Decision No. 468/QD-BYT 2020 Guidance on prevention COVID-19 at medical establishments

DECISION

ON PROMULGATING THE GUIDANCE ON PREVENTION AND CONTROL OF ACUTE RESPIRATORY INFECTION CAUSED BY CORONAVIRUS 2019 (COVID-19) AT MEDICAL EXAMINATION AND TREATMENT ESTABLISHMENTS

____________

MINISTER OF HEAL

Pursuant to the Government's Decree No. 75/2017/ND-CP dated 20/06/2017 defining the functions, tasks, powers and organizational structure of the Ministry of Health;

Considering the request of Director of Medical Administration Department, Ministry of Health,

DECIDES:

Article 1.  Promulgated with this Decision the “guidance on prevention and control of acute respiratory infection caused by coronavirus 2019 (covid-19) at medical examination and treatment establishments”.

Article 2. This Decision takes effect from the date of signing

Article 3.  Mr. and Mrs.: Chief of Ministry Office; Chief Inspector of the Ministry; Directors of Departments, Administrations of Ministry of Health; Directors of Departments of Health provinces and centrally-run cities; Directors of Hospitals, Research Institutes with hospital beds under the Ministry of Health; Heads of health agencies of ministries, sectors and heads of relevant units are liable to execute this Decision./.

For the Minister

The Deputy Minister

The National Steering Committee for Prevention of Acute Respiratory Diseases Caused by New Strain of Coronavirus

Nguyen Truong Son

GUIDANCE

ON PREVENTION AND CONTROL OF ACUTE RESPIRATORY INFECTION CAUSED BY CORONAVIRUS 2019 (COVID-19) AT MEDICAL EXAMINATION AND TREATMENT ESTABLISHMENTS

(Attached to the Decision No. 468/QD-BYT dated February 19, 2020 of the Minister of Health)

LIST OF ABBREVIATIONS

BYT:            Ministry of Health

KBCB:         Examination and Treatment

KSNK:         Infection Control

NB:              Patient

COVID-19:  Acute Respiratory Tract Disease caused by 2019 Coronavirus

NVYT:         Healthcare worker

PHCN:         Personal Protective Equipment (PPE)

PNC:            Standard Precaution

XN:              Test

CONTENTS

List of abbreviation................................................................................................. 8

Definitions............................................................................................................ 11

Strategy, principles and measures to control COVID-19 infection............................. 6

Triage, reception and isolation of COVID-19 confirmed or suspected patients......... 18

Guidance on establishment of isolation ward in a medical facility........................... 24

Use of personal protective equipment..................................................................... 29

Hand hygiene........................................................................................................ 36

Handling of medical instruments............................................................................ 36

Linen handling...................................................................................................... 44

Handling of eating utensils.................................................................................... 46

Cleaning and disinfection of environmental surfaces............................................... 48

Cleaning of transportation vehicles for patients with confirmed or suspected COVID-19   52

Waste treatment.................................................................................................... 54

Collection, packaging and transport specimens ...................................................... 57

Prevention of COVID-19 infection in laboratory.................................................... 65

Treatment of the corpse of COVID-19 confirmed or suspected patients .................. 68

Guidance on prevention of COVID-19 infection over patient families and visitors .. 72

Appendixes .......................................................................................................... 74

References ........................................................................................................... 83

DEFINITIONS

For the objectives of this Guide, the terms below are construed as follows:

Anteroom: is a small chamber located between the corridor and an isolation chamber, a place to prepare necessary facilities for the isolation room

Healthcare workers: are all employees, employees in medical facilities related to examination, treatment and care of patients (including doctors, nurses, medical technicians, physiotherapists, social workers, psychologists, pharmacists, hygiene workers, etc.)

Contact transmission: is the most common mode of transmission. Contact transmission is divided into 2 groups:

- Transmission through direct contact: microorganisms are transmitted from person to person due to direct contact between the body's tissue or organization (including skin and mucous membranes) with the human skin and mucosa of other, not through an infected medium or intermediary

- Transmission through indirect contact through contaminated things

Transmission by contact is the most common way of spreading microorganisms from a patient to another or a healthcare worker (HCW) to a patient and vice versa.

Healthcare workers who have activities in direct or indirect contact with the patient, with blood or body fluids from the patient are at risk of contracting or spreading the disease in the medical facility.

 Droplet transmission: Droplet transmission occurs when the recipient's mucosa (nasal mucosa, conjunctiva, and less frequently the oral mucosa) encounters droplets of ³5μm pathogen. These particles contain pathogenic microorganisms that are created when coughing, sneezing, talking or performing certain procedures (suction, intubation, chest physiotherapy, cardiopulmonary resuscitation, etc.)

Droplet transmission occurs when there is close contact (<2 meters between a patient and close contacts). Common droplet-borne pathogens are: microorganisms that cause pneumonia, pertussis, diphtheria, influenza, SARS, mumps, Ebola, COVID-19, etc.

Occupational exposure: is the term indicating the direct contact of non-intact mucosa or skin with blood, tissue or body fluids containing sources of infectious diseases or direct contact with chemicals, dangerous rays for the body in the working process of HCWs. Occupational exposure can occur through damaged skin (needle or sharp objects through the skin), contact with mucous membranes (such as eyes, nose or mouth) and contact with non-intact skin.

Standard precaution: is a set of basic preventive measures that apply to all patients in healthcare facilities regardless of diagnosis, infection status and time of care in the principle of considering all blood, secretions and excreted substances (except sweat) risk of disease transmission. Standard precautions should be applied when caring for and treating all patients in the medical facility, regardless of the diagnosis and infection status of the patient.

Transmission-based precaution: are measures to prevent transmission through 3 main routes during medical examination and treatment, including: contact, droplets and air.

Personal Protective Equipment (PPE): are the means to wear to protect HCWs from getting infected when in close contact with patients. Personal protective equipment can also protect the patient from being infected with resident and current microorganisms from HCWs. The most commonly used PPEs include gloves, masks, gowns, waterproof aprons, hats, goggles, face shields and boots or shoe covers, etc. Depending on the risk of transmission of etiology, we can select appropriate PPE.

Hand hygiene: Hand hygiene includes the techniques of hand hygiene with soap and clean water or hand hygiene with alcohol-based solutions or solutions of alcohol and disinfectant.

 Aerosol: are procedures in medical examination and treatment that can make patients' respiratory tract fluid become aerosol particles such as bronchoscopy, endotracheal intubation, tracheostomy, cardiopulmonary resuscitation, non-invasive air ventilation, etc.. These particles are able to survive in air environment.

(Air change per hour – ACH or ACPH):  is a number of times that a total volume of air in a certain area circulating per hour (air change per hour – ACH or ACPH).  If the air or the space in the room is homogeneous or the mixture of them is perfect, the air that changes every hour is a measure of the number of times after which the air in a given space is replaced.

For example: ACH = 12 in a 30 m³ room is the volume of air circulating the room within an hour: 30 m³ x 12 = 360m³.

Medical mask or Surgical mask: The mask used every day by healthcare workers in medical facilities, during surgery or contact with patients who can transmit infection via droplets or respiratory activities. A medical mask is also called surgical mask. In Vietnam, medical mask standards are regulated in TCVN (Vietnam Standard) 8389-2010, including:

- TCVN 8389-1:2010: Normal medical mask.

- TCVN 8389-2:2010: Medical mask for prevention of infection.

- TCVN 8389-3:2010: Medical mask for prevention of chemical toxicity.

In this Guidance, medical mask is construed as a mask meeting TCVN 8389-2 or equivalent.

Respirators mask: In this Guidance, the concept of respirators mask is construed as that meeting the N95 Certification under the standards of National Institute for Occupational Safety and Health  (NIOSH) or the FFP2 standard of European Union (EU) or equivalent (hereinafter collectively called as N95 mask).

STRATEGY, PRINCIPLES AND MEASURES TO CONTROL COVID-19 INFECTION

1. Generalities on Coronavirus and COVID-19

Coronavirus (CoV) is a large family of virus in residing in animals and human. The Coronavirus family consists of 2 types of alpha and 2 types of beta causing diseases in human, with the symptoms from normal flu to more severe cases of diseases. There are about 30% of upper respiratory tract infection caused by the 229E and OC43 originating from the type alpha-CoV and NL63, HKU1 from the type of beta-CoV. The type of beta Corona is the cause of severe acute respiratory disease SARS-CoV and the Middle East Respiratory Syndrome (MERS-CoV), causing severe pneumonia that can lead to death.

Coronavirus has spherical shape with the diameter about 125nm, having spiniform protein on its surface. The virus has 4 major structural proteins which are Spike protein (S), Membrane Glycoprotein (M), Envelope Protein (E) and Nucleocapsid (N). Inside the virus envelope is a single positive fiber, symmetrically spiral. The virus has its RNA of single positive fiber, no segments, about 30 kb.

Figure 1: Coronavirus structure

In April 2012 in Saudi Arabia, a patient had to be hospitalized of pneumonia, acute renal injury and died later. This is the first case to be confirmed infected and died of a new strain of virus. Soon after that time, there were many other patients having the same symptoms and the same history to have passed or stayed in Saudi Arabia. The disease-causing agent was then determined a totally new virus strain that caused the acute respiratory disease syndrome and was named Middle East Respiratory Syndrome of Coronavirus (MERS-CoV) and was categorized in Group A of infectious disease. The epidemic caused by MERS-CoV made 2,494 infected case of which 858 died (up to December 2015) in 27 countries, and China was thee place having secondary case due to person-to-person transmission.

          The origin of MERS-CoV has not been thoroughly understood. Some suppositions say that it might originate from bats and transmitted to camels. Infected patients often have the symptoms of acute respiratory disease: fever, cough, severe pneumonia that quickly leads to acute respiratory failure. Additionally, it might cause digestive symptoms such as diarrhea and might cause organ failure, especially renal failure. The death rate is up to 40%. This disease so far has not had specific drug or vaccine.

          At the end of 2019 in China, a pneumonia outbreak, also called Wuhan pneumonia epidemic, emerged. The epidemic began in the middle of December 2019 at Wuhan city when a group of people had pneumonia with unknown reason, mostly associated with those working at Huanan seafood market. Chinese scientists then subdivided a totally new Coronavirus strain (at first WHO marked it as 2019-nCoV, and officially named it COVID-19 later). This strain of virus is found to have the gene sequence resemble at least 70% with SARS-CoV.

The first suspected cases were reported on 31 December 2019 and the initial symptoms appeared on 08 December 2019. The COVID-19 so far has developed very complicatedly. At the end of 18 February 2020, the world has 73,335 infected cases and 1,874 of which died, mostly at the epidemic centre: Wuhan city, Hubei Province, China. All over the world, there have been 28 countries and territories announcing confirmed cases of COVID-19 such as Hong Kong, Macau, the Philippines, Cambodia, Thailand, Singapore, Malaysia, Sri Lanka, India, Nepal, UAE, Japan, Korea, Taiwan, Australia, Germany, France, Spain, Italy, England, Sweden, Finland, Belgium, Russia, USA, Canada, Egypt and Vietnam; people-to-people transmission has been determined.

In Vietnam, up to the date of 18 February 2020, 16 people have been confirmed to be infected with COVID-19. At first, 02 cases of two Chinese were confirmed COVID-19 infection (the father came from Wuhan city and transmitted to his son who is residing and working in Vietnam. Both of them have been recovered and discharged from hospital); 06 Vietnamese returning from Wuhan (05 has recovered and discharged, 01 has recovered, under monitoring); 06 Vietnamese had close contact with COVID-19 positive person (02 has recovered and discharged, 01 has recovered, under monitoring); 01 American coming to Vietnam, transited Wuhan, China; 01 03-month-old baby having close contact with a COVID-19 positive person.

COVID-19 mostly transmits via droplets in close distance with a COVID-19 confirmed patient and via contact. Therefore, wearing medical mask, applying hand hygiene and cleaning environmental surfaces are the utmost important measures in infection prevention. Measures of prevention of infection via air must be applied at areas having aerosol procedures, especially at close distance (< 2 meters) and in tight and badly-ventilated areas.

2. Disease case definitions:

2.1. Suspected cases: including the following cases:

A. The patient has fever and acute respiratory disease AND the disease cannot be explained by other causes AND the patient has the history to come/stay/return from a COVID-19-hit region within 14 days before the symptom onset. OR:

B. The patient has any respiratory symptom AND has at least one of the two following epidemiologic factors emerging within 14 days before the symptom onset:

a. Having close contact (*) with a COVID-19 potential or a confirmed case.

b. Having worked or been present at a medical facility where acute respiratory disease cases or COVID-19 confirmed or potential cases are treated AND having direct contact with these patients.

* Close contact includes:

- Contact at medical facilities, including: providing direct care to COVID-19 confirmed patients; co-working with COVID-19 confirmed healthcare workers; coming to visit the COVID-19 confirmed patient or stay in the same room of a COVID-19 confirmed case.

- Having direct contact in the distance ≤ 1-2 meters with a COVID-19 suspected or confirmed case.

- Living under the same roof with a COVID-19 suspected or confirmed case.

- Working in the same room, learning in the same class, having close domestic activities, etc. with a COVID-19 suspected or confirmed case.

- Having traveled on the same vehicle with a COVID-19 suspected or confirmed case.

2.2. Potential case:

Those cases that are suspected but specimen for testing cannot be collected or the specimen for testing has not been available.

2.3. Confirmed case:

Those cases that are suspected or may be confirmed by real-time RT-PCR test  positive to COVID-19 or by gene sequence decoding technique.

3. COVID-19 Preventive Strategy

The Infection Control Strategy aims at the stop or restriction of COVID-19 spread at medical facilities, including:

- Apply standard precautions to all patients.

- Have early detection, isolate and put the infection source under control.

- Apply standard precautions. It is necessary to prevent droplet transmission and contact transmission. Apply measures to prevent airborne transmission in the areas where aerosol procedures are performed.

- Administrative measures.

- Control the environment and techniques.

4. Preventive Principles

- Apply standard precautions combining with prevention of contact transmission and droplet transmission in examination and care provided to COVID-19 confirmed or suspected patients.

- In the care provided to COVID-19 confirmed or suspected patients with aerosol procedures, measures to prevent airborne transmission must be added.

- Apply respiratory hygiene to all patients having symptoms of respiratory diseases.

- Good control of ventilation, hand hygiene, and sufficient wearing of personal protective equipment are the most important measures to prevent infection to healthcare workers.

5. Measures to control transmission in medical facilities

5.1. Standard precautions

Standard precautions is a set of basic preventive measures that apply to all patients in healthcare facilities regardless of diagnosis, infection status and time of care in the principle of considering all blood, secretions and excreted substances (except sweat) risk of disease transmission. Standard precautions include:

- Hand hygiene must be performed in 5 moments of hand hygiene and with the 6-step hand hygiene technique.

- Use appropriate personal protective equipment subject to the situation as working with blood, body fluids and excretions or expecting to work with blood, body fluids and excretions.

- Execute the rules of respiratory hygiene in coughing or sneezing.

- Prevent injury caused by sharp things during patient care.

- Properly treat utensils used for patient care for re-use.

- Collect, transport, treat soiled linens in a safe manner.

- Disinfect the environment of patient care.

- Treat wastes properly.

- Arrange patients safely.

+ Arrange severe COVID-19 confirmed patients in emergency room, isolation ward or isolation room with sufficient special emergency means.

+ Arrange non-severe COVID-19 confirmed patients in a separate room or a group of the same condition may be arranged in the same room.

+ A COVID-19 positive test (+) patient must not be arranged with COVID-19 suspected patients.

5.2. Transmission-based precautions

5.2.1. Contact Precautions

Contact precautions require the following contents:

- The patient must have a separate room. If there is no separate room, this patient should be arranged in the same room with patients of the same pathogen.

- Wear clean gloves when entering the isolation room. During the process of patient care, gloves should be replaced after contact with things having high concentration of virus or bacteria (stools, drainage fluids, excretions, etc.).

- Wearing clean gown and shoe-covers when entering the patient room and putting them off before leaving the anteroom. After putting off the gown and shoe-covers, make sure that your clothes do not touch any surface of the environment or other things.

- Putting off gloves and gown before getting out of the room and performing hand hygiene immediately with disinfectant solution. After putting off gloves and having hand hygiene, hands must not touch any surface of environment or things in the anteroom.

- Patient transportation must be minimized. On-bed techniques (X-ray, ultrasonography, etc.) are recommended. In case transportation is required, a notice must be sent to the arrival. Before transportation, have the patient wearing mask during the transportation. In case of skin lesion, it must be covered to avoid spread of infectious source. Use designated special pathway to minimize exposure to other healthcare workers other patients and other people.

- Utensils and equipment of patient care: should be used one time for each individual patient. If it is impossible, they must be cleaned, disinfected and sterilized before using them to another patient.

5.2.2. Droplet Precautions

Droplet precautions require the following contents:

- The patient must have a separate room. If there is no separate room, this patient should be arranged in the same room with patients of the same pathogen. Arrangement with other patients may be allowed but the minimum appropriate distance must be over 2 meters.

- Wearing medical masks, goggles or face shield, especially when having close manipulation with the patient.

- Patient transportation must be minimized. In case of transportation, the patient must wear medical mask, use the special pathway to void infection to other healthcare workers, patients and people.

5.2.3. Airborne Precautions

When implementing aerosol-producing procedures over a COVID-19 patient, it is necessary to apply measures to prevent airborne transmission.

Air treatment and ventilation in the patient room are necessary to prevent the spread of the epidemic.

The measures to prevent airborne transmission include:

- Arrange the patient in a separate room. In case there is no separate room, it is recommended to arrange the patients in the same confirmed infection group or the suspected group in the same room.

- Ensure safe ventilation: run the system of natural ventilation, mechanical ventilation or combine both provided that the minimum circulating air volume must reach ≥12 air flow/hour. A system may be used to draw air outwards (underground, 10-15 cm under the floor) to the no-people area and avoid the re-circulation of contaminated air.

- Any person entering the isolation room must wear a Respirator mask (for example: N95 mask).

- Patient transportation must be restricted. Transportation can only be done in extremely necessary situations and the patient must wear medical mask when getting out of the room.

- Procedures must be performed in a single room with its doors tightly closed, with safe ventilation and far apart from other patients.

- In case of sputum sucking prescription, tools and non-open sputum sucking method must be applied to a patient in mechanical ventilation.

5.3. Strict compliance with respiratory hygiene rule

The recommended principles of respiratory hygiene are as follows:

- All patients or healthcare workers having any respiratory symptom must apply the principles of respiratory hygiene, including:

•  Cover the mouth and nose with tissue when coughing and sneezing, and then discard it into the waste bin.
•  In case no tissue is available, a person may cough onto the upper side of the elbow, NOT use the hand to cover mouth when coughing.
•  Ask the patient who has symptoms of coughing or sneezing to wear medical mask when having close contact (<2m) or the healthcare worker examining a patient who has risk of COVID-19 via droplet transmission.
•  Wash hands after having contact with excretions.
•  Stand or sit at least 2 meters apart from a COVID-19 confirmed or suspected patient.

- Poster should be hung to instruct respiratory hygiene at those places easily to see: examination area, isolation ward.

5.4. Environment Control

5.4.1. Environment of surfaces of floors, walls, corridors

Environment control is the important measure to prevent COVID-19 infection. The following principles should be paid attention to:

- The surfaces in the environment must be leaned and disinfected with proper permitted disinfectant chemicals.

- Patches of blood or biological release or excretion as vomit, stool on surfaces of environment must immediately be eliminated with towel soaked in chemical having 0.5% active Chlorine (5,000 ppm), then wipe it with clean towel and clean it the second time with 0.05% active Chlorine.

Refer details in the section of Cleaning and Disinfecting surfaces in environment.

4.5.2. Ventilation

Proper ventilation must be assured at the following areas:

• Patient reception areas, corridors, waiting room should not be tight and should be clear.
• Patient room areas:

•  The optimal isolation room is the negative pressure room.
•  In case the negative pressure room is not available, the facility should use mixed air or natural ventilation, assuring ventilation in the isolation room must reach at least ³ 12 circulating airflow/hour.
•  The room where aerosol-causing procedures are performed must have proper room ventilation (≥12 circulating airflow/hour).
•  In case such a standard room is not available:

•  Perform procedures in a room far apart from other patients. The procedure room must be well-ventilated, leeward, having 2-way convectional windows open towards a no-people area.
•  A system to draw air outwards may be used. The drawn air must be released to an empty area, having no people, and must not release to the corridor or the surrounding rooms.

4.5.3. Vehicles, machines, beds and cabinets

Clean and disinfect them every day, at least twice and when necessary (between two patients, when a patient died, transferred or discharged) with appropriate permitted disinfectant chemical.

Refer details in the section of Cleaning and Disinfecting surfaces in environment.

4.6. Community transmission prevention

During the time to care a COVID-19 confirmed or suspected patient or a patient during the monitoring time, a healthcare worker must restrict contact with relatives or community until the risk ends, avoiding disseminating and spread across the hospital and the community.

The medical facility should assign a special group of healthcare workers to care the COVID-19 confirmed or suspected patients. During this process, the group of healthcare workers must not take care of other patients.

Propagate people restrict to go to epidemic zones. Those having arrived or those having close contact with a COVID-19 confirmed or infected patient should have self-isolation and monitor body temperature within 14 days. Come to the hospital right after a fever or symptoms of respiratory disease appear.

Those not having respiratory symptoms should:

- Avoid gathering and avoid coming to crowded places frequently.

- Keep a distance at least 2 meters off any person having respiratory symptoms (for example: coughing, sneezing).

- Do hand hygiene regularly: with alcohol-based solution for unsoiled hands or with soap and water for soiled hands.

- When coughing or sneezing, shield the mouth and nose with your elbow or with tissue, which must be immediately discarded right after use and do hand hygiene.

- Hands are recommended to avoid touching to eyes, nose, and mouth.

Those having respiratory symptoms are recommended:

- To wear medical mask and to have a visit as soon as possible in case of fever, cough, dyspnea, etc.

- To use and manage masks properly.

Mask management:

If someone wears a medical mask, it is necessary for him/her to use and discard it properly, ensuring the efficiency and avoiding risks of transmission related to the improper use and discard of mask.

Wearing mask must be duly as prescribed and technically. Do not overuse masks. Improper use of mask may spread pathogens.

Detailed guidance about putting on and putting off masks are provided in section of use of personal protective equipment.

5.6. Other principles of prevention and control

Many measures of infection control must be combined, including the process of triage, isolation, environment hygiene, waste management, proper use of process of putting on and putting off personal protective equipment; control of infection in transportation, operation and treatment of corpse, control of infection in laboratories.

TRIAGE, RECEPTION AND ISOLATION OVER COVID-19 CONFIRMED OR SUSPECTED PATIENTS

COVID-19 has high risk of spread so the tasks of triage, early detection and well-timed isolation are very important. A COVID-19 confirmed or suspected patient must be isolated immediately and measures to prevent transmission must be strictly applied.

1. Objective

Have triage over patients who come to visit in order to detect and isolate early a COVID-19 confirmed or suspected patient, whereby prevent the risk of COVID-19 infection from patients to healthcare workers, to other patients and across the hospital environment.

2. Principles for execution

• The medical facility should establish the system to detect and respond quickly when there is a COVID-19 confirmed or suspected patient.
• The medical facility should make scheme for triage, categorization, and management of COVID-19 confirmed or suspected patient right when they come and have examination.

•  The medical facility must execute measures to prevent and control infection strictly (standard precautions and transmission-based precautions).
•  Do the task of categorization upon patients as soon as they come to have examination of the medical facility with the triage questionnaire.
•  Arrange special area/examination room for those patients having or not having acute respiratory symptoms (cough, fever, etc.) but having the epidemiologic factors (arrive at or pass Hubei Province, China within 14 days) (refer Guidance at gathered isolation unit for prevention and control of COVID-19, enacted with Decision 344/QD-BYT dated February 07, 2020 by the Ministry of Health).
•  When a COVID-19 confirmed or suspected patient is detected, that patient must be isolated in a timely manner (according to the signs of disease and the informing epidemiologic factors).
•  Declare, inform, report disease cases as regulated.

3. Scope of application: All medical facilities.

4. The task to prevent and control COVID-19 infection.

Medical facilities should strictly execute the processes and regulations on prevention and control of epidemic spread enacted by Ministry of Health.

All resources must be mobilized to control COVID-19 infection; cure confirmed patients, prevent infection to other patients and limit death; actively combine with other forces to zone pestholes, transport, run emergency, isolate, treat patients, treat the environment of pesthole in the timely manner.

Medical facilities should actively prepare and execute the following activities:

4.1. Organization, personnel

- Establish the COVID-19 prevention & control Steering Committee at hospitals, consisting of: The Directors, Department of General Planning, Outpatient Department, Accident & Emergency, Infectious Disease, Pediatrics Department, Respiratory Department, Administrative Personnel Department, Infection Control Department, Facility Department, Pharmacy, Nursing Department, Administrative Personnel Department and Agency Health Unit. At central-level and province/centrally-run city, the Steering Committee may have subcommittees of treatment and subcommittees to prevent and control infection, subcommittees of logistic, etc.

- Based on the actual conditions of each hospital, the Hospital Management shall determine which department in charge of reception and treatment of COVID-19 confirmed or suspected patient. The Department in charge of reception, triage, and treatment of patients must have enough conditions for proper isolation. Staff of this department must be fully trained in infection control, especially the use of personal protective equipment as instructed to prevent infection in the hospital.

4.2. Reception and isolation

- Zoning the risk and streaming the movement of COVID-19 confirmed or suspected people in the hospital are as follows:

• The high risk zone (red) comprises of the departments receiving and treating COVID-19 confirmed or suspected patients (for example: isolation ward; Outpatient department; Emergency & Resuscitation Department, Infectious Disease Department, Laboratory, etc.).
•  The medium risk zone (yellow) comprises of departments receiving patients having cough or fever (Example: examination room for patients having cough and fever of Outpatient Department, Emergency Department, Respiratory Department, Pediatrics Department);
•  The low risk zone (green) comprises of the departments less likely receiving, examining and treating COVID-19 confirmed or suspected patients (for example: Surgical Department, Maternity Department, etc.).

- The risk zoning helps the hospital have the foundation in assignment, development of scheme of reception, treatment and concentration of its limited resources to the task of prevention (vehicles, personnel, training, monitoring) for high risk zones.

- The hospital must have plan to zone isolation wards, arrange personnel, vehicles, etc. for the situation of scattered and mass COVID-19 confirmed or suspected patients.

4.3. Conditions and means

4.3.1. Hand hygiene means

Soap, alcohol-based hand hygiene solution, tissue or disposable hand tissue must be available at all necessary places.

4.3.2. Personal protection

 Anti-epidemic gown, apron, paper hat, medical mask, N95 mask, goggles (or face shield), boots, shoe-cover, medical gloves and hygiene gloves.

4.3.3. Equipment

- Ventilation assisted equipment and other means of emergency and resuscitation (handheld oxygen saturation meter, monitoring machine, bed X-ray machine), oxygen and the system to create and supply oxygen, the system of close sputum sucking;

- HEPA air disinfection filter.

For high effectiveness of COVID-19 transmission control, the above-mentioned means must always be available at each receiving and treating area even in or not in epidemic time. Healthcare worker must be trained to master the use of personal protective equipment and other hospital regulations in infection control.

4.3.4. Disinfectant chemicals – surface and tool disinfection

The facility must make estimate, purchase and provision of sufficient chemicals for tool treatment; environment surface disinfection and cleaning; hand hygiene; waste treatment in case of epidemic.

4.3.5. Isolation room

The hospitals must arrange standard isolation wards or isolation rooms as regulated and must always be available for epidemic situation.

Other medical facilities must prepare wards (rooms) to receive and triage COVID-19 confirmed or suspected patients.

4.3.6. Medications

Medication list is subject to the treatment protocol.

4.4. Training

Medical facilities must establish the scheme and hold training courses to educate all healthcare workers at the facility on COVID-19 infection control. The Infection Control Department will be responsible for the contents, programs, materials, means to educate the theory and practice for healthcare workers as in materials of Ministry of Health.

4.5. Drill

The COVID-19 prevention and control Steering Committee at medical facilities has to hold drill to examine, assess, and learn from experience upon the defective contents for modification, correction and improvement of the facility’s plan of epidemic prevention and control in line with those of the locality, region, and country.

Some notable points in the contents of drill are as follows:

• Early control: Stream, screen, diagnose, early isolate patients having symptoms of COVID-19 infection or suspected patients who come for examination and hospitalization. Duly execute regulations in patient transportation in the hospital, department transfer, hospital transfer ensuring safety of healthcare workers, transporters and the community.
• Ensure necessary conditions for the reception, treatment and organize prevention and isolation in the medical facility.
• Ensure that healthcare workers use personal protective equipment properly, prepare adequate number of available means and have solutions when the supply of personal protective equipment is limited.
• Comply with standard precautions and transmission-based precautions (via droplet, contact and perhaps airborne transmission) by heath are workers. Ensure compliance with regulations, hand hygiene process, disinfection and sterilization of medical equipment, cleaning and disinfection of the isolation ward and leaning the hospital environment.
• Practice infection prevention over healthcare workers, patient families, visitors in medical waste management, linen management, eating and drinking things of patients in the isolation ward, provide guidance on prevention of infection when the patient died
• Pay proper attention to other hospital-acquired infection related to the care of COVID-19 confirmed or suspected patients (lung infection, septicemia, urinary infection, etc.).

4.6. Inspection and monitoring

• The Infection Control Department has the professional specialty in inspection and monitoring upon the COVID-19 infection control; set the process of infection control applied in the hospital after it is approved by the Infection Control Committee and the Anti-Epidemic Steering Committee of the hospital, submitted for approval by the Hospital Management who then monitor the compliance with the process of epidemic prevention and control and infection control.
• The General Planning Department combines with the Infection Control Department monitor, make statistics, give timely notice about the number of COVID-19 confirmed or suspected patients and the healthcare workers having close contact, inspecting and monitoring the execution of regulations on infection control.
• The Nursing Department combines with the Infection Control Department, the General Planning Department and the head nurses of clinical departments, head technicians of subclinical departments to inspect and monitor the execution of regulations on infection control.

4.7. Assignment and execution

The Directors, leaders of departments and relevant persons are responsible for the contents of activities on COVID-19 infection prevention at medical facilities.

The contents on infection control must be shown in the scheme of COVID-19 prevention and control scheme of the hospital.

The Director has the duty to fully equip infrastructure, purchase equipment, materials, chemicals, necessary vehicles to serve the task of infection prevention. The isolation ward must be arranged at appropriate place. The facility must have the scheme to renovate, upgrade and build the isolation ward duly as guided.

4.8. Expenditure

Expenditure is applied under regulations on epidemic prevention and control of the Government. Purchase and spending must be under regulations. During the epidemic time, when the Ministry of Health or an authority declares epidemic state, the spending will be applied urgent epidemic prevention and control regulations.

The Hospital Director is responsible for the allocation of budget and expert for regular activities in infection control. The Hospital is required to have a backup budget for epidemic prevention and control.

5. Triage, isolation of COVID-19 confirmed or suspected patients

5.1. Preparation of infrastructure and means

• Arrange, establish the isolation ward and isolation room to meet the isolation requirement.
• Personal protective equipment (Refer the Guidance on use of personal protective equipment).
• Hand hygiene utensils must be available from patient reception areas to the triage, examination and treatment area.
• Essential tools, equipment and disinfectant chemicals used in patient care and treatment.
• Means to collect waste, tools, linens, etc.

5.2. Steps of execution

Each medical facility must have triage area right at the examination rooms (as at the security post, patient reception desk). There must have at least one examination room to isolate the cases of cough and fever with unknown cause. The staff in charge of triage must instruct the patient the measures of prevention and isolation as soon as the patient comes into the examination room.

* The diagnoses to early detect a COVID-19 infected or suspected patient are as follows:

- There is an epidemic factor within 14 days before the symptom onset:

•  A patient returning to Vietnam from a COVID-19-hit region or having contact with someone returning from such region.
•  Having contact with blood or body fluid of a patient who has been confirmed or suspected COVID-19 infection in the epidemic-hit region.
•  Having resided or arrived at a COVID-19-hit region within 14 days;
•  Having directly contacted animal from the epidemic area.

- Having clinical signs of the disease:

•  Having high fever suddenly ≥ 38⁰C; headache or muscle ache may appear.
•  Cough and dyspnea.
•  Having signs of acute pneumonia or acute respiratory failure (Refer the Guidance on diagnosis over those suspected of COVID-19 infection of the Ministry of Health, page 8).

- When having the symptoms or history as mentioned above, the patient should be arranged in the isolation ward, isolated from other patients as soon as possible as the steps in Instructive Chart (Appendix 1).

- During the epidemic time, instructive boards should be hung at the entrance (Security gate) and the examination room to instruct patients, families of patients having symptoms of fever, cough to come directly to the examination and triage area, not let them go to other areas.

- The areas of waiting, examination, procedures for the COVID-19 infected or suspected patients must be assured well-ventilated, with at least more than 12 airflow circulating each hour. This can be achieved by opening all windows and doors in the same direction in case of natural ventilation. If the hospital runs the system of central air-conditioning, the ACH index must be added and the safety of the system of central air-conditioning must be checked regularly and periodically. 

- A family member accompanying a COVID-19 infected or suspected patient should be considered to have exposed to COVID-19 and must also be screened to the end of monitoring time as regulated to help early diagnosis and to prevent the epidemic-causing ability of COVID-19.

- In case transportation is required, the transporter must use personal protective equipment and dedicated vehicle. Contaminated things, the transporting vehicle, discarded things and wastes of the patient must be collected and treated as regulated.

* Notes:

- Those staff who directly care for patients must strictly execute preventive measures such as: wearing personal protective equipment; wash hands with soap or other disinfectant solutions after each contact with patients (refer the section of hand hygiene and use of personal protective equipment).

- Patients must wear medical masks.

- Minimize the contact with or transportation of patients.

- Execute personal hygiene, use hygiene solutions, disinfect the nasopharyngeal tract.

- Disinfect the patient-transporting vehicles after each use.

- Make list of persons having close contacts and monitoring their health within 14 days since the last contact. Advise the contact person on the signs of disease and measures of prevention and control so that they can apply self-prevention and self-monitoring, early detecting symptoms of COVID-19 confirmed or suspected patients. If there is any symptom, it must immediately be reported to the nearest medical facility for timely diagnosis and treatment.

5.3. Inspection and supervision

- The Department of Infection Control, Department of General Planning, and the Nursing Department have the duty to inspect, supervise and train the implementation of isolation of healthcare workers.

- Contents of supervision:

•  The patient room/ward must meet the standard of isolation.
•  Be equipped with all personal protective equipment as regulated (clothing, hat, mask, goggles, gloves, boots,).
•  The compliance awareness by healthcare workers in isolation in each stage of diagnosis and treatment.

- Supervision is done by direct observation and the results are recorded into the Supervision note.

Time for isolation of COVID-19 confirmed or suspected patients: Isolate and treat patients at medial facilities under the Guidance by Department of Health.

Announcement of a disease case:

- Announcement must be cascaded across the medical facility duly as regulated and degraded: The Clinic/Department of Emergency having a COVID-19 confirmed or suspected case must immediately give notice to the following persons:

•  The patient himself/herself and his/her families.
•  The members of that shift (if in duty hours) or all members of the department (in office hours).
•  The hospital management and the relevant departments (Department of General Planning, Department of Infection Control, Nursing Department, etc.).

- Announcement outwards the medical facility: Urgent written notice must be reported on all confirmed or suspected cases to the superior health management and to the leaders of equivalent preventive health authorities as regulated.

Factors ensuring the triage, early detection, timely isolation, treatment and management of COVID-19 infected patients who are able to spread epidemic in medical facilities:

- Establish an epidemic prevention & control Steering Committee.

- Establish the specific and detailed process to receive and treat patients in screening, detection and isolation of COVID-19 confirmed or suspected patients right at the areas of examination room to the isolation ward.

- All healthcare workers must be trained on clinical symptoms, treatment, spreading ways and process of preventive isolation in the hospital.

- Have enough means ensuring strict isolation.

- Inspect and assess the availability whether the epidemic has come/not come yet.

GUIDANCES ON ESTABLISHMENT OF ISOLATION WARD IN A MEDICAL FACILITY

COVID-19 is a very highly infectious disease. The early isolation upon a COVID-19 confirmed or suspected patient plays a very critical role. To execute well the isolation measures, the medical facilities must always have isolation ward and isolation room with full equipment. Healthcare workers must be trained in compliance with technical procedures in isolation:

- The medical facilities must establish the isolation area right at the patient-reception place, including the waiting area for COVID-19 suspected patients, triage area, isolation room and personal protective equipment, utensils for the treatment and care for patients to receive COVID-19 patients.

- The Outpatient Department, Emergency Department, Pediatrics Department, Infectious Disease Department must prepare an isolation room with full of necessary equipment to opportunely isolate patients if necessary.

1. Isolation ward pattern

1.1. Objective

- Restrict and control the spread of COVID-19 in the environment of examination and treatment facility and the community, especially for healthcare workers, patients, families and visitors.

- Isolate the pathogen in the isolation ward for treatment.

1.2. Principles for isolation ward establishment

- The isolation must be located at the end of the corridor, deserted place, at the end of the main wind direction.

- Patient families must not join the care and visitors must be minimized.

- The isolation ward should be divided into 3 different areas subject to the infection risk:

• Low-risk infection area: The Administration area, the workplace of healthcare workers. This area must have the green signboard and restricted. Healthcare workers should wear medical masks.
• Medium-risk infection area: The area of corridor, the anteroom where utensils of care and treatment are stored. This area must have the yellow signboard. Only healthcare workers are allowed to come to this area with full and appropriate personal protective equipment.
• High-risk infection area: The reception room, emergency room, treatment room, restroom, utensil treating room. This area must have the red signboard. Healthcare workers must have full personal protective equipment and must do hand hygiene after each contact with a patient, with surfaces in environment and before the isolation ward.

1.3. Requirements at an isolation ward

1.3.1. Isolation ward design in province-level, (centrally-run) city-level hospitals

- Functional chambers:

1) Administration chamber.

2) Patient-reception chamber.

3) Patient-treatment chamber.

4) Chamber for severe COVID-19 patients of emergency (having full emergency means and treatment used individually for each patient).

5) Patient-retaining chamber for COVID-19 suspected patient.

6) Tool-treatment chamber having all equipment for initial disinfection: tool washing basin, drying cabinet and disinfectant chemicals.

7) Chamber used to store essential things for patient care and treatment.

8) The patient restroom must have hand wash basin, disposable hand tissue and soap for hand wash.

9) Bathroom for healthcare workers having hand wash soap.

The chambers in the isolation ward must have hand wash basin, hand tissue, alcohol-based hand hygiene solution, hand wash soap. The pathway must be from the low-risk to the high-risk infection area.

10) Ventilation system: The optimal measure is that the negative pressure system is equipped at the isolation room. In case this system is not available, it is required to have the forced airflow running from the low-risk area to the high-risk area (from the green to the red area). The frequency of airflow must reach at least 12 times/hour. Air released from the isolation ward must be disinfected with UVC or with combined method of disinfection and HEPA filtering.  In case such a system is not available, the released air must be blown into an empty environment having no people.

11) The floors and walls (with the minimum height of 2 meters) should be pressed with eramic tiles for easy cleaning and disinfection.

12) The corner of the house and the floor should be designed with obtuse or rounded angle, avoiding acute angle for easy cleaning and not to gather soil.

13) The windows must be made from materials that are easily to be cleaned (glass, few items, easily to be washed and cleaned).

1.3.2. Isolation room design in district-level hospitals

1) Those hospitals in the region of epidemic risk should always put aside an area in the Infectious Disease Department or a special area inside the hospital to receive COVID-19 confirmed or suspected patients.

2) The isolation room should also be arranged so that it is not near the places of other patients or crowded place.

3) The isolation ward may not have all functional chambers as that of the upper-level hospital but it must at least have the following rooms:

• Room to examine and receive patients.
• Room to isolate and treat severe patients.
• The restroom and utensil-treating room (it may be located right in the isolation room).

4. The isolation ward should have the system of mechanical ventilation flowing from the isolation to a deserted place with windows to circulate air with the outside environment.

A: Disinfection place

B: Cabinet for PPE, clean linen and tools

C: Bag for after-use PPE, waste, soiled linen

D: Hand-wash basin with soap, alcohol-based hand hygiene solution

E: Windows opening to the outside, far from residential area, without people

Figure 2. Diagram of COVID-19 confirmed isolation room

1.4. Patient bed arrangement in the isolation room

It is most preferable to arrange each COVID-19 confirmed patient in a separate isolation room (if possible).

In case of not possible or if there are too many OVID-19 confirmed or suspected patients hospitalizing, the suspected patients may be arranged in the same room (group isolation), COVID-19 confirmed patients may be arranged in the same room. Patients suspected of infection and waiting for test result may be arranged in the same room. The distance between two beds must be at least 2 meters to prevent droplet transmission.

2. List of essential things necessary at the isolation ward/room:

- These things must always be available in the isolation ward, isolation room, located on board or in the anteroom’s cabinet right in front of the isolation room.

- Those departments and units (such as environmental hygiene, waste treatment, patient transportation, etc.) related to the task of care and treatment of COVID-19 confirmed or suspected patients must wear all appropriate personal protective equipment (rubber boots, aprons, masks, goggles, etc.).

- List of tools and personal protective equipment that must always be available in the isolation ward and must be checked and sufficed on daily manner. It is notable to have all sizes for users and the mandatory minimum number must always be available (see Table 1).

Table 1. Means and tools must always be available
in the isolation ward/room

(The daily minimum number in case there are patients hospitalized for monitoring and treatment)

3. Ventilation

Ventilation enhancement is the important measure in COVID-19 prevention and control. There are 3 ways to enhance ventilation:

3.1. Mechanical ventilation:

A negative pressure room is created by bringing clean air into the room and drawing contaminated air outwards so that it must have at least 12 airflow exchange every hour (ACH) and the negative pressure must be at least -3Pa. Air released will be led through the preliminary filtration system and HEPA filtering combined with disinfecting with UVC.

3.2. Natural ventilation:

Airflow brought into and released outwards the isolation room or ward through the main entrance or windows. The patient room has 2 windows located opposite. If all 02 windows are opening, they ensure ventilation in the patient room for at least 12 ACH. A patient room having natural ventilation should be located leeward, having 2-way convection windows opening towards a deserted place.

3.3. Mixed ventilation:

The natural ventilation is combined with the system of fan to blow air outwards. Air must not be released to crowded places, the corridor or into other rooms. Air released from exhaust fan must be disinfected with UVC or a combined way between disinfection and HEPA filtering. In case such a system is not available, the exhaust fan must be located to release air to a deserted environment.

The capacity, number of exhaust fans must be counted subject to the room volume to ensure the ventilation at least 12 ACH.

USE OF PERSONAL PROTECTIVE EQUIPMENT (PPE)

Personal protective equipment are an essential means to protect healthcare workers from the risk of infection when they have a close contact with blood, secretions and respiratory droplets carrying infectious pathogens of patients. PPE is also used to protect patients from being infected with resident and transient microorganisms from healthcare workers and the hospital environment. Use of PPE when taking care of infected or suspected COVID-19 patients is the most important measure in preventing infection for healthcare workers.

1. Objectives

To prevent the risk of COVID-19 infection from patients to healthcare workers, other patients and visitors, and the spread to the environment surrounding patients and the community

2. Scopes of application

All healthcare workers, patients’ relatives, visitors, people having contact with confirmed or suspected COVID-19 patients or specimens from confirmed or suspected COVID-19 patients.

3. Principles of implementation

3.1. General principles

- Use PPE as recommended by standard precautions combined with transmission-based precautions suitable to the situation in care and treatment of confirmed or suspected COVID-19 patients.

- Ensure the availability of PPE dotation in isolation areas, anteroom of isolation rooms, laboratory, waste treatment areas and corpse management areas.

- PPE is only effective when used in conjunction with other infection control measures such as organizing the process of screening, isolation, surface and environmental sanitation and waste management.

- It is necessary to comply with the instructions and procedures of putting on and taking off PPE.

3.2. Rules for using personal protective equipment

  1. Always wear PPE when contacting, examining, and taking care of confirmed or suspected COVID-19 patients.

  2. The practice of putting on and taking off PPE must be done competently before taking care of infected or suspected COVID-19 patients and must be supervised by a trained member.

  3. Prepare adequate PPE suitable to the situation to be implemented.

  4. Putting on and taking off PPE must be done in the anteroom before entering and after leaving the isolation room. Avoid touching or adjusting PPE in the isolation room.

  5. Ensure PPEs cover the entire body.

  6. Change gloves when moving from one patient to another patient, change gloves if torn, perform hand hygiene before putting new gloves on.

  7. When taking off PPE, pay attention to the following principles:

• The outer surface of PPEs has a high risk of contamination, thus turn the outside in and do not shake while taking off PPE.
• The front of PPE has a higher risk of infection than the back. Avoid touching the front of PPE.

  8. PPE is disposable, and is infectious wastes; it must be discarded into infectious waste containers (yellow containers) immediately after removing. Waste containers must be large enough and must have automatic lids.

4. Types of personal protective equipment

4.1. Type of personal protective equipment

  In fact, there are many types of PPE, which can be classified into two categories as follows:

  Type 1: Detached pants, gowns and caps

Waterproof gowns or gowns with waterproof covers.

Waterproof pants.

Waterproof aprons

Medical masks

-   High filtration capacity masks (e.g. N95 respirators)

Goggles or face shields.

Medical gloves.

Hood caps (cover the entire head and neck).

High-length shoes covers

Rubber boots

Type 2: Coveralls and cap:

Coveralls and caps.

High-length shoes covers.

Waterproof aprons.

Medical masks.

N95 respirators.

Goggles or face shields.

Medical gloves.

Rubber gloves.

High-length waterproof shoes covers.

Rubber boots.

4.2. Technical criteria

Goggles and face shields must fit tightly against the face to prevent fluid from absorbing.

Medical masks must be qualified, waterproof and have metal strip that may bend to fit the nose bridge and prevent the air and droplets from passing through.

Masks have a high filtration capacity (e.g. masks meet N95 or FFP2 standards or equivalent).

Gloves: It is recommended to use gloves made of nitrile rather than latex with appropriate sizes for user’s hands

Gowns has a mid-thigh length, long sleeve, plastic wrist and aprons must be impermeable to blood and fluids.

Rubber boots should not be torn or punctured with appropriate sizes for user’s feet.

Shoes covers should be knee-length, waterproof material, and slip resistance.

Caps must cover head and neck, with a front opening to remove later.

Clothes worn beneath personal protective equipment.

5. Procedure of putting on and taking off personal protective equipment

5.1. Putting on and taking off mask

5.1.1. Medical mask:

* Technique to put on masks:

- Hand hygiene.

- Open the package; remove the mask from the bag, one hand holds one side of the mask.

- Place the mask on the face, the waterproof side (blue) faces outwards, the absorbent side (white) turns inwards. One hand secures the front of mask on the face, another hand places one strap around the ear then repeat for another side.

- Use the tip of index finger to mould the metal strip to fit snugly over the nose bridge and face.

- Use 2 fingers to hold the lower edge of mask and pull down slightly, extend the mask to fully cover the bottom of the chin

* Technique to take off mask:

- Remove the mask strap, do not let hand touch the mask, discard the mask into the waste container as prescribed.

- Hand hygiene.

5.1.2. High filtration capacity mask (N95 Respirator)

* Technique to put on respirator:

- Hand hygiene

- Open the package, place the mask on the palm of hand, the metal edge covers nose bridge and faces forward, let the strap drop freely under the hand.

- Place the mask under the chin, the nose cover faces upwards.

- Pull the top strap over the head and set it at the top back of head over the ears. Pull the bottom strap over the head and place it at the back of the neck below the ears. Do not let two traps overlap each other behind the head.

- Check and adjust the strap if twisted or twirled.

- Place tips of 2 index fingers at the top of nose bridge, mold the nose cover to help the mask fit snugly over the nose.

- Tightness test of the mask:

+ Inhalation test (negative): exhale slowly, if the respirator is tight, the negative pressure helps the respirator cover the face snugly. If the respirator is not tight, the air will pass through the opening into the mask, thus it is necessary to adjust the tension of the strap and repeat the inhalation test again.

+ Exhalation test (positive): exhale strongly, if the mask is tight, positive pressure creates airflow inside the mask. If the mask is not tight, it is required to adjust the tension of the strap and repeat the exhalation test again.

* Technique to take off respirator:

- Remove the bottom strap by lifting the strap over the head, then pull the top strap over the head, do not let your hand touch the mask when removing.

- Hand hygiene.

5.1.3. Points to note when putting on and taking of masks

- Wear masks with the right upper and lower direction.

- Wear masks with the right inside and outside surface.

- Do not touch the inside surface of mask while wearing.

- Place masks carefully to cover mouth and nose.

- Adjust the nose strip and the strap to ensure the mask fit the nose bridge and face snugly.

- Do not touch the front of mask when removing.

- After removing or whenever accidentally touching used masks, it is required to wash hands with alcohol-based hand sanitizers or wash hands with soap and water.

- Change masks after performing a clean/aseptic procedure, as soon as a mask is contaminated or damp/wet or after every shift.

- Do not reuse used masks.

5.2. Order to put on personal protective equipment

Step 1:  Hand hygiene.

Step 2: Wear boots/shoes cover.

Step 3: Put on pants and gown (wear apron if indicated).

Step 4: Wear mask

Step 5: Wear goggles (for goggles with ear-hanging frame)

Step 6: Wear hood cap to cover hair, head, ears, and mask straps completely.

Step 7: Wear face shield or goggles (for goggles with headband outside the hood cap)

Step 8: Wear clean gloves

5.3. Order to take off personal protective equipment

5.3.1. Type of detached pants, gown and cap

Step 1: Remove gloves. Roll the inside out when removing, then put them into waste container. In case of wearing apron, remove the apron, release the lower strap first, then release the upper strap, roll the inner surface of the apron out, and put in the waste container.

Step 2: Hand hygiene

Step 3: Remove gown, roll the inside out and put it into waste container.

Step 4: Hand hygiene

Step 5: Remove pants and boots/shoes cover simultaneously, turn the inside out and put them into waste container. In case of wearing boots, place the boots in a container with disinfectant solution.

Step 6: Hand hygiene

Step 7: Remove face shield or goggles

Step 8: Hand hygiene

Step 9: Remove cap by slipping hand into the cap

Step 10: Remove mask (by holding the strap behind the head or ears)

Step 11: Hand hygiene

5.3.2. Type of coveralls and cap

Step 1: Remove gloves. Roll the inside out when removing, then put them into waste container. In case of wearing apron, remove it by releasing the lower strap first, then releasing the upper strap, roll the inside of the apron out, and put into the waste container.

Step 2: Hand hygiene

Step 3: Remove face shield or goggles

Step 4: Hand hygiene

Step 5: Remove cap, coveralls. When removing, turn the inside out and put them in the waste container.

Step 6: Hand hygiene

Step 7: Remove boots or shoes cover, turn the inside out and put them into waste container. In case of wearing boots, place the boots in a container with disinfectant solution.

Step 8: Hand hygiene

Step 9: Remove mask (by holding the strap behind the head or ears)

Step 10: Hand hygiene

Note: Remove PPE at the anteroom of isolation rooms and areas.

6. Inspection and monitoring of use of personal protective equipment

Infection Control Department and Nursing Department are responsible for inspecting, monitoring and training the use of personal protective equipment for healthcare workers:

Content of monitoring:

PPE are available all the time at the anteroom of isolation rooms and areas

Healthcare workers use the necessary PPE adequately and properly.

Used PPE should be sorted, collected and treated.

Method of monitoring: by direct observation and by recording in monitoring form.

HAND HYGIENE

Hand hygiene is one of the important measures to help prevent and control COVID-19 infection. The hand hygiene needs to be done regularly all the time, all places at the right time in accordance with 5 moments of hand hygiene during care and treatment of the patient.

All medical facilities must

1. Hand hygiene equipment

Fully supplement hand hygiene facilities at all areas with people infected or suspected of COVID-19.

1.1. Hand hygiene equipment with soap

- The hand hygiene sinks must be placed in the isolation rooms, buffer rooms, administrative rooms, drug and fluid preparation rooms, testing rooms, nutrition rooms, waste and dirty clothes treating area, mortuary convenient for patients and healthcare workers to use.

- The hand hygiene sinks must have soap solution, clean water, container of disposable hand towel (in paper or cloth)

Some specific provisions:

- The hand hygiene sinks must be sufficiently deep to avoid water splashing outside and splashing into the washers, with no corner, smooth surfaces, no stains and stagnant water. The height of the sink is in line with the height of the hand cleaners.

- Faucet: fixed to the wall. The handle should be automatic, pedal or lever.

- Water system: tap water, water pipes should be placed in the wall, but must be easy to install, clean and disinfect when necessary.

- Soap and soap holder for hand hygiene: it is best to use liquid soap, put in a closed container, with a standard quantitative pumping, fitted properly. If using bar soap, you need to keep in a box with a tight lid, keep it at dry place and avoid splashing water.

- Disposable hand towel: may be in disposable paper or reused cotton towel put in tight box and easy to take it out.

- Dirty towel container: is conveniently designed so that it is easy to put towels into the container without touching the lid.

Fig. 9 Washing hands under running water

1.2. Hand hygiene equipment containing AlcohoL/chlorhexidin

- Equip vials (bottles) of hand disinfectant solution containing 60% - 80% alcohol or chlorhexidin in all areas where patients are taken care of, at each bed head of severe patients or in emergency conditions. On injection or dressing change trolley, medical examination tables. On the wall right next to the entrance (door) to the patient room, buffer room, isolation room, in front of the elevator door, corridor, etc. where there is a risk of exposure to patient’s blood, body fluids.

- Regularly changing and sanitizing bottles of hand-disinfecting alcohol solution and making sure the bottles are available at designated locations.

- Bottle of hand-disinfecting alcohol solution with a standard pump, fixed to the wall or hung at the patient’s bed head, in front of the patient room, injection trolley, etc.

2. Hand hygiene indication

2.1. Hand hygiene with soap and clean water

- Whenever hand touches blood and body fluid which can be visible, during the care and treatment of the patient (performing invasive procedure, patient body hygiene care, handling of dirty equipment, waste, etc.) even though gloves are worn but suspected of gloves puncture or accidental removal leading to exposure to source of infection.

- Hand hygiene with soap and water should be done before and after working session, after going to the toilet, after collecting cloths, tools, waste, etc.

2.2. Hand hygiene with alcoholic solution

- Only do hand hygiene with alcoholic solution only when the hands are dry, no blood stain and body fluid is visible, during care, treatment, after removing the personal protective equipment.

- In places where hand washing sink cannot be installed and places where care operations are not at risk of visual contact with blood and body fluids possibly detected with naked eyes.

- Indication of hand hygiene with alcoholic solution: similarly as in hand hygiene with soap and water in case of visible blood or body fluid.

- Moments when healthcare workers need to do hand hygiene: 5 moments when healthcare workers must comply with hand hygiene (as recommended by the World Health Organization)

In addition, hand hygiene must be done in some of the following cases:

In the procedures for putting on and off the personal protective equipment

Before wearing gloves

When transporting patient from infectious place to clean place

Before finishing work at isolation area and going outside.

Before going home.

3. Techniques

3.1. Hand hygiene with soap and water (Figure 11)

- Step 1: Wet your palms with water. Take the soap and rub your palms together to create bubbles.

- Step 2: Rub one palm over the back of the hand and space of fingers of the other hand and vice versa.

- Step 3: Rub your palms together, strongly press the space of fingers.

- Step 4: Rub the outside of the fingers of one hand into the palm of the other.

- Step 5: Use this hand to turn the thumb of the other hand and vice versa.

- Step 6: Turn these finger tips into the palm of the other hand and vice versa. Wash your hands under running water.

Fig 11: Hand hygiene techniques with soap and clean water

3.2. Hand hygiene with alcoholic solution (Figure 12)

- Step 1: Use 3ml - 5ml of alcoholic/chlorhexidin hand sanitizer and rub 2 palms together.

- Step 2: Rub one palm over the back of the hand and space of fingers of the other hand and vice versa.

- Step 3: Rub your palms together, strongly press the space of fingers

- Step 4: Rub the outside of the fingers of one hand into the palm of the other hand.

- Step 5: Use this hand to turn the thumb of the other hand and vice versa.

- Step 6: Turn these finger tips into the palm of the other hand and vice versa until it is dry.

Figure 12. Hand hygiene techniques with alcoholic solution (20-3- seconds)

Note:

- Clip fingernail short.

- Remove all jewellery on your hands (ring, bracelet, watch, etc.).

- The techniques of hand hygiene are similar to the ones with soap and water. Rub at least 5 times each step.

See also Instruction on hand hygiene in health facilities issued under the Decision No. 3916/QD-BYT dated 28/08/2017 by the Minister of Health.

HANDLING OF MEDICAL INSTRUMENTS

All equipment used for the care and treatment of a person infected or suspected of COVID-19 are potentially infectious, and if not handled properly, they will spread and infect healthcare workers and communities.

1. Objectives

- Staff who handles medical instruments must strictly comply with the cleaning, disinfection and sterilization procedures for medical instruments after patient care and treatment.

- Ensure safety for patients, healthcare workers and communities.

2. Principles

- The specialized medical equipment and instruments used for patient care and treatment are ideally disposable (ex: respiratory assistive devices such as sputum suction tubes, aerosol masks, ventilator cords, dental care kit, etc.). The reusable tools must be handled in accordance with MOH regulations

- All disposable medical equipment and instruments but handled for reuse must be cleaned and disinfected in accordance with the manufacturers' instructions and the MOH regulations.

- Ensure medical instruments and equipment used for patients are properly handled, disinfected and sterilized, ensure the functioning of the instruments and their availability.

- Ensure adequate disinfection instruction procedures for all medical instruments and patient care facilities in the place they are used and the place of handling.

- Fully provide facilities, chemicals, consumables and personal protective equipment to the handling people (especially goggles, face shields, waterproof gown, elbow-length rubber gloves, rubber boots).

- Staff working on disinfection and sterilization must be trained and have a certificate of training in disinfection and sterilization.

- The disinfection and sterilization must be checked and monitored for the quality of equipment (test, storage records), ensure the safety of healthcare workers and the environment upon collection, transportation, cleaning, disinfection.

- Make statistics and report on the handling and provision of care and treatment instruments for people with confirmed or suspected COVID-19.

3. Subjects and scope of application

3.1. Subjects of application

- Person handling medical instruments (in isolation area, clinical unit, subclinical area related to care for people with confirmed or suspected COVID-19 and central sterilization units).

- Healthcare workers who directly provide care at the treatment and care units for people with confirmed or suspected COVID-19.

3.2. Scope of application

- Isolation room/area.

- Central sterilization units/ Department of infection control.

- Areas of receipt, classification and visiting for people with confirmed or suspected COVID-19.

4. Facilities

4.1. Sterilization and disinfection facilities

- Personal protective equipment: masks, rubber gloves and waterproof aprons, goggles or face shields, boots (designated areas).

- Adequate provision of clean water.

- Instrument soaking container with lid and capacity suitable for all kinds of instruments.

- Instrument washing sink (made of easy-to-clean and disinfect materials).

- Instrument washer.

- Steam sterilizer, drying cabinet

- Low-temperature sterilizer (ETO, Plasma, etc.)

4.2. Chemicals

- Cleaning solution: detergents/enzymes, enzymes-containing disinfectants

- Medium level disinfectant solution:

Chlorine compounds: Sodium hypochlorite: Presept, Javel, Chloramin B, etc.

Enzyme-containing compound: Cidezyme, etc.

- High-level disinfectant solution: glutaraldehyde ≥2%, orthophthaldehyde 0.55%, Peracetic acid, etc.

4.3. Water: Clean water, sterile water.

5. Method of implementation

5.1. At isolation room/area

5.1.1. Preparation

- Staff handling medical instruments wears personal protective equipment (mask, rubber gloves and waterproof apron, goggles/face shield) before handling medical instruments.

- Prepare enough instruments and facilities for cleaning and disinfecting:

 Instrument washing sinks - washers

 Chemicals

Cleaning tools (brush, tube wiping stick, etc.).

Clean water, sterile water.

5.1.2. Implementation procedures

Mix cleaning and disinfecting chemicals as instructed

- The medical instruments after being used for patients, must be handled immediately by healthcare workers:

Immerse instruments into cleaning solution (detergent) or enzyme solution and then soak it in medium level disinfectant solution in line with the regulations on time and concentration of the solution (see Appendix 4).

Rinse chemicals under clean running water. Clean instrument under water

- Dry the instrument, place it in a closed container with the name of the person with confirmed or suspected COVID-19 and put it in a yellow bag/box before transporting it.

- Make a call to inform the central sterilization unit/Department of infection control before transport.

5.2. At the central sterilization unit/Department of infection control

The reception area must be arranged and immediately handle instruments transported from the isolation area, giving priority to immediate or separate handling in order to prevent spread and infection in the area and to the other departments.

5.2.1. Preparation of facilities

- Arrange facilities and staff who separately handles instruments of people with confirmed or suspected COVID-19 in the isolation area if possible.

- The staff handling instruments must wear the personal protective equipment before handling of instrument (including: mask, rubber gloves and waterproof apron, goggles/face shield).

- Prepare all facilities and tools for cleaning and disinfection:

Instrument cleaning basin - instrument cleaner.

Chemicals.

 Cleaning tools (brush, tube wiping stick

 Clean water, sterile water.

Multi-function instrument washer, cleaner and disinfecting machine (can wash various types of metal instruments and airway plastic instruments).

Steam sterilizer for heat resistant instruments.

Low temperature sterilizer

5.2.2. Implementation procedures

* Case for manual cleaning and disinfection (without instrument washer and disinfecting machine):

The joints of instruments to be disassembled are opened and put into the trays, racks in accordance with the manufacturer's regulations.

Mix disinfectant chemicals as instructed (Appendix 4).

Immediately immerse instruments into disinfectant solution prepared in line with the prescribed concentration and time.

Scrub and clean tools under the water surface of the instrument soaking sink, gently brush the instruments to avoid splashing.

Rinse the chemicals under running water

Dry the instruments (drying cabinet, wiping dry).

Soak, spray lubricant to protect instruments.

Move the instruments to the packaging area (labelling, calibration tests, writing of expiry date) and transport them for sterilization.

Clean and disinfect by specialized machine

The joints of instruments to be disassembled are opened and put into the trays, racks in accordance with the manufacturer's regulations.

Install the washing program of the machine (heat-resistant and non-heat resistant instruments).

   Heat-resistant instruments: soap, water, temperature 90⁰C.

   Non-heat-resistant instruments: soap, water, temperature less than 50⁰C

   Chemicals: as recommended by the manufacturer of machines and instruments.

  Put lubricant into the machine

Run the machine under the installed program.

-  At the end of the cycle, take the equipment out of the packaging machine as prescribed.

In case the washer does not have a drying mode: put instruments into the dryer or dry by wiping manually with clean, dry cloth before packing.

Conduct the disinfection procedure.

After being disinfected, the instruments must be stored in closed cabinet and ventilated storage room (ideally clean rooms with air-conditioner with temperature maintained at 200C-220C, humidity <60%).

Dispensing as daily required by the area providing care to people with confirmed or suspected COVID-19.

Note:

After finishing work, the staff handling instruments in each area must remove the personal protective equipment and do hand hygiene before moving to another area.

Clean the instrument handling area at the end of shift/working day.

6. Inspection and surveillance over compliance with cleaning, disinfection and sterilization

Heads of Department and Head Nurses should regularly inspect and monitor the strict compliance:

- Healthcare workers fully have facilities, consumables, chemicals and personal protective equipment when handling instruments.

- Monitor the cleaning, disinfection and sterilization procedures at the area with dirty instruments (consultation/isolation room, laboratory, etc.).

- Monitor the procedures for putting on/off the personal protective equipment of the healthcare workers working in areas related to these patients.

- Save the list of healthcare workers who handle instruments, regularly monitor, survey and detect signs of infection.

See also Guidance on sterilization and sterilization in medical facilities issued under the Decision No. 3671/QD-BYT dated 27/9/2012 by the Ministry of Health.

LINEN HANDLING

1. Objectives

- Healthcare workers must comply with the linen handling procedures of persons with confirmed or suspected COVID-19.

- Ensure safety for patients, healthcare workers, patient families, visitors and communities.

2. General principles and regulations

- Do not shake, dump or count linen collected from the process of care and treatment of persons with confirmed or suspected COVID-19.

- After being collected, the linen must be tightly packed, transported immediately to the laundry house by dedicated means and must be washed immediately separately without soaking, or storing dirty linen.

- Linen of persons with confirmed or suspected COVID-19 at the consultation area, patient bed, isolation room must be collected into yellow bag with label after use and write “Potential COVID-19 linen”.

- Linen bags must not be torn, punctured, and impermeable.

- Staff collecting, transporting and handling dirty linen must follow the procedures for wearing and removal of protective equipment in accordance with the instructions on Compliance with hand hygiene.

- Wash linen with machine at high temperature and chemicals. In the absence of a washing machine, handwashing of line is required. Soak the linen in disinfectant before washing with an active chlorine concentration of 0.05% (see Appendix 4).

- Wash and dry or naturally dry linen in line with procedures for infectious linen handling.

3. Subjects and scope of application

3.1. Subjects of application

- Laundry staff and staff collecting and transporting linen.

- Staff in the isolation area or room or patient reception place.

3.2. Scope of application

- Patient room, isolation room.

- Laundry house.

- Other areas related to linen of persons with confirmed or suspected COVID-19

4. Facilities

- Washing machine with washing mode at temperature of 60⁰C-70⁰C, dryer

- Yellow non-perforation bags, with lace and symbol for high-risk infectious linen (COVID-19 patient linen), yellow containers, separate infectious linen transporting vehicles.

- Personal protective equipment for collecting, transporting and washing staff.

- Washing chemicals: Soap, detergent, disinfectant (Javel, Cloramin B).

5. Implementation

5.1. At isolation room/patient room

- Staff collecting dirty linen must wear prescribed personal protective equipment before tasks and do hand hygiene after finishing work.

- Linen in patient room/isolation area must be collected into waterproof yellow bag put in container with lid and tightly tied before being transported to the laundry.

- Disposable linen: Gowns, caps, masks, shoe covers are all put in a yellow bag, and placed in a container with lid and tightly tied to the top of the bag when being transported to infectious medical waste storage for destruction.

- All bags of linen when moved out must be put into another bag and then moved to the laundry, the bag labelled "Potential COVID-19 linen".

- Laundry come to pick up the linen at the scheduled time or unexpectedly on request.

5.2. At laundry

- After collecting linen to the laundry, immediately put them into the washing machine and washed by chemical or soap washing mode at the temperature of 60⁰C-70⁰C. Soak linen of people with confirmed or suspected COVID-19 in a chemical solution containing 0.01% -0.05% of active chlorine depending on the degree of contamination of linen for at least 20 minutes before washing. For washing facilities with washing machines, use them to soak linen.

- It is ideal to dry linen, if it cannot be dried in a private, high, sunny place.

- Linen after being dried must be ironed and put into closed and dry cabinet.

Note: For places where there is no washing machine, the linen after being moved in is immediately dumped into a soaking container with chemical disinfectant (active chlorine at the concentration of 0.01% -0.05%) in the minimum time of 20 minutes before washing.

Staff performing the manual washing procedure must strictly adhere to regulations, wear personal protective equipment during washing and after finishing work, put off personal protective equipment and do hand hygiene.

5.3. Linen storage and dispensing

- Linen used for people with confirmed or suspected COVID-19 must be stored in closed cabinet or put on clean shelf in storage and used by quantity and types as requested.

- The list of linen of solation areas, consultation rooms for people with confirmed or suspected COVID-19 must be notified to the laundry.

- A base number of clean linen (at least a triple base number) is stored in the isolation area for daily use.

6. Inspection and surveillance

- Department of Infection Control, Nursing Department, relevant Heads of Department and Head Nurses are responsible for training, inspection, surveillance and urging of strict compliance with dirty linen handling procedures (from classification, collection, transport, handling).

- Content of surveillance:

Facilities for dirty linen handling (bag, container, transporting vehicle).

Procedures for instructions and techniques for linen handling.

Wash hands and clean instruments after finishing work.

Chemicals used in linen handling.

Personal protective equipment for healthcare workers

Procedures for use of personal protective equipment.

  HANDLING OF EATING UTENSILS

1. Objectives

- Staff of Nutrition Department strictly adheres to the procedures for providing and handling of eating utensils of people with confirmed or suspected COVID-19.

- Ensure safety for patient, healthcare workers, patient families, visitors and environment.

2. Principles of implementation

- All utensils used for living, eating and leftover food of people with confirmed or suspected COVID-19 are potentially infectious and need to be treated like infectious waste. They must not absolutely be used for other purposes (watering plants, raising cattle, poultry, etc.).

- It is ideal to use disposable utensils and then collect, transport and destruct them immediately after use as infectious medical waste.

- Food and drink containers used for each patient must be separately collected and handled.

- In the absence of disposable utensils, the reuse of used utensils must strictly follow the disinfection of reusable utensils like the disinfection and sterilization procedures for care and treatment instruments used for people with confirmed or suspected COVID-19.

3. Subjects and scope of application

People with confirmed or suspected COVID-19; staff of Department of Nutrition directly provide care for people with confirmed or suspected COVID-19.

4. Facilities

- Personal protective equipment to prevent infection from contact.

- Sink/lavabo, soap.

- Buckets, containers of disinfectant solution with anti-evaporation lids.

- Chemical disinfectant prepared with exact concentration of 0.05% (500 ppm) active chlorine.

5. Method of implementation

5.1. Use disposable utensils

- After persons with confirmed or suspected COVID-19, their eating utensils and leftover food must be put into infectious waste container in isolation room.

- Sanitation workers collect and treat this waste as infectious medical waste.

5.2. Use reusable utensils

- Healthcare workers must instruct persons with confirmed or suspected COVID-19 to put their utensils after use into the reusable utensil container and their leftover food into infectious waste container.

- Healthcare workers collect the reusable utensils and put them into closed container with label of eating utensils of persons with confirmed or suspected COVID-19 and then move them to the Department of Nutrition (or Department of Infection Control) for proper handling.

- When handling the eating utensils, staff should wear person protective equipment as instructed.

- The liquid from leftover food, water will be collected as infectious waste of the isolation area properly before being transported to the treatment place.

- Transport the reusable tools to the centralized handling area, store in bags, containers with lid. Do not carry it in your arms and on shoulders with bare hands.

- Soak to disinfect food and drink containers after use in a solution of 0.05% active chlorine active ingredients for 10 minutes-20 minutes. Note completely immerse such utensils in disinfectant solution. In the absence of chemical disinfectant, it is possible to boil the utensils for 10 minutes.

- Encourage the use of automatic utensil washing machines with closed doors and operation with chemical and temperature cycles, then automatically drying for different types of utensils (including many different types) for people with confirmed or suspected COVID-19.

6. Inspection and surveillance

Department of Infection Control, Nursing Department, relevant Heads of Department and Head Nurses are responsible for training, inspection, surveillance and urging of strict compliance with the procedures:

- Surveillance over procedures for use of personal protective equipment when handling the reusable utensils.

- Surveillance over procedures for collection, transportation, handling and reuse.

See also Guidance on sterilization and sterilization in medical facilities issued under the Decision No. 3671/QD-BYT dated 27/9/2012 by the Ministry of Health.

               CLEANING AND DISINFECTION OF ENVIRONMENTAL SURFACES

1. Objectives

- Sanitation workers strictly follow the environmental cleaning procedures in the reception and treatment area for people with confirmed or suspected COVID-19.

- Cut off the COVID-19 transmission routes by contact.

- Ensure the safety for patients, healthcare workers and communities.

2. Principles of implementation

The surface of the screening and isolation area for people with confirmed or suspected COVID-19 must be cleaned and disinfected as per the following principles:

- All surfaces in the screening, isolation and treatment areas with visible or unclear blood, secretions, waste from people with confirmed or suspected COVID-19 must be cleaned and disinfected at least 2 times a day and when needed (after examination, testing, procedures, spillage of blood and fluids, post-transfer/discharge, death).

- All surfaces (in the isolation area of people with confirmed or suspected COVID-19, including the surface of care instruments, transportation vehicles must be cleaned, disinfected with disinfectant chemicals licensed by the Ministry of Health).

- Healthcare workers when cleaning and disinfecting surfaces associated with people with confirmed or suspected COVID-19 should strictly follow the principles and techniques for surface cleaning and precautionary measures of transmission.

- Personnel performing surface cleaning and disinfection of the environment in the treatment and isolation area of people with confirmed or suspected COVID-19 must be trained in procedures for surface cleaning and disinfection and proper use of personal protective equipment when performing their duties.

3. Subjects and scope of application

- All healthcare workers performing the environmental cleaning in all areas related to care and treatment of people with confirmed or suspected COVID-19.

- All surfaces of facilities and utensils related to patients, beds, cabinets, tables, chairs, toilets , etc. in screening, receiving area, isolation room, laundry, waste collection area, handling area of reusable instruments, transportation vehicles related to care and treatment of people with confirmed or suspected COVID-19.

4. Facilities

-  Personal protective equipment (see Use of personal protective equipment).

- Procedures for implementation, instruction table for environmental cleaning and disinfectant chemical preparation on transportation vehicles.

- Hand washing soap.

- Prescribed cleaning and disinfectant chemicals preparation (it is possible to use the hand-held spray for surfaces difficult to wipe with cloth) with 0.05% active chlorine, cloth impregnated with disinfectant solution or other appropriate germicidal chemicals licensed by MOH.

- Surface disinfectant with active chlorine 0.5% or other disinfectant chemicals licensed by the Ministry of Health for cleaning surfaces with blood, fluid, vomit, excretion.

- Special cleaning wipes for screening and isolation areas, mops, buckets containing chemicals and collecting buckets.

5. Techniques for implementation

- Divide the area into two, with signs to avoid slipperiness, wetness before cleaning floors, halls and stairs.

- Wipe in a zigzag fashion, from top to bottom, inside and out, from the cleanest to the least clean area.

- When using chemical sprays, spray chemicals into cloth then wipe; If cleaning the floor, spray low, spray and wipe immediately. Do not spray when patient is present.

5.1. Method of implementation

- Step 1: Prepare adequate facilities of cleaning and disinfection (containers/buckets containing disinfectant solution, wipes, mops, etc.), use separate facilities for isolation areas (administrative area, isolation rooms, toilets, instrument and linen handling area, etc.).

- Step 2: The staff performing the environmental sanitation wears the personal protective equipment as instructed before entering the isolation area and during the process of cleaning and disinfecting the surface of the isolation area's environment (see Use of personal protective equipment).

- Step 3: Wet wipe and collect waste in bags and containers of infectious waste in accordance with regulations before disinfecting wipe.

- Step 4: Perform disinfectant wiping periodically with a solution of specified concentration (with active chlorine concentration of 0.05%), let the surface dry for 10 minutes and wipe again with clean water to avoid residual chemicals affecting patients. The frequency of cleaning on all surfaces in the isolation area is at least 2 times/day and when required. Apply the correct procedure of 2-bucket cleaning (one bucket of clean water, one bucket of disinfectant solution) and each wipe is with a clean cloth, do not wash again in buckets, each cloth is used no more than 20 m². When wiping, pay attention to:

For surfaces that are frequently in contact (injection trolley, equipment and linen transporting vehicles, doorknobs, etc.), disinfect immediately after each use or contact.

Immediately remove and wipe again with disinfectant with active chlorine concentration of 0.5% whenever the surface shows patient’s blood, secretions, feces or vomit. The chemical exposure time to the environment is at least 10 minutes.

- Step 5: Collect tools after cleaning the environment to clean and disinfect before removing them from the isolation area including waste that must be isolated (see Waste treatment, page 54), wiping cloth is put into isolation bags and transported to the laundry (See also Instruction on transportation of infected linen and waste out of the isolation area).

- Step 6: Healthcare workers remove their personal protective equipment and do hand hygiene with soap solution immediately after finishing the environmental sanitation work.

Note: Healthcare workers' hands that have direct contact with patient’s blood, secretions, and waste and must wash their hands with soap and water after removing the personal protective equipment.

5.1. Daily surface cleaning and disinfection

The procedure is the same as above and requires strict adherence to regulations:

- Do the cleaning twice daily and when required. A table should be used to monitor disinfected surfaces every day.

- For each cleaning, sanitize surfaces with disinfectant chemicals before wiping again with cleaning solution. Sanitation should be carried out from less polluted areas (administrative areas) to heavily polluted areas (isolation rooms), equipment surfaces before floor cleaning and disinfection.

- Use COVID-19 disinfectant chemicals for all surfaces in the room and ensure the right time for contact with disinfectant chemicals. For example, at least 10 minutes with active chlorine compounds 0.05% (500 ppm).

Note: do not bring cleaning tools in the isolation areas to the other areas, the cleaning wipe is collected and treated separately to avoid COVID-19 infection to other areas in the hospital.

5.2. Cleaning after the patient is discharged/transferred/dead

- Move the other patient under isolation in the patient room (if any) to another isolation room before performing the final disinfection cleaning.

- Collect dirty tools and reusable linen into bags/containers to laundry and disinfection centers. Collect and remove the patient’s waste and other personal belongings in accordance with regulations on collection and management of infectious waste.

- Wipe surfaces with disinfectant chemicals before wiping with cleaning solution. Sanitation should be carried out from less polluted areas (administrative areas) to heavily polluted areas (isolation chambers), equipment surfaces and surfaces before floor cleaning and disinfection.

- Use COVID-19 disinfectant chemicals for all surfaces in the room and ensure the right time for contact with disinfectant chemicals, for example at least 10 minutes with solutions of active chlorine 0.05 % - 0.5%.

Details of chemical concentrations used in cleaning and disinfecting surfaces are in Appendix 4.

5.3. Disinfect surfaces spilled with blood or body fluids

- This should be done as soon as it appears or when blood or body fluids are detected.

- Wear adequate personal protective equipment.

- Remove blood stain or body fluids in the following order: (1) Use a cloth or gauze impregnated with solution containing 0.5% (5,000 ppm) of active chlorine to remove the blood (if there is a large amount of blood, it must be done many times to when removing all blood on the surface; (2) Remove the blood-soaked cloth (gauze) into the collection container for infectious waste; (3) Use a cloth or gauze soaked in a solution of 0.5% active chlorine on the surface of blood spilled area; (4) Wipe the disinfected surface with a cloth or gauze soaked in cleaning solution.

- Put off the personal protective equipment and do hand hygiene after going out of isolation rooms.

5.4. Cleaning mortuary and shrouding area of COVIS-19 patient

- Wear adequate protective equipment as prescribed for COVID-19.

- After the completion of shroud and autopsy, all instruments and surface of the surgical table, the operating room and facilities related to corpses must be disinfected immediately with active chlorine solution of 0.5% and let them dry for 30 minutes to 1 hour.

- Clean and disinfect sanitary facilities in accordance with the procedures.

- Put off the personal protective equipment and do hand hygiene after finishing work.

5.5. Cleaning of sanitary tools

- Hospital sanitary tools must be cleaned after every shift and at the end of each day.

- Sanitary tools to be treated include, mop handle, bucket/basin containing chemical, rinse water/soaking water for disinfection. The wiping cloths are cleaned with clean water and soap and put in proper and dry place.

- Disinfect buckets/basins containing cleaning and disinfecting solution at the active chlorine concentration of 0.05%, rinse again with clean water and place them on the drying rack.

- Clean up sanitary tools and place them properly. Do not use untreated cleaning tools for daily cleaning.

6. Inspection and surveillance

- Department of Infection Control, Nursing Department, relevant Heads of Department and Head Nurses are responsible for training, inspection, surveillance and urging of strict compliance with the procedure for daily or unexpected environmental disinfection.

- Daily monitoring of compliance of healthcare workers in the implementation of the procedure for disinfection and cleaning of surfaces, spills of blood, biological fluids, use of personal protective equipment when working in isolation and treatment areas of people with confirmed or suspected COVID-19.

- Surveillance results should be immediately given to the supervised person and reported to the department head and the hospital leader.

See also Instruction on cleaning of environmental surfaces in health facilities issued under the Decision No. 3916/QD-BYT dated 28/8/2017 by the Minister of Health.

CLEANING OF TRANSPORTATION VEHICLES FOR PATIENTS WITH CONFIRMED OR SUSPECTED COVID-19

The hospitals must strictly apply technical procedures and principles of environmental control, safety practices control in the use of personal protective equipment (PPE) while transporting patients within and outside the hospitals.

1. Objectives

- Healthcare workers properly and strictly follow regulations on cleaning and disinfection of surfaces of transportation vehicles for patients with confirmed or suspected COVID-19.

- Prevent COVID-19 infection due to contact with surfaces of transportation vehicles for people with confirmed or suspected COVID-19.

- Ensure the safety for healthcare workers in charge of transportation and community

2. Principles of implementation

- The surfaces of transportation vehicles requiring the cleaning and disinfection include: the inner compartment of patient transportation vehicles (stretchers, control panels of medical equipment, adjacent floors, walls, ceilings and working surfaces, door handles, radios, keyboards and phones) and the outer surface of transportation vehicles (door handles, doors, the entire outer surface of vehicles).

- Persons in charge of handling transportation vehicles (is the person who are directly involved in transporting or who are assigned to perform the final cleaning of transportation vehicles) must be trained and properly adhere to principles and techniques of cleaning the surface of machines, equipment and transportation vehicles, standard precautions and contact precautions.

- The hospital has regulations on fully equipped area for handling of transportation vehicles to ensure the safe handling of vehicles.

- The area used for conducting the disinfection of patient transportation vehicles must have adequate personal protective equipment, chemicals, tools for cleaning, sterilization and disinfection, collection of medical waste.

- All patient transportation vehicles, devices for patient intervention and care at the end of use must be handled immediately according to the procedure before using for next patients.

3. Subjects and scopes of application

- All vehicles used for patient transportation to the hospital and within the hospital.

- All healthcare workers involved in patient transportation at all departments related to transporting patients with confirmed or suspected COVID-19.

4. Facilities

- Personal protective equipment (PPE): have enough PPEs, N95 respirators, medical masks, goggles or face shields, rubber boots, clean gloves, sterile gloves for separate invasive procedures to be replaced and used as needed.

- Cleaning chemicals and disinfectants:

Disinfectant soap

Alcohol-based hand sanitizer

Surface disinfectant with 0.05% and 0.5% active chlorine ingredients, ethanol 70% or disinfectants in the list licensed by the Ministry of Health.

- Equipment for handling: spray bottles, cloths, waste bag/containers

- Separate area for handling of transportation vehicles within the hospital.

5. Procedure

Healthcare workers wear person protective equipment as instructed and follow these steps:

- Step 1: Dilute chemicals as regulated and place it in chemical containers at the treatment area.

- Step 2: Wear person protective equipment.

- Step 3: Collect tools and waste into yellow bags/containers then seal it tightly, clearly indicate the waste generated from or to the centralized waste treatment area.

- Step 4: Clean all surfaces of transportation vehicles with disinfectants, leave it for at least 10 minutes then clean again with cleaning chemicals (detergents or clean water with soap), then dry or blow dry. In case of excessive blood/fluid or spillage of blood or body fluid (e.g.: vomitus, blood, biological secretions, etc.), at first use a disposable tissue impregnated with 0.5% active chlorine to localize and remove, cover the spill by a cloth soaked with 0.5% active chlorine solution for at least 10 minutes, then wipe off by disinfectant solution with 0.5% active chlorine.

- Step 5: Once the cleaning is done, personal protective equipment is discarded in a sealed bag or container, and moved to the disinfection or destruction area, then perform hand hygiene with disinfectant soap and personal hygiene.

Note: For vehicles traveling to the epidemic area, it must be sprayed with disinfectants, disinfectant with a solution of 0.05% active chlorine concentration must be used for car bodies, tires and undercarriage when leaving the epidemic area.

6. Inspection, monitoring and responsibility

- Infection Control Department, Nursing Department, Head of Departments and Head Nurses of relevant departments are responsible for training, inspecting, monitoring and urging the strict implementation of cleaning procedures for transportation vehicles for patients with confirmed or suspected COVID-19.

- General Planning Department together with Intensive Care Department perform the checking of emergency equipment, ambulances and emergency regulations for prevention of epidemics and natural disasters.

- Medical Supplies and Equipment Department, Pharmacy Department (or unit assigned with the duty of supplies provision) is responsible for providing adequate personal protective equipment and chemicals for sterilization and disinfection in the list licensed by the Ministry of Health.

- Infection Control Department will monitor the compliance with equipment cleaning and disinfection procedure, medical waste treatment and environmental sanitation for areas where cleaning and disinfection of equipment are performed.

WASTE TREATMENT

1. Objectives

- Personnel, patients with confirmed or suspected infection strictly follow the procedures for sorting, isolating, collecting, transporting and treating waste generated from isolated areas.

- Prevent the spread of COVID-19 from waste to the environment and community.

-  Ensure the safety for patients, healthcare workers and community

2. Principles

- All wastes which must be collected and treated immediately at the generating area from screening areas, isolation areas for ​​patients with confirmed or suspected COVID-19 are considered as infectious wastes, which must be collected in yellow plastic bags and containers with biohazard symbol.

- Ensure no spread of pathogens in the process of collecting, transporting and treating of medical waste from screening areas, isolation areas for ​​patients with confirmed or suspected COVID-19; ensure the safety for healthcare workers and participants in medical waste management.

- When disposing of medical waste, it must be placed into a yellow bag before being transferred to the centralized waste storage in the hospital and noted with “Potential COVID-19 Waste” warning.

- Healthcare workers and participants in medical waste management and environmental sanitation must be fully equipped with appropriate personal protective equipment while working.

3. Scope of application

3.1. Subjects

- Personnel in charge of collecting, transporting and treating waste generated from patients with confirmed or suspected COVID-19.

- All healthcare workers involved in the care and treatment of patients with confirmed or suspected COVID-19.

- Patients with confirmed or suspected COVID-19, patient relatives, visitors.

3.2. Areas

- In all areas having waste generated from patients with confirmed or suspected COVID-19: reception, screening, isolation, testing areas, etc. for patients with confirmed or suspected COVID-19.

- Waste treatment area.

4. Facilities

- Containers and plastic bags used for collection of infectious medical waste as regulated (in yellow) with symbol of infectious waste are placed in screening areas, isolation rooms, patients rooms and breathing chamber.

- On injection trolleys or in isolation rooms equipped with sharp containers (yellow, puncture resistant, disposable).

- On transportation vehicles for patients with confirmed or suspected with COVID-19.

- Protective equipment (cap, masks, goggles, clothing, rubber boots/shoes covers) for personnel involved in collection, treatment and management of medical waste.

5. Method of implementation

- Waste which are specimens from patients with confirmed or infected COVID-19 must be safely treated according to the instructions for handling of wastes at high risk of infection before placing into the centralized treatment system.

- All solid waste generated in screening areas, isolation areas and areas related to patients with confirmed or suspected COVID-19 must be collected immediately into infectious waste containers, boxes or bags.

- Infectious waste containers at temporary storage area must be closed tightly, ensure waste are not dropped or leaked during the collection process to centralized storage areas within the healthcare facilities at least twice a day.

- Personnel in charge of collecting and transporting waste must wear protective equipment in accordance with regulations.

- Waste must be transported to the centralized waste storage in the hospital once containers become 3/4 full or more or at least twice a day and when required.

- Once being transferred to the centralized waste storage in the hospital, waste is treated and disposed in a centralized manner like other highly infectious wastes. Never open these waste bags when storage, transportation and treatment are performed.

- Liquid wastes such as faeces, urine generated from isolation rooms or isolation areas need to be collected according to the general medical wastewater collection and treatment system of the hospital. In cases the healthcare facilities do not have the wastewater treatment system that meet environmental standards, liquid wastes generated from isolation areas must be collected and disinfected with chemicals containing 1.0% active chlorine before disposing to the environment.

- Respiratory secretions (sputum, saliva, throat fluid, bronchial fluid of patients must be thoroughly treated with solution of 1.0 % active chlorine in a 1: 1 ratio for at least 10 minutes after it is collected according to regulations in healthcare facility.

- At healthcare facilities with high-temperature autoclaves, solid waste and specimens generated from the laboratory should be steamed at 121^oC for 20 minutes before waste is centralized and treated in accordance with regulations.

- Centralized transportation and treatment: Infectious waste containers must comply with the Joint Circular No. 58/2015/TTLT-BYT-BTNMT dated 31 December 2015 of the Ministry of Health and the Ministry of Natural Resources and Environment stipulating regulations medical waste management with “Potential COVID-19 Waste” label, firm container wall, tightly covered lid and wheelchair. Infectious waste must be transported and treated immediately during the day. Time and path for waste transportation should avoid crowds.

- Linens, used clothes of patients with infected or suspected with COVID-19, personal protective equipment of healthcare workers and participants in medical waste management and environmental sanitation in screening, monitoring, isolation, care and treatment areas for patients with confirmed or suspected COVID-19 must be collected and treated as infectious waste stated above.

6. Inspection and surveillance

- Infection Control Department, Nursing Department, Head of Departments and Head Nurses of relevant departments are responsible for training, inspecting, monitoring and urging the strict implementation of waste management procedure for patients with confirmed or suspected COVID-19. Content of monitoring:

Vehicles for collection and transportation.

Practices of classification, collection, transportation and destruction

Amount of waste generated.

- Immediately report to Head of Departments, Head Nurses, the COVID-19 Epidemic Prevention Team and the hospital leaderships in cases of incidents or any problems related to spreading the source of contamination from waste.

                   COLLECTION, PACKAGING AND TRANSPORT OF SPECIMEN

All biological specimens from people with confirmed or suspected COVID-19 are potential and dangerous sources of infection for persons who sample, collect, transport and handle. Strict compliance with biosafety level 2 requirements is required when contacting and handling this source of specimen.

1. Objectives

- Prevention of COVID-19 infection through contact with specimens and people having contact with patient during the process of collecting, preserving, packaging and transporting, handling and performing specimen-related tests related to people with confirmed or suspected COVID-19.

- All sampling personnel must correctly and strictly follow the procedures and regulations when collecting, storing, and transporting specimens of people with confirmed or suspected COVID-19.

- Avoid spreading disease sources, ensuring safety for healthcare workers and the environment.

2. Principles of implementation

Prevention of contact-borne infection is a top priority in the procedure for sampling, preserving, packaging, transporting, handling specimen and doing tests related to specimens of people with confirmed or suspected COVID-19.

2.1. Requirements on persons sampling, preserving, packaging, transporting specimens of people with confirmed or suspected COVID-19

Persons who sample, store, pack, transport, handle and do tests related to patient specimens of people with confirmed or suspected COVID-19 must be the healthcare workers who are trained with good practice skills of directions on infection prevention.

- Strictly comply with biosafety regulations in collecting, preserving, packaging, transporting, handling and doing tests related to blood-borne specimen, transmission of airborne agents and the route of contact.

- Use personal protective equipment skilfully and properly

- Understand the risk of infection, have the ability to detect and assess risks for individuals, have knowledge of health control after performing tasks and handle themselves in accordance with the exposure procedure.

- It is ideal that healthcare workers who are monitoring and caring for suspected patients take specimens, minimizing the number of people having contact with patients.

2.2. Requirements for instruments

All instruments used to collect, store, package and transport specimens and all the testing instruments, redundant specimen of the people with confirmed or suspected COVID-19 are waste with high risk of infection and must be disinfected at the Laboratory before becoming infectious medical waste.

- Priority is given to use the disposable tools that are destroyed immediately after use as infectious waste.

- Instruments if reused, must be disinfected and sterilized in accordance with regulations, there must be separate treatment tanks to avoid infection to other patient's instruments.

- Instruments separately used for each patient must be collected and separately handled.

2.3. Requirements for sampling and testing areas

- The sampling and testing areas must be the isolation areas

3. Subjects and measures of application

- Healthcare workers must strictly follow regulations on biosafety and proficiently use the personal protective equipment.

- People with confirmed or suspected COVID-19 must be kept in the isolation areas.

- Sampling instruments and testing instruments and redundant specimens of people with confirmed or suspected COVID-19 must be treated as medical waste with high risk of infection.

4. Facilities

4.1. Personal protective equipment

- Anti-epidemic disposable clothes.

- Waterproof cape.

- Hood or cape covering head and neck with waterproof material.

- Mask with high filtration capacity (for example, N95), or mask with filter and breathing support component (boosting oxygen).

- Goggles or face shield.

- Double-layer gloves, first layer (inner layer) as medical gloves always kept clean, avoid contact with dirty equipment.

- Rubber boots/waterproof boots with high neck.

- Hand sanitizer containing alcohol/soap for hand hygiene.

4.2. Specimen taking instruments

- Sterile soft and hard handle cotton swabs

- Tongue depressors

- The collected specimens are contained in a 3 ml medium tube (VTM, UTM).

4.2.1. Respiratory specimens:

- Nasopharyngeal fluid: Sterile soft handle cotton swabs (as regulated by Laboratory).

- Throat fluid swab: Sterile hard handle cotton swabs to collect specimens (as regulated by Laboratory).

- Mouthwash fluid: physiological saline, sterile plastic beaker (specimens are collected into petri dishes or beaker and diluted in the specimen medium as regulated by Laboratory).

- Endotracheal/bronchial/alveolar/pleural fluid: specialized instruments

4.2.2. Blood specimen:

- Sterile 10ml syringe

- Blood collection tube with or without anticoagulant (as regulated by Laboratory)

- Tourniquet, cotton balls, alcohol, etc.

4.2.3. Specimen packaging:

- Plastic containers with tight lids, plastic racks or plastic bags for packaging patient specimens.

- Styrofoam cooler and container for specimen transportation.

- Antiseptic gauze (for handling of spillage or splashing of specimens)

4.3. Information on specimen tube

- Name of patient (or specimen code).

- Age.

- Date and time of specimen collection.

- Type of specimen.

4.4. Test request form and epidemiological investigation questionnaire

Complete information (as in the form prescribed in Decision 343/QD-BYT dated 07/02/2020 promulgating the provisional Guidance on surveillance, prevention and control of acute respiratory infections caused by new strains of Corona virus ).

5. Step of implementation

5.1. Wearing of personal protective equipment

Properly wearing of personal protective equipment (see also the Use of personal protective equipment). Pay attention to wearing mask N95 and 2-layer gloves when taking specimens.

5.2. Regulations on taking specimens

5.2.1. Specimens

For collection of specimen. It is obligatory to take 01 respiratory specimen; an additional blood specimen can be taken; the specimens are as follows:

- Upper respiratory tract specimens:

• Nasopharyngeal fluid and throat fluid swab
• Throat rinsing fluid

- Lower respiratory tract specimens:

• Sputum
• Alveolar fluid, endotracheal fluid, pleural fluid
• Organization of lungs, bronchi, alveoli (when indicated)

- Blood specimen: 3-5 ml of venous blood with or without EDTA anticoagulant. Serum or plasma specimens are stored as required by the Laboratory (perform the test as required)

5.2.2. Time to collect specimens

The time of collection of respiratory specimens should be taken as soon as possible after the onset.

        Table 2. Time of collection of specimens for COVID-19 confirmation

5.2.3. Specimen taking techniques

5.2.3.1. Nasopharyngeal fluid and throat fluid swab (use 02 cotton swabs for 2 types of specimen), are collected at the same time.

*. Throat fluid swab

- Ask the patient to open his mouth wide.

- Use the instrument to gently press the patient tongue.

- Insert the cotton swab into the oropharynx, rub and gently rotate 3-4 times at the 2 sides of the tonsils and the back wall of the throat to get fluids and cells.

- After taking the specimen, the cotton swab is put into a tube containing 3 ml of medium (VTM or UTM) for storage. Note, the cotton swab tip must be completely submerged in the medium, and if the cotton swab is longer than the medium canister, it is necessary to break/cut the swab handle to fit the length of the medium canister.

*. Nasopharyngeal fluid

- Ask patient to sit still, face slightly back, children must be kept by an adult

- The person taking specimen tilts the patient's head back about 70^o, hands holding patient’s neck.

- Use the other hand to gently insert the cotton swab into one nostril, pushing and turning to make the cotton swab easier to go forward about ½ length from the nose edge to the earlobe of the same side.

Note: if you have not reached such a depth but feel a clear resistance, remove the cotton swab and try to get specimen from the other nostril. When you feel the cotton swab touch the back of the nose and throat, stop, turn and slowly withdraw the cotton swab.

- Hold the cotton swab at the sampling site for 5 seconds to ensure maximum infiltration

- Slowly turn and withdraw the cotton swab.

- Place the tip of a cotton swab in the medium canister and break the swab handle at the marking point to have a length consistent with the length of the medium canister. After taking nose swab specimen, the cotton swab will be put into the medium canister which also contains throat cotton swab.

- Recap, tighten and wrap with paraffin paper (if any).

Store the specimen at a temperature of 2-8° C before transportation to the laboratory. If the specimens are not transported to the laboratory within 48 hours after being taken, the specimens must be stored at minus 70°C (-70 ° C).

Note: For small children, let them sit on the parent's lap, the child's back is facing parent's chest. Parent need to hold the baby's body and arms tightly. Ask the parent to tilt the baby's head back.

5.2.3.2. Throat rinsing fluid

Patients gargle with 10 ml of washing solution (physiological saline). Throat rinsing fluid is collected into a beaker or petri dish and diluted at 1: 2 in a viral storage medium.

5.2.3.3. Endotracheal fluid

The patient is under mechanical ventilation and intubated. Use a suction tube, placed in the endotracheal route and use the syringe to suck the endotracheal fluid out along the intubation tube, put the endotracheal fluid into the viral storage medium tube.

5.2.3.4. Blood specimen taking:

Use a sterile needle and syringe to take 3ml-5ml of venous blood and transfer it into a tube (with or without EDTA anticoagulant) and store it at 4° C for 24 hours.

Note:

- Write the patient’s name, age and address, type of specimen, day of sampling on the specimen holding tube.

- Specimens collected in the lower respiratory tract (endotracheal, alveolar, pleural fluid) must be coordinated with clinicians during the collection of patient specimens.

5.2.4. Disinfection of instruments and specimen collection area.

- Instruments for sampling and personal protective equipment must be treated as infectious waste.

- Surfaces of specimen collection area must be disinfected as isolation room.

5.3. Regulations on specimen storage

Specimens after being collected should be transported to the Laboratory in the shortest possible time.

- Specimens are stored at 2°C-8°C, and transported to the Laboratory as soon as possible, ensure no more than 48 hours after collection.

- The specimens are stored at -70°C in the event that the expected time of transportation to the laboratory is later than 48 hours after collection.

- Do not store specimens in the freeze compartment of fridge or -20°C.

5.4. Regulations on specimen packaging

Specimens when being transported must be packaged by the 3-layer principle to ensure biosecurity.

- As stipulated in Circular No. 40/2018/TT-BYT on management of specimens.

5.4.1. Packaging specimen for transportation to perform routine tests.

- The innermost layer: the specimen vial as required by Laboratory. Do not allow the specimens to spill out.

Fig.13. Packaging specimen (3 layers) for transportation within hospital to perform routine tests

- Middle layer: plastic rack, styrofoam rack, plastic box to keep the specimen upright.

- Outer layer: rigid plastic box with lid and handle, labelled biohazard on the box

5.4.2. Packaging specimen for long-distance transportation to do tests for COVID-19 confirmation.

Transported specimens must be carefully packed in 3 protective layers as guided by the World Health Organization.

- Tube containing medium: directly containing specimen. Plastic tube with tight lid properly closed.

- Plastic box or rack: containing specimen tube.

Respiratory specimens and blood samples of the same patient are placed in a sealed plastic container with screw cap tightly closed or plastic rack for specimen tube.

- Container for specimen transportation: contains box (or rack) of specimen.

Reliable container with tight lid to ensure no break.

Temperature retention (use of cooler)

- Steps of specimen packaging and transportation

Note:

- Attach the test request form.

- Outside the specimen transportation container, there are WHO regulations logos (biohazard label, directional label and impact avoidance label) painted on it.

Fig 14. Sample of biohazard label, directional label and impact avoidance label

 (Issued together with Decree No. 92/2010/ND-CP dated 30/8/2010 by the Government)

5.5. Regulations on specimen transportation

- Notify the Laboratory of the day of sending and expected time of arrival to Laboratory.

- Specimens are transported to the Laboratory by road or air as soon as possible.

- Within the hospital, transporting specimens by hand. Do not use pneumatic specimen transport system.

- Absolutely avoid spillage and breakage of specimen tube during transportation.

- Ensure all staff transporting specimen are trained in safe handling practices and procedures for decontamination of blood and fluid spillage.

- Specimens should be stored at 4°C when transported to the Laboratory, avoiding the multiple thawing process, reducing the quality of the specimens.

- Specimens should be transported together with the test request Form with all prescribed information.

6. Inspection and surveillance

- Department of Infection Control, Nursing Department, relevant Heads of Department and Head Nurses are responsible for training, inspection, surveillance and urging of strict compliance with regulations on biosafety, skillful use of personal protective equipment during collection, storage, packaging, transport, handling and performance of tests related to COVID-19 specimens.

- Monitor the treatment of medical waste with high risk of infection for specimen collecting instruments, testing instruments and residue of specimen after testing.

- Monitor the treatment of areas of specimen collection, handling and performance of tests related to COVID-19 specimens.

See also Guidance on diagnosis and treatment of acute pneumonia caused by new strain of Corona virus (nCoV) issued under Decision No.125/QD-BYT dated 16/01/2020 and temporary Guidance on monitoring, prevention and control of acute respiratory infection caused by new strains of Corona virus (nCoV) issued in accordance with Decision No.343/QD-BYT dated 07/02/2020 by the Minister of Health.

PREVENTION OF COVID-19 INFECTION IN LABORATORY

1. Objectives

- To prevent the COVID-19 infection by droplets and contact from types of specimen and persons contacting patients during performance of specimen testing of persons confirmed or suspected of COVID-19.

- All staff in Laboratory must strictly and properly follow the procedures and regulations upon collection, storage and transport of specimen.

- To avoid spreading disease sources and ensure safety for healthcare workers and the environment.

2.  Subjects of application

- Laboratory staff must strictly follow regulations on biological safety and must proficiently use personal protective equipment.

- All specimens of persons confirmed or suspected of COVID-19 infection may come from outpatient department, A&E, department of infectious diseases, etc. or transported from other medical facilities.

3. Method of application

3.1. Specimen

- Specimens of upper respiratory tract.

- Specimens of lower respiratory tract.

- Serum specimen

3.2. Testing of suspected cases

- Hematological testing.

- Biochemical testing.

- Biological testing

• Differential diagnosis:

Severe flu.

Atypical pneumonia.

Septicemia causing renal and respiratory failure.

Acute hand-foot-and-mouth disease with complications of respiratory and renal failure.

• Other routine tests.

3.3. Testing for confirmation of COVID-19

  Detecting positive COVID-19 with the Real time RT-PCR or Next Generation Sequencing – NGS technique.

4. Requirements for biosafety assurance

Preventing the COVID-19 infection by droplets, contact and aerosol dispersion when performing aerosol manipulation is the first priority during testing for persons confirmed or suspected of COVID-19.

4.1. Material facilities

- Routine tests: Biosafety level II

- Tests for COVID-19 diagnosis: Biosafety level II

4.2. Equipment

- Ensure the requirements on equipment for Biosafety level II Laboratories

- Biosafety cabinet level II calibrated and certified.

- Personal protective equipment:

• Routine tests: general personal protective equipment.
• Tests for definitive diagnosis of COVID-19: with full personal protective equipment, including epidemic resistant costumes, powderless gloves, N95 mask, goggles or face shield.

4.3. Laboratory staff

- The Laboratory staff must be experienced and proficient when performing tests for persons confirmed or suspected of COVID-19. The specialized staff should be assigned to do such tests.

- Strictly follow the regulations on biosafety and use personal protective equipment properly and proficiently.

- When doing routine tests: wear the general personal protective equipment such as gloves, waterproof gown, face shields, goggles, masks.

- When performing tests for definitive diagnosis of COVID-19, wear all personal protective equipment, including epidemic resistant costumes, powderless gloves, N95 mask, goggles or face shield.

- While wearing gloves for testing related to specimen of persons confirmed or suspected of COVID-19 infection, do not touch the keyboard controlling machinery, doorknobs, phones, electrical switches, etc.

- Staff performing tests of persons confirmed or suspected of COVID-19 must not wear personal protective equipment when going out of COVID-19 Laboratory.

- Understand risks of infection, be able to detect and assess risks for individuals, have knowledge of health control after carrying out duties and handle themselves in accordance with the procedures in case of exposure.

- Absolutely do not contact bare hands with specimens and testing tools for persons confirmed or suspected of COVID-19.

- When performing tests related to specimens of patients with positive result of COVID-19 or suspected patients, do not touch face, nose, mouth.

5. Inspection and surveillance

The Department of infection control, Nursing Department, Heads of Departments and Head Nurses of the relevant departments are responsible for training, inspection, surveillance and urging of the strict compliance with procedures and regulations on biosafety when performing tests for patients confirmed or suspected of COVID-19.

- Surveil the medical operations on strict adherence to disinfecting tools and specimen collection areas.

- Surveil the surveillance of medical operations on strict adherence to regulations on biosafety and proficient use of personal protective equipment during the process of testing.

- Surveil the treatment of reused instruments after doing tests.

- Surveil the treatment of medical waste with high risk of infection for specimens after doing tests.

- Surveil the treatment of laboratory environment as an isolated area.

Note:

- Specimen collection area must be treated as an isolated area.

- Laboratory must ensure ventilation and must not exhaust gas to places where many people travel or go into corridor or other rooms.

Testing operations with risk of aerosolization, droplets should be carried out in a biosafety cabinet of level II, such as opening test tubes containing specimens; division and dilution of specimens; mixture of specimens (with vortex mixer); DNA/RNA extraction.

- Gloved hands for testing related to specimens of COVID-19 confirmed patients must not touch the keyboard controlling machinery, doorknobs, phones, electrical switches, etc.

- When putting off personal protective costumes (gloves, gown, mask, etc.), roll the dirty side (the outer side) inward to limit the risk of spreading the infectious agent to collection tools and means of transport.

- Instruments used for collecting specimens and specimens of COVID-19 confirmed or suspected persons must be treated as high-risk medical waste after doing tests.

TREATMENT OF CORPSE OF COVID-19 CONFIRMED OR SUSPECTED PATIENTS

1. Objective

- The healthcare worker must duly treat and strictly comply with the process and regulations in treatment of corpse of COVID-19 confirmed or suspected patients.

- Prevent COVID-19 infection to healthcare workers, patient families, funeral attendees and the community.

2. Scope of application

- The Department of Pathological Surgery, the Mortuary and clinical departments where a COVID-19 confirmed or suspected patient died.

- Healthcare workers and patient families who have direct contact with the corpse of a COVID-19 confirmed or suspected patient.

3. General principles

- Absolutely apply all measures of standard prevention and prevention by isolation over contact or droplets when a corpse is being transported and treated.

- Only authorized healthcare workers and patient families who have been educated and process of prevention and are fully equipped with appropriate personal protective equipment can join the treatment of the corpse of a COVID-19 confirmed or suspected patient.

- Ensure not to spread pathogen during the process of treatment, transportation, cremation and burial of corpse of a COVID-19 confirmed or suspected patient.

- Move the other isolated patient(s) in that room (if any) to another isolation room before treating the corpse.

- The corpse of COVID-19 confirmed or suspected corpse must be cremated. Burial can only be applied when cremation is impossible.

- A corpse must be shrouded as soon as possible and must be cremated or buried within 24 hours since the time of death.

- All wastes produced during the process of treatment, transportation, cremation or burial of a COVID-19 confirmed or suspected corpse must be treated like infectious wastes.

4. Vehicles

4.1. Vehicles used to transport, store and treat the corpse

- The coach or stretcher used to transport a corpse must be disinfected right after each time of use.

- Dedicated bags for corpse containing must be available. In case of not, there must have waterproof nylon bags having zip fastener, mechanically durable, having appropriate size and disposable bed-sheets.

- Cool room used for corpse storage or corpse keeping must be equipped with basin for hand-wash, chemical for disinfection of surface, floor and hygiene utensils for disinfection of surface.

4.2. Personal protective equipment, hand hygiene and waste collection

At the clinical department where there is a COVID-19 confirmed or suspected patient and at the Mortuary there must always have utensils for infection prevention practice, including:

- Hand hygiene utensils: hand-wash soap, alcohol-based hand hygiene solution.

- Personal protective equipment: are those disposable things (gloves, paper hats, medical masks, gowns, goggles, aprons). All of them must be waterproof.

- Utensils for waste collection: yellow bag and bin with size big enough to collect after-use personal protective equipment.

- Corpse disinfecting chemical: solutions having 0.5% active Chlorine.

- Utensils for environmental hygiene and disinfection: Towel used to clean surface, hand sprayer or hand spraying machine.

5. Execution

5.1. At the unit where a COVID-19 confirmed or suspected patient died

As soon as a COVID-19 confirmed or suspected patient died, the healthcare staff who directly treat and care that patient must execute the following tasks:

- Not to arrange another patient (including a COVID-19 confirmed or suspected patient) in the room having the corpse. In case that room has another patient, that patient must be moved to another room immediately.

- Make a telephone call and send a written request to ask the Mortuary to assign staff to come and transport the corpse to the Mortuary.

- Unauthorized persons and patient families are strictly prohibited to get into the room.

- Explain the patient families about the risk of infection and instruct them the regulations and the infection prevention measures that must be applied when having contact with the corpse and during the shrouding and visiting.

- No things are allowed to be brought out of the room if this room has not been disinfected for the last time.

- While waiting for the Mortuary staff to come and transport the corpse, the department’s staff must cover the corpse with a bed sheet and must clean all the surfaces where the patient lies with solution of 0.5 active Chlorine.

- The Mortuary staff must wear all personal protective equipment during corpse treatment. Details of personal protective equipment are mentioned in Appendix 3.

- The corpse is isolated in the following steps:

• The corpse must be closely covered in a corpse bag with waterproof material lining inside to prevent the outward leakage of body fluids.
• Spray disinfectant chemical of 0.5% (5,000 ppm) active Chlorine outside the first layer of bag. Do the same with the second layer of corpse bag. The corpse bag must be made from waterproof material which is opaque, firm, not easily torn/pierced; the bag wall must be ≥ 150μm in thickness; the zip fastener must be tight and firm.
• In case there is no corpse bag, the corpse must be closely wrapped up with 02 thick layers of cotton fabric. Spray disinfectant chemical of 0.5% (5,000 ppm) active Chlorine outside the first layer of nylon. Do the same with the second layer of nylon.
• After the corpse bag is tightly closed, use a tag or sticker of biological harmful symbol (as the form in Regulations of medical waste management enacted with the Decision 43/2007/QD-BYT) to label outside the bag.
• Spread out a clean bed sheet on the corpse transporting vehicle, put the corpse on the clean bed sheet, move towards the room and put off personal protective equipment (put inside the patient room), disinfect hands and get out of the patient room.
• The Mortuary staff wearing all personal protective equipment receives the corpse at the outer of the patient room and transport it to the Mortuary.

- Repeat disinfecting the entire patient room and the corridor after treatment.

- During the time since the death of the patient until the corpse is brought out, the healthcare staff at the department where the patient died must watch and advise all persons getting into the patient room to duly execute the regulations on infection prevention.

5.2. Transport the corpse from the patient room to the Mortuary

- During the corpse transportation, the healthcare staff must fully wear personal protective equipment (surgical mask, gloves, paper gown, hat and boots). Details of personal protective equipment for corpse treating staff are mentioned in Appendix 3.

- Transport the corpse on the isolation way and the disinfection spraying must be done immediately after; In case the corpse is transported in the elevator, other person(s) must not be accompanied; if the patient family request an accompaniment, he/she must fully wear personal protective equipment. The corpse should not be transported through crowed places.

- Right after the corpse is moved into the storage room, the Mortuary staff transporting it must spray the vehicle with disinfectant solution of 0.05% active Chlorine and must not use it in 30 minutes, then put off personal protective equipment as order, discard them into the yellow nylon bag, carefully wash hands and do personal hygiene before doing other tasks.

5.3. Corpse shrouding         

The shrouding process must comply with the special procedure of dangerous epidemic:

- Shrouding must be executed as soon as possible.

- Corpse shrouding must be executed at the Hospital Mortuary. The shrouding attendees must be minimized.

- The staff directly executing shrouding must fully wear personal protective equipment (surgical mask, gloves, paper gown, hat and boots). Clean hands with alcohol-based solution and carefully wash hands with soap.

- The patient families must absolutely not be allowed to visit the corpse during the time of storage until the shrouding is completed.

- Corpse shrouding process:

• On the bottom of the coffin, put a nylon sheet large enough to cover the corpse.
• Wrap the corpse closely with the underlying nylon sheet.
• Tightly shut the coffin. Check and seal all coffin gaps (if any) with waterproof adhesive tape.

- The Funeral Home staff must spray disinfectant over the entire surface of the shrouding room and the coffin surface with solution of 0.05% active Chlorine.

• Put off all personal protective equipment (surgical mask, gloves, paper gown, hat and boots) and discard them into the yellow nylon bag.
• Clean hands with alcohol-based solution and carefully wash hands with soap.
• Have shower and body cleaning before doing other tasks.

5.4. Visit, treat the corpse of a COVID-19 confirmed or suspected patient

- Visitors are not encouraged. Visitors must wear mask, must not touch the coffin and must have their hands cleaned with alcohol-based solution after visiting.

- The corpse must not be transported out of the province. The corpse must be transported in a dedicated vehicle directly to the cremation site. Patient families must not gen on the corpse-carrying vehicle. The corpse-carrying vehicle driver must fully wear personal protective equipment.

- The corpse of a COVID-19 confirmed or suspected patient should be cremated as soon as possible. It must not be laid more than 24 hours since the moment of death.

- Right after the coffin is transported to the cremation site or burial site, the coffin-carrying vehicle must be disinfected with disinfectant solutions that are certified to be circulated by the Ministry of Health.

- In case there is a demand to transport the corpse, remains across the border, it must be executed under the Decree 89/2018/ND-CP dated June 25, 2018 by the Government stipulating details to execute articles of Law on Prevention and Control of Infectious Diseases in health quarantine at border.

6. Examination, supervision and duties

- The Department of Infection Control, Nursing Department, Heads of Department and Head Nurses of the relevant departments have the duty to train, examine, supervise and encourage the strict execution of corpse treatment process and regulations on COVID-19 confirmed or suspected patient.

- The unit where the patient died: ensure to abide by regulations of infection prevention and control at the area under its management.

- The Funeral Home: receive and transport the corpse to the Mortuary, have it shrouded and organize the visit and treatment of corpse as regulated.

- The Service Unit: arrange vehicle to transport the corpse and implement the regulations during the time the corpse is being transported to the cemetery. A certain number of personal protective equipment should be available to transfer to the patient families for use if necessary.

- The General Planning Department: monitor the examination, reception and report to ask for the Hospital Management to resolve problems arising during the execution of this regulation.

- The Department of Infection Control: examine and monitor the proper execution.

- Make the list of all healthcare staff, patient families, etc. who attend to treat and shroud the corpse for report and monitoring within 14 days as regulated and instruct them the symptoms that require detection, report and examination.

GUIDANCES ON PREVENTION OF COVID-19 INFECTION OVER PATIENT FAMILIES AND VISITORS

Patient families and visitors are the subjects having risks of being confirmed and spreading the source of infection to the community. All medical facilities must carry out the propagation of limited visit and must provide personal protective equipment to such subjects.

1. Objectives

- Preventing infection to visitors, patient families when contacting the persons confirmed or suspected of COVID-19.

- Ensure the safety for community to avoid wide spread of COVID-19.

2. Principles of implementation

- Absolutely do not let close contact or visit when the confirmed or suspected persons are under isolation for treatment and monitoring at medical facilities.

- Do not permit visit at the isolation area when performing procedures which can create close aerosols, droplets to prevent dangerous infection.

- Maximally limit visit to the isolation area to prevent spread of disease to community.

- In case of compulsory visit or contact with patients, all visitors must comply with the preventive principles at the isolation area. The visitors should be instructed on how to wear or remove the personal protective equipment before coming to the isolation area.

- Upon permission for patient visiting, do not let visitors closely contact patients (within 2 meters).

- Children of breastfeeding mothers confirmed or suspected of COVID-19 must be isolated from their mothers to prevent spread and do not let children breastfeed their mothers until the primary doctor gives indications.

When going out of the isolation area after visiting, comply with the procedures for removal all personal protective equipment and hand hygiene properly before leaving the isolation area. Provide all personal information and keep regular contact with the medical authorities as instructed for post-contact exposure monitoring.

- There should be healthcare workers escorting and guiding visitors to strictly comply with regulations and write names for further monitoring.

3. Subjects and scope of application: All visitors, patient families, healthcare workers having close contact with patients at any time of isolation.

4. Implementation

4.1. Before entering isolation room

- Patient families and visitors before entering the isolation area must be instructed and properly wear the personal protective equipment, especially paying attention to the personal protective equipment to prevent infection via respiratory tract.

- Healthcare workers will be present to instruct visitors to follow steps of wearing and removing personal protective equipment and monitor the visitors’ actions.

- Healthcare workers will check the compliance with instructions and understanding of requirements on prevention of infection before allowing visitors into the isolation area.

4.2. In the isolation room

- All visitors must comply with the instructions and surveillance of the healthcare workers at the isolation area, do not arbitrarily touch all items in the isolation area, and not directly contact patients (embracing, kissing, shaking hand).

- Keep a distance of at least 2 meters from the patient.

4.3. Going out of isolation room

- Remove all protective costumes as instructed by the healthcare workers right at the buffer area of isolation area.

- Do not bring any item or personal protective equipment in the isolation area after use to other places.

- Make a list of close contact with persons confirmed or suspected of COVID-19 and inform the local preventive medical agencies for proper health monitoring and handling.

- Give advice to patient families and visitors to proactively declare all personal information for monitoring and self-monitoring of symptoms after leaving the isolation area within 14 days. When there are abnormal signs of health, immediately go to the nearest medical facility for report and advice.

- Inspection and surveillance:

+ Department of infection control, Nursing Department, Heads of Department and Head Nurses of relevant departments are responsible for training are responsible for training, inspection, surveillance and urging of the strict compliance with procedures and regulations on involvement in care for patients with COVID-19 confirmed or suspected, including:

+ Supervise whether the healthcare workers provide training, instructions and monitor patient families and visitors or not.

APPENDIXES

Appendix 1

FLOWCHART OF RECEPTION OF COVID-19 SUSPECTED PATIENTS

                                                     Appendix 2

FLOW CHART OF INFECTION PREVENTION AND CONTROL

FOR EACH STAGE OF DIAGNOSIS

 Appendix 3

USE OF PERSON PROTECTIVE EQUIMENT (PPE) FOR HEALTHCARE WORKERS IN THE PREVENTION AND CONTROL OF COVID-19

Notes:         (+) Need to use.

(+/-) Consider to use case by case.

Appendix 4:

CHEMICALS USED IN PREVENTION AND CONTROL OF EPIDEMIC

The epidemic has become more and more unpredictable, many countries around the world are experiencing the emergence and increase of emerging and dangerous epidemics. During outbreaks, it is important to use chemicals to disinfect contaminated items and areas, which can prevent the spread of epidemic and reduce the number of victims.

There are many types of disinfectants used in healthcare facilities, users must be fully informed about those chemicals, chemicals must ensure the high efficiency during the stages of environmental, school, room air, medical equipment and waste treatment. Here are some chemicals commonly used to prevent and control epidemics in healthcare facilities nowadays:

1. Chemical group commonly used for skin disinfection and hand hygiene

1.1. Alcohols

1.1.1. General characteristics 

In disinfection, alcohols used are either Ethyl alcohol 70⁰ or Isopropyl alcohol 50⁰. The antiseptic effect of alcohols is often highly recommended. In hand hygiene preparations, alcohol is at 60% -80%. The higher the concentration of alcohol, the faster its evaporation, thus it may reduce the antiseptic effect.

1.1.2. Mechanism of action

Alcohols may denature the proteins of bacteria and viruses that have an effect on vegetative cells (including BK (Bacille de Koch) - mycobacterium tuberculosis, virus with lipid envelope, fungi) but have no effect on spores.

Alcohol destroys the lipid structures of virus, thus virus will be killed within several tens of seconds after exposure.

1.1.3. Instructions for use

Alcohols and alcohol preparations are used for hand hygiene during the process of putting on and taking off personal protective equipment (PPE). In addition, alcohols can also be used to disinfect devices such as thermometers, retinal endoscopes, rubber stoppers of multi-dose vials or vaccine bottles, ambu bags, ultrasound devices or devices used for drug preparation.

Alcohol is flammable so it should be stored in a cool environment with good ventilation. Alcohol evaporates quickly so alcohol-containing containers must have lids, and devices need to be disinfected must be immersed completely in alcohol.

1.2. Chlorhexidine gluconate-containing solutions

1.2.1. General characteristics

Chlorhexidine-containing solutions have a fast, strong, broad-spectrum antibacterial effect with additional emollients and moisturizers in the composition. The antibacterial effect lasts longer than solutions containing alcohol and iodophor, and does not cause skin irritation.

1.2.2. Mechanism of action

Chlorhexidine is effective on a wide range of Gram (+) and Gram (-) bacteria, yeasts, dermatophytes and lipophilic viruses. This chemical has no effect on the spores.

1.2.3. Instructions for use

Chlorhexidine solution 2% is used to disinfect skin like bathing, hand hygiene, and disinfect mucous membranes such as aerosols for oral inhalation.

Chlorhexidine solution 4% is used for hand hygiene before surgery or delivery.

1.3. Iodophor compounds

1.3.1. General characteristics

Iodophor antiseptics used in healthcare facilities such as Povidone-Iodine (a combination of Polyvinylpyrrolidone and Iodine) are able to kill bacteria and viruses but unable to kill spores, this chemical cause less skin irritation and does not leave colour after use.

1.3.2. Mechanism of action

Iodophor compounds are able to penetrate very quickly into the cell walls of microorganisms and destroy their protein and nucleic acid structure.

1.3.3. Instructions for use

Iodophor chemicals are used in skin disinfection, wound dressing and disinfection of non-invasive medical instruments and equipment such as thermometers, stethoscope, sphygmomanometer, etc.

2. Chemical group commonly used in environmental treatment

2.1. Chlorine and Chlorine compounds

2.1.1. General characteristics

Chlorine and chlorine compounds are most commonly used in epidemic prevention and control at healthcare facilities. This chemical exists in two forms: liquid (Javel) or solid (Calcium Hypochloride). Chlorine disinfectants have broad antibacterial spectrum, fast antibacterial effect and low cost. However, the limitation of this chemical is the erosion of medical instruments and equipment upon contact and the decreased activity in the presence of organic substances.

Chlorine-releasing compounds used in hospitals include two types: Chloramine B (Chlorine Dioxide) and Chloramine T.

2.1.2. Mechanism of action

The presence of chlorine compounds inhibits the reactions of necessary enzymes involved in the virus replication process, alters the protein nature and inactivates viral nucleic acids.

2.2.3. Instructions for use

Chlorine disinfectants should reach a minimum concentration of 0.05% (500 ppm) after mixing. 0.05% diluted solution is used to decontaminate surfaces such as floors, walls, ceilings, etc. For transportation vehicles such as ambulances, stretchers, and other items must be sprayed with disinfectants after transporting.

Solutions diluted from chlorine-containing chemicals on the market currently are at concentrations of 0.05, 0.5%, 1% and 1.25% active chlorine depending on the purpose and method of disinfection. The calculation of solution concentration must be based on activate chlorine. Because different chemicals have different concentrations of active chlorine, it is necessary to calculate the fully amount of chemicals needed to achieve the solution with the desired concentration of active chlorine.

The amount of chlorine-containing chemicals required to mix the litres of solution with the required concentration of active chlorine is calculated by the following formula:

* Active chlorine concentration of chemicals used is always stated by the manufacturer on the label, packaging or instruction sheet of products.

For example: