 mg qd for at quine is prescribed days. ten and chloroquine of dose the is What 20. the confirmed for hydroxychloroquine infection? coronavirus can be used on adults A: Chloroquine 500 mg bid (at old 18-65 years between ≥ 50 kg those weighted for days seven for days, the first two 500 mg bid for while at for days five the following 500 mg qd for ≤ 50 kg). Hdroxychloro those weighted about 400 mg qd for at quine is prescribed days. ten young that the chances are What 21. individual without underlying healthy ARDS? develops comorbidities ItA: inflammatory the on depends re of the patients. sponse and immune status is and IL-10 of IL-6 Monitoring levels the assess the risk of progression helpful to of levels higher The condition. severe a to the higher the risk of ARDS. and IL-10, IL-6 - - - -

18. What is your experience with the the with experience your is What 18. converting (angiotension of ACE use patients enzyme) in COVID-19 inhibitors inhibi ACE Should hypertension? with 19. Is there any difference in treating treating in difference any there Is 19. - 19 com COVID- with women pregnant populations? the other patient to pared the to select medicines according We A: women. pregnant for grading drug safety tablets serve an as Lopinavir/ritonavir and chloroquine option, while favipiravir clin- The contraindicated. are phosphate pneumonia in of COVID-19 ical course the others of is similar to women pregnant the same age. tors be avoided? tors with hyper patients COVID-19 A: Several one of the ACE captopril, on were tension it did not pro show Our data inhibitors. COVID-19 on the effects therapeutic duce do not suggest ACE and we condition, COV option for as a treatment inhibitors ID-19.

FAQs about COVID-19 20 22. When is the use of steroids intravenously justified?

A: We do not use IV steroids routinely. Steroids are used at 1-2 mg/kg/d amid progressive deterioration of oxygenation parameters or imaging manifestation, and excessive inflammatory response.

23. About diet, is there a diet recommended? Is a restrictive diet necessary?

A: Our national guidelines suggest patients should have sufficient energy and fluid intake while we monitor their electrolyte balance to maintain internal environment stability. We do not routinely recommend a restrictive diet.

24. What is the effectiveness of ivermectina as a treatment?

A: A recent in-vitro study from Australia reveals ivermectina may have antiviral effect on SRAS-COV-2, but its efficacy as a treatment for COID-19 need further research.

Part Five Imaging Examination

1.What is the role of CT scan in COVID-19 diagnosis?

A: A positive result of the nucleic acid of SARS-CoV-2 is the gold standard for the diagnosis of COVID-19. However, considering the possibility of false negatives in nucleic acid detection, suspected cases with characteristic manifestations on CT scans can be treated as COV- ID-19 cases even if the nucleic acid test is negative. Such patients are put under isolation and continuous etiological monitoring.

2.Is X-ray useful as a first-line investigation for suspected COVID-19 patients? Should patients with lower respiratory symptoms receive CT directly?

A: As we know, chest CT is more sensitive in detecting mild lesion in lung during the early onset of COVID-19. We recommend chest CT directly for suspected cases in order to isolate the cases earlier when they are waiting for the nucleic acid test reports. X-ray is useful as a first-line investigation for the regular patients with fever or respiratory symptoms but without epidemiological history. PAGE

21 - - six products of antibody tests have been been have tests antibody of products six - Medical the National Prod by approved China, including in ucts Administration and Yingnuote Wanfu, by those produced Boaosaisi. them, some detect Among IgM/ In a antibodies. total IgG while others test consistency total the study, retrospective and a nucleic test an antibody between To 88.03%. was COVID-19 for acid test we unnecessarily, panic creating avoid should be cautious about false-positive re sults from antibody tests. Overall, the de Overall, tests. antibody sults from tection of serum IgM and IgG antibodies and screening is an effective COVID-19 to infection, COVID-19 for tool diagnostic the false-neg to and a viable complement - possibility of nucleic acid tests. ative - - - -

A: In the Chinese clinical guidelines for A: In for the Chinese clinical guidelines se constitutes IgM/IgG specific COVID-19, rological evidence for COVID-19. Recently, Recently, COVID-19. for evidence rological A: In fact, any assay comes with limitations with limitations comes A: In assay fact, any The analytical of sensitivity and specificity. limit the as sensitivityoftenis represented which means the low of detection (LOD), available test serological any 2. Is there COVID-19? for 1. What do we know about the sensitivity do we What 1. and specificity of RT-PCR? could in a specimen that est concentration speci of 95% in ≥ consistently detected be are and interference Cross-reactivity mens. specific of analytical components the two be caused by may results False-positive ity. and with other organisms contamination do in clini- should we What nucleic acids. validity the evaluate to is cal laboratories to ones of kitsthe appropriate and choose the performance evaluate need to We use. it releasing before procedure of the test Laboratories use in a clinical laboratory. for SARS-CoV-2 an improved should develop with compared framework verification methods. molecular diagnostic traditional assessed three have we In our laboratory, types of RNA kits mainly used in China and Additionally, use. chosen the best one for im- to clinical laboratories it is crucial for the quality of SARS- management prove in laboratories especially RNA tests, CoV-2 conditions. with suboptimal operational Nucleic Acid Test PartSix

FAQs about COVID-19 22 4.Is there any rapid assay for COVID-19 screening?

A: In Chinese Clinical Guidance for COV- ID-19 Pneumonia Diagnosis and Treat- ment (7th edition), specific IgM/IgG are considered as serological evidence for COVID-19. However, we had no rapid kits for screening in our hospital. Recently, six kinds of different kits for antibodies test have been approved by the National Medical Products Administration in China, including those produced by Wanfu, Ying- nuote, Boaosaisi, and so on. Among them, 3.What is the accuracy of PCR test? some detect IgM/IgG while the others detect total antibodies. In a retrospective A: RT-PCR may be the most sensitive meth- study, the sensitivity of serum IgM and IgG od for identifying pathogens and has been antibodies to COVID-19 were 70.24% and considered as the gold standard for con- 96.10% respectively and the specificity firming COVID-19. To validate the accuracy were 96.20% and 92.41% respectively. The of an assay, which means the likelihood positive and negative predictive values of a kit in detecting the true-positive pa- of COVID-19 antibodies were 95.63% and tients, one may compare it with the gold 91.03%, respectively, and the positive and standard methods, such as other kits or negative predictive values of COVID-19 nu- sequencing. The accuracy of kits varies as cleic acid test were 100% and 80.61%, re- their performance is different. Some could spectively. As the article showed, the total be as high as 95% or above while others consistency rate of diagnosing COVID-19 may be lower than 80%. PCR test provides infection between antibody tests and evidence for early diagnosis, early isolation nucleic acid test were 88.03%. To avoid of a patient and interruption of the trans- creating unnecessary panic, we should mission chain. All of us try to choose more pay more attention to the false-positive reliable kits for our laboratory by assessing results by antibody tests. Overall, joint de- parameters including accuracy, sensitivity tection of serum IgM and IgG antibodies and specificity. I am sure that staff in the to COVID-19 is an effective screening and clinical laboratory knows how to evaluate diagnostic tool for COVID-19 infection, the analytical performance of candidate and an effective complement to the false kits in handling clinical specimens. At last, negative results to nucleic acid test. If you we could share the brand of the PCR test need these kits, we could provide contact that our lab uses, if you need it. information. PAGE

23 -

A: It is important that samples reach a required level of quality startA: It to level is important with. Because a required COV reach samples that 7.Which site is better in generating accurate results, nasal swab or throat swab, given given swab, or throat nasal swab results, accurate in generating is better site 7.Which equal symptomatology? A: Based on Chinese practice, novel coronavirus RNA testing should be carried RNA testing out in clin- coronavirus novel A: Based on Chinese practice, And of COVID-19. and treatment the diagnosis hospital for of designated ical laboratories Clinical LaboratoryThe is a in our hospital required. was 3 (BSL-3) level protection biosafety three for operation has been in steady CNAS-certiﬁed system and the ISO15189 laboratory, years. 6.What are required for laboratory to provide COVID-19 test result? test COVID-19 provide laboratory to for required are 6.What but only 28% of optimal, sputum samples are tract respiratory ID-19 disease, is a lower False-negative evaluation. a diagnostic sputum for produce able to are patients COVID-19 because they have patients sputum samples of COVID-19 from be generated may results revealed mucus, are lined with jelly-like bronchi difficultyand as the lungs expectoration, in load than 30% (6/10) had a higher viral of nasal swabs 60% in China. Herein, pathologists by the same time in our study. at the same patient of sputum samples (3/10) obtained from Therefore, load in this study. a highest viral samples (1/10) showed Only 10% of the throat used in our hos- respiratory tract that are suggest specimens of sputum and nasal swabs we swabs. throat of instead RNA tests SARS-CoV-2 pital for A: Until now, our laboratory has completed 4,000 SARS-CoV-2 RNA testing. Since the start the Since of testing. RNA SARS-CoV-2 4,000 our laboratory completed has now, Until A: However, the word. around countries has been detected in many the outbreak, SARS-CoV-2 novel of results false negative a bottleneck. remains Generally, the sensitivity of reagents results 40% false negative maybe example, For common. be more may RT-PCR coronavirus earlythe stage at enough sensitive not kits many because were ago, months three existed testing RNA kits SARS-CoV-2 types of reagent for many in China. Now, outbreak of COVID-19 key The China. in Administration Medical Products National the by approved been have the performance characteris- clinical laboratory, is used in a a new test before is that, point testing of verification specificity kits in Good confirmed. and be must procedure of the tics cases. and negative including false positive sensitivity decline the false results, could 5.What is the percentage of false-positive cases by PCR in Hubei or other regions in Chi- of false-positiveother regions PCR in Hubei or cases by is the percentage 5.What na?

FAQs about COVID-19 24 Part Seven Hospital Infection Control

1.What is the protocol in general surgical 2. What changes have you made to the department for coronavirus prevention? OR checklist regarding the coronavirus pandemic? A: We have several suggestions: A: 1) Any patient expecting surgery re- 1) All patients need to receive nucleic acid ceives epidemiological investigation, and antibody test for the novel corona- which includes “Are you from an epidemic virus and CT scan of the lungs before the area? ” , “Do you have any respiratory operation. Patients are counseled to make symptoms, such as fever, cough, sore sure the necessity and emergency of the throat, and weakness during the last 14 operation in question. days? ”, ”Have you been in contact with a diagnosed patient or people from the 2) Surgeries of confirmed or suspected coronavirus epidemic area?” COVID-19 patients are arranged in designated negative pressure room. All the 2) Before each operation, the surgeons, staffs wear level 3 PPE. anesthesiologist and nurses verify the information on the list, including the result 3) Emergency case where it is impossible of coronavirus RNA test, antibody test and to screen the patient immediately (in CT scan of the lungs. life-threatening condition) should be han- dled as COVID-19 patients.

3. What are the rules in handling surgical and medical appliances used on COV- ID-19 patients?

A: Single-use surgical and medical appliances are recommended. For appliances to be reused, they are pretreated, such as being soaked in chloride disinfectant for at least 30 minutes, before being packed in fully closed package and sent to the centralized sterilization supply department (CSSD). In the CSSD, the devices should be treated according to the sequence of disinfection first, then cleaning and finally sterilization. PAGE

25 7.About isolation units in the Emergency units in isolation 7.About the important in how are Room, they only have Because we process? care resource-limited. Very of them. three very units are important isolation The A: and staff, nurses, doctors, protecting in the But if it is not available, other patients. can be used areas independent relatively units. as isolation recommend? kind of PPEs do you 8.What personal A: Our hospital has formulated staff according guidelines for precaution settings: of different the risk levels to - - - -

A: Generally, the medical area is cleaned cleaned is area medical the Generally, A: If the day. a times three disinfected and area the entire case, is a confirmed patient after he or she immediately is disinfected is discharged. - be disin need to area the entire 6.Does has left? afterfected a patient osols. We strictly the pre-ex implement We osols. and all and triageamination process, the fever guided to are with fever patients to admitted are patients Confirmed clinic. and suspect ward, pressure the negative we since in single room, ed cases isolated rooms. pressure negative only three have definedto the risk PPE according use Staff out had any haven’t we So till now, levels. within the hospital. break A: It is an accepted fact that the virus is factA: It the virus is that is an accepted respiratory droplets through transmitted - transmis while aerosol and close contact, sion is plausible in enclosed environment aer viral and concentrated with sustained 5.Is airborne transmission possible from possible from 5.Is airborne transmission experience? your A: It can on whether the material depends be masks can’t example, For be reused. reusable. but goggles are reused, 4. In the case of medical appliance short4. Inappliance of medical the case - as materials reuse it possible to is age, the last resort?

FAQs about COVID-19 26 Region Precaution Level Protective Equipment

Disposable surgical cap Level I Common Clinic Zone Disposable surgical mask protection Scrub

Disposable surgical cap Medical protective mask (N95) Triage Scrub Level II Fever Clinic Disposable isolation gown or medical protective uniform protection Disposable latex gloves Goggles or face shield Shoe cover

Disposable surgical cap Medical protective mask (N95) Observation Ward Level III Scrub Quarantine Ward protection Disposable medical protective uniform Double disposable latex gloves Goggles or face shield Shoe cover

9.When staff provides care to mild and 11. How to disinfect surfaces of objects? severe cases, are 3M suits always required? A: Surfaces of doors and windows, tables and chairs, door handles, taps, sinks, eleva- A: 3M suits are required whenever the tors and the ground should be disinfected healthcare staff comes into contact with with disinfectant (with an active chlorine any confirmed patient. content of 500mg/L) more than 30 minutes every day.

10. If an HCW being in contact with a patient develops symptoms, and testing result is not available, can he or she go back to work?

A: It depends on whether the healthcare worker is a close contact. If yes, he or she needs to stay in isolation for 14 days; if no, he or she can go to work while closely monitoring the body temperature. PAGE

27 - - 13. Disposal procedures for COVID-19 COVID-19 for 13. Disposal procedures waste medical related suspected from generated waste All (1) A: be disposed should patients or confirmed of as medical waste; a dou- into the medical waste (2) Put bag seal the bag, ble-layer medical waste tie it in a gooseneck fashion, with a cable, the bag with 1000 mg/L chlo and spray rine-containing disinfectant; - plas sharp dedicated a objects into Put (3) mg/L it with 1000 seal it and spray tic box, chlorine-containing disinfectant; a medical into the bagged waste (4) Put and it properly cover box, transfer waste chlorine-contain mg/L 1000 with it spray ing disinfectant; box transfer the medical waste (5) Put special a attach it, seal bag, large a into 1000 mg/ it with and spray infection label, L chlorine-containing disinfectant; a designated to the waste Transfer (6) a at a defined route along holding point sepa- waste and keep the time point fixed location; a fixed at rately collectedbe should waste medical The (6) medical an approved and disposed of by disposal operator. waste

A: The walls of the elevator is sprayed with is sprayed the elevator of walls The A: chlorine-containing from disinfectant Medical goggles the top. to the bottom of dis- during the process should be worn al- an be can goggles (swimming infecting can of the elevator buttons The ternative). and sprayed with plastic wrap be covered with the chlorine-containing disinfectant. - should be changed im plastic wrap The the with and sprayed if it is torn mediately chlorine-containing again. disinfectant of and buttons disinfecting the walls After sprayed is floor elevator the elevator, the with the chlorine-containing disinfectant. the residual remove to clean water Use afterdisinfectant 30 minutes. 12. How to disinfect elevators? to 12. How

FAQs about COVID-19 28 14. Procedures for handling bodies of deceased suspected or confirmed patients

A: (1) Staff PPE: The staff must make sure they are fully protected by wearing scrubs, disposable surgical caps, disposable gloves and heavy duty rubber gloves with long sleeves, medical disposable protective gown, medical protective masks (N95) or powered air purifying respirators (PAPRs), face shields, work shoes or rubber boots, waterproof boot covers, waterproof aprons or isolation gowns, etc.

(2) Corpse care: Fill all the natural orifices or wounds the patient may have, such as mouth, nose, ears, anus and tracheotomy access, with cotton balls or gauze impregnated with 3000- 5000 mg/L chlorine-containing disinfectant or 0.5% peroxyacetic acid.

(3) Wrapping: Wrap the corpse with a double-layer cloth sheet impregnated with disinfectant, and pack it into a double-layer, sealed, leak-proof corpse wrapping sheet soaked with chlorine containing disinfectant.

(4) The body is transferred by the staff in the isolation ward via the contaminated route and the designated elevator directly to a designated location, where the body will be picked up for cremation by a special vehicle as soon as possible.

(5) Terminal disinfection: Perform terminal disinfection to the ward and the elevator.

15. Surgical operations for suspected or confirmed patients

A: (1) Arrange the operation in a negative pressure operating room. Verify the temperature, humidity and air pressure in the operation room;

(2) Prepare all required items for the operation and use disposable surgical items if possible;

(3) All surgical staff (including surgeons, anesthesiologists, scrub nurses, and charge nurses) should put on PPEs in the buffer room before entering the operating room: caps, medical protective mask (N95), medical goggles, medical protective clothing, boot covers, and latex gloves;

(4) The surgeons and the scrub nurses wear disposable sterile operating gowns and sterile gloves in addition to the PPEs mentioned above;

(5) Patients wear disposable caps and surgical masks as situation requires;

(6) The charge nurses in the buffer room are responsible for delivering items from the buffer area to the negative pressure operating room;

(7) During the operation, the doors to the buffer room and the operating room should be properly closed, and the operation must be carried out only if the operation room is under negative pressure;

(8) Irrelevant personnel are declined entry into the operating room. PAGE

29 - - 17. How to manage the patients in isola- manage the patients to 17. How tion wards? should be visits and nursing A: Family their electronic use Patients declined. with their loved keep in touch to devices them help to patients Educate ones. further and of COVID-19, prevent spread sur instructions wear to on how provide cough handwashing, proper masks, gical observation medical and home etiquette, after discharge. quarantine dis- spraying or fogging about What 18. Ifinfectant? Is it effective? this method effec is used in china, has it been tested tive? What about personal precaution for for about personal precaution What tive? disinfectant? personnel spraying is one disinfection or spraying A: Fogging disin- of the methods of environmental combine to It fection. recommended is effect the ensure to wiping with spraying or spraying fogging When of disinfection. ad- the personnel shall wear disinfectant, equipment, protection personal equate such as N95 mask, shield. goggles or face

A: Suspected and confirmed patients A: Suspected patients and confirmed Sus- areas. ward in different should stay in pectedbe isolated should patients is room Each single rooms. separated equipped with facilities such as a pri- activity and the patient’s bathroom vate ward. to the isolation should be confined in can be arranged patients Confirmed 4 (appx least 1.2 meters at the same room be equipped should room The apart.feet) and the with facilities such as a bathroom activity to the be confined must patient’s ward. isolation 16. What are the requirements for the the for the requirements are What 16. ward?

FAQs about COVID-19 30 REFERENCES

1.National Health Commission and National Administration of Traditional Chinese Medicine of the People’s Republic of China. Protocols for Diagnosis and Treatment of COVID-19 (7th Interim Edition), published by China National Health Commission on March 4, 2020 2.National Health Commission of the People’s Republic of China. Protocols for Prevention and Control of COVID-19 (6th Edition), published by China National Health Commission on March 7, 2020 3.National Institutes of Health (NIH): COVID-19 Treatment Guidelines. 4.Covid-19 Epidemic Prevention and Control Manual 5.Handbook of covid-19 prevention and treatment 6.Shaoyong Zhu, Nanshan Zhong, et al. Clinical Characteristics of Coronavirus Disease 2019 in China. N Engl J Med. DOI: 10.1056/NEJMoa2002032. 7.Wang W, Xu Y, Gao R, et al. Detection of SARS-CoV-2 in Different Types of Clinical Speci- mens. JAMA. 2020 Mar 11. doi: 10.1001/jama.2020.3786. [Epub ahead of print] 8.UpToDate: Coronavirus disease 2019 (COVID-19): Epidemiology, virology, clinical features, diagnosis, and prevention. last updated: Apr 23, 2020. 9.Chaolin Huang, Yeming Wang, et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet. 2020 15-21 February; 395(10223): 497–506. 10. Wang D, Hu B, Hu C, et al. Clinical Characteristics of 138 Hospitalized Patients With 2019 Novel Coronavirus-Infected Pneumonia in Wuhan, China. JAMA. 2020 Feb 7. doi: 10.1001/ jama.2020.1585. [Epub ahead of print] 11. Burd EM. Validation of Laboratory-Developed Molecular Assays for Infectious Diseases. CLINICAL MICROBIOLOGY REVIEWS. 2010; 23 (3): 550-576. 12. Xu Wanzhou, Li Juan, He Xiaoyun, Zhang Caiqing, Mei Siqing, Li Congrong, Li Yan, Cheng Shaohua, Zhang Pingan. The diagnostic value of joint detection of serum IgM and IgG antibodies to 2019-nCoV in 2019-nCoV infection. Chin J Lab Med, 2020, 43: Epub ahead of print. DOI: 10.3760/cma.j.cn114452-20200223-00109 13. Huang CL, Wang YM, Li XW, Ren LL, Zhao JP, Hu Y, et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. The lancet 2020; 395: 497-506.

14.Li Q, Wang RS, Qu GQ, Wang YY, Liu P, Zhu YZ, et al. Gross examination report of a COV- ID-19 death autopsy. Journal of Forensic Medicine 2020; 36(1): 1-3. 15.Pan Y, Zhang D, Yang P, Poon LM, Wang Q. Viral load of SARS-CoV-2 in clinical samples. The Lancet Infectious diseases 2020; 20(4): 411-412. DISCLAIMER

THIS HANDBOOK DOES NOT PROVIDE MEDICAL ADVICE. The information, including but not limited to, text, graphics, images and other material contained on this handbook are for in- formational purposes only. No material on this handbook is intended to be a substitute for professional medical advice, diagnosis or treatment.

Always seek the advice of your physician or other qualified healthcare provider with any questions you may have regarding a medical condition or treatment, and never disregard- professional medical advice or delay in seeking it because of something you have read on- this handbook. EDITORIAL BOARD

Editor-in-Chief XU Jian

Executive editor XU Zhihao

Expert panel CHEN Yagang HE Jianguo DU Xiaoxing

YANG Hong XU Kaisheng LI Ning

MA Guofeng HUANG Guangyu YANG Jie

WANG Xingguo SHENG Jiehua ZHANG Huafang

YUAN Fengqin HUANG Jian YUAN Zhefeng

LU Yunrong XIE Haiyan YIN Li

LI Bin LOU Tao LIU Tian

WU Yingping ABOUT ZJU4H

Founded in 2014, The Fourth Affiliated Hospital of Zhejiang University School of Medicine (ZJU4H) is a provincial hospital affiliated to Zhejiang University. With six years’ effort, it has evolved into a top medical center in Zhejiang Province focusing on excellent healthcare, medical education and research. As an affiliated hospital of a world-class university and a bearer of JCI, HIMSS EMRAM 6 and ISO15189 accreditations, ZJU4H boasts 3000 beds (1000 beds in use), 35 clinical depart- ments and more than 1600 employees. Over the years, the hospital has successfully established a multitude of first-class disciplines in China. A number of centers have rapidly risen to the top level in Zhejiang Province, including Obstetrics, Gynecology and Reproductive Medicine Center, Surgery Center, Ortho- pedics Center, Brain Center, Heart Center, Cancer Center, Digestive Disease Center, Pulmo- nary and Critical Care Medicine, etc. As The Fourth College of Clinical Medicine of Zhejiang University School of Medicine, ZJU4H is also one of the best standardized residency trainers in Zhejiang Province with 12 teaching sections and 4 residency programs. More than 250 medical students and physicians receive education and training here every year. The hospital is also funded by more than 250 national, ministerial, and provincial research grants, with hundreds of research articles having been published in the SCI-indexed journals. Located in Yiwu, an international city known as the world’s largest wholesale hub of con- sumer goods, ZJU4H works in close collaboration with the top universities and medical institutions around the globe in areas of patient care, medical education and research. Our partners include Alberta University, Tokyo University, Mayo Clinic, Singapore University, etc. We aim to become an international medical center with world-class disciplines in the near future. In its pursuit of safeguarding people’s health, ZJU4H is constantly ready to provide quality healthcare for everyone in need. PAGE